Infertility Flashcards
Secondary infertility is…
Conceived at least once and not again for at least one year
Primary infertility is…
Never conceived
Prime causes of infertility from greatest to least…
Unexplained Sperm problems Ovulatory failure Tubal damage Endometriosis/cervical mucous Coital problems Other
5 steps of conception…
Ovulation Insemination Fertilization Transportation Implantation
The cervix needs to provide a __________ environment to harbor sperm.
Non hostile
In the cervix, the glands need to secrete __________ and crypts need to hold __________.
Mucus
Sperm
How is ultrasound used to evaluate the cervix?
Cervical length to assess for cervical incompetence
2 main objectives in evaluating the uterus…
Assess structural anatomy
Assess endometrium
In evaluating the uterus, assessing for structural anatomy refers to…
Evaluating uterine shape (unicollis, bicornuate, etc.)
DES treatments - T shaped uterus
Evaluate the uterus for…
Echogenicity
Masses - fibroids
Assess endometrium - thickness, echogenicity, lesions
Why measure the endometrium?
Make sure it changes appropriately throughout the menstrual cycle
In the first half of the menstural cycle, mucosa begins to…
Proliferate because of increasing estrogen levels
Proliferative endo =
Triphasic endo - 3 stripes
After ovulation, what is secreted and by what?
Progesterone by the corpus luteum
Secretion of progesterone begins in what phase?
Secretory phase of endometrial cycle
What happens to the endometrium during the secretory phase and why? What is lost?
Endo becomes thickened and very echogenic as a result of stromal edema
Loss of the triple line sign
How thick does the endometrium have to be to achieve pregnancy?
At least 6 mm thick
What happens to the endometrium if not enough progesterone is produced during the luteal phase?
A thin endometrial lining by US
Lack of progesterone production is known as?
Luteal phase deficiency
Luteal phase deficiency (lack of progesterone) is associated with?
Infertility and early pregnancy loss
Why is endometrial appearance important for planning infertility treatments?
For embryo transfer
4 things that can make an endometrium irregular…
Submucosal fibroids
Polyps
Adhesions
Synechiae - scar tissue from d&c’s
What can be used in situations to further delineate anatomic structures of irregular endometriums?
Saline infusion sonography
When evaluating the fallopian tubes what accounts for 50% reduction in pregnancy rate and doubling spontaneous miscarriage rate?
Hydrosalpinx
What improves in vitro fertilization success?
Tube removal
How is tubal patency assessed?
By injecting saline into the tube and looking for spillage of fluid into the cul de sac or around the ovary or by using contrast to evaluate for spillage
If spillage is seen from the fallopian tubes, ________ is inferred.
Patency
If no spillage from the fallopian tubes is noted and patient complains of pain during injection, tube may be _______.
Blocked
What can obstruct a fallopian tube?
Adhesions
During follicular phase several antral follicles on the ovary measure?
Less than 5 mm
What hormone creates the dominant follicle?
FSH
What is the dominant follicle growth rate?
Approximately 1 to 3 mm/day until it reaches 22 mm
At what size do the dominant follicles rupture?
22 mm
Rupture of a follicle is associated with?
Increased or decreased size
Sonographic ovulation findings?
Eh ones within fluid left behind (corpus luteum)
Free fluid in peritoneal cavity
Key drugs in ovarian induction therapy?
Clomiphene citrate (clomid) oral Human menopausal gonadotropins (pergonal) injected
Once therapy is started, US is used to monitor the number and size of follicles in what days?
8-14 (follicular phase of menstrual cycle)
What size follicles get counted by the sonographer after ovarian induction therapy?
Greater than 1 cm in long and trans
Measurement of an optimal mature follicle?
16-20 mm
During ovarian induction therapy, what is US correlated with?
Serum estradiol levels
Why is correct measurement of the follicle important?
HCG may need to be given to trigger ovulation - pergonal
Monitor endometrium for what 2 things?
Thickness 2-3 mm to 12-14 mm
Echogenicity
What is OHSS?
Syndrome that presents sonographically as enlarged ovaries with multiple cysts, ABD ascites, pleural effusions
If this is seen patient will be removed from meds immediately
What is IVF?
Method of fertilizing human oocytes outside the body
During IVF, what happens to the mature oocytes?
They are collected and mixed in a dish with a sample of sperm
Resulting embryos see placed back in the uterus
Treatment plan for IVF is…
Ovarian monitoring Needle aspiration of oocytes Incubation of oocytes Fertilization Transferring embryos into uterus
With IVF, how many follicles are evaluated before triggering ovulation?
4
Oocytes are retrieved with what kind of US guidance?
TV’s
What is intrauterine insemination?
Technique used to treat male factor infertility
Catheter containing sperm placed into uterine fundus
What is TDI?
Therapeutic donor insemination or artificial insemination
What is GIFT?
Gamete intrafallopian transfer - sperm and egg injected into the fimbrated end of tube
What is ZIFT?
Zygote intrfallopian transfer - trans cervical placement of zygote into fallopian tubes
Complications of assitive reproductive technology (ART)?
OHSS
Ectopic
Multiple gestation
Factors of ART?
Central/ovulatory Male Cervical Uterine Tubal/peritoneal
What is an anovulation?
Failure of hypothalamus and pituitary to produce hormones stimulating ovulation
What happens when ovulation fails?
LUF - luteinized unruptured follicle syndrome - enlarges but fails to rupture and release the oocyte
Central/ovulatory factors…
BEST predictor of ovulation is basal body temperature - spike of .6-.8°
Regular menses does not guarantee ovulation
Male factors…
Enough sperm to penetrate and fertilize ovum
Sperm count
Sperm motility - #1 test
Cervical/mucus factors…
Cervical mucus must allow transportation of sperm into uterus
If mucus is poor (high viscosity), it’ll act as a barrier
2 types of mucus changes?
Pre ovulatory - clear & copious
Post ovulatory - mucus becomes tacky & sparse
What checks mucus consistency?
Spin barkeit and ferning
What evaluated sperm mucus interaction?
Post coital test - PCT
Endometrial/uterine factors…
Fertilized ovum must be able to implant within endometrial lining
Luteal phase inadequacy
Tubal/peritoneal factors…
Oviducts must allow transport of sperm to ovum
Passage of fertilized ovum to uterus
Adhesions cause issues
Distal fallopian tube - MOST COMMON BLOCKAGE
Laparoscopy - gold star for evaluating
