Infertility Flashcards
subfertility
inability of a couple to conceive, usually w/in 1 yr of unprotected intercourse
primary infertility
those couples who have never conceived
secondary infertility
couples who conceived at some time in their past- individually or together
sterility
intrinsic inability to achieve pregnancy, few pts are truly sterile
fecundity
probability of achieving live birth in 1 menstrual cycle
fecundability
likelihood of conception per month of exposure;
best perception of fertility of a given woman or couple
20% chance of conception/ month
male eval
semen analysis- checks sperm count, motility, morphology
if initial tests of both partners fail to reveal cause, further male tests needed
spematogenesis takes how many days
74
Collecting semen
abstain from sex for 2-3 days before
get to lab w/in 1 hr
Further male tests
male autoantibodies
sperm penetration assay
more sophisticated semen analysis
men with less than 5 million sperm need an endocrine eval (FSH, LH, testosterone, genetic karyotype)
Sims-Huhner test
postcoital exam/ mucous study
determines # of active sperm in cervical mucous & length of survival in hrs
value of test never proven; some say no effect on pregnancy rate
analyzes for spinnbarkheit & sperm motility
not really used much anymore
female eval & ovulatory factors
women who menstruate every 25-35 days & experience moliminal sx’s (breast tenderness, etc) do not req. lab confirmation of ovulation
if h/o abnormal cycles/ reg. cycles w/o menstrual sx’s then check for ovulation
mittelschmerz
bleeding into abdominal cavity from ruptured follicle causes irritation
CL secretes
estrogen
progesterone
androgens
& requires continued LH secretion to function
progesterone & estrogen peak
middle of luteal phase
increased estrogen & progesterone inhibit
FSH & LH from pituitary
CL during pregnancy
persists supported by hCG
estrogen & pregest levels maintained= no menses
CL & menstruation
CL degenerates to fibrous corpus albicans & estrogen & progest fail
menstrual phase
lining sloughs days 1-5 secondary to decreased estrogen & progest as CL degenerates
proliferative phase
stimulated by follicular phase estrogen secretion, lining renews & begins glycogen storage days 6-13
secretory phase
days 14-28, stimulated by luteal phase progest & continued estrogen secretion
glycogen storage increases
vascular & glandular changes support implantation
Postaglandins found in secretory endometrium produce…
vasospasm
max potential for oocyte fertilization occurs for how long
12-24 hrs
max potential for sperm fertilization is
3 days
most fertile days are_____days prior to ovulation
3 days= 20% chance
day of= 15% chance
how long after LH surge does ovulation occur
24-36 hrs
cervical mucous changes during ovulation
slippery, stretchy (spinbarkheit), clear w/ ferning changes w/in 48 hrs of ovulation to thick, tacky, cellular w/ loss of ferning
Temp change when measuring BBT
.5 F rise about 1 day after ovulation that lasts about 10 days
2/2 thermogenic effects ofprogesterone
hypogonadotropic hypogonadal anovulation (5-10%)
includes secondary amenorrhea from wt loss/anorexia, stress, severe exercise regimens, pituitary & hypothalmic d/o’s
normogonadotropic normoestrogenic anovulation (70-85%)
includes women w/ PCOS & those w/ oligomenorrhea who might ovulate occasionally
secrete normal amounts of gonadotropins & estrogen but subnormal FSH during follicular phase; all women experience occasional anovulatory cycles
hypergonadotropic hypoestorgenic anovulation (10-30%)
premature ovarian failure, ovarian resistance, gonadal dysgenesis, Turner’s syndrome, Swyer’s syndrome, hyperprolactinemia
may have regular anovulatory cycles, usually have oligomenorrhea or amenorrhea; serum gonadotropin levels usually normal
ovarian function eval in women over 35 yo & those at risk of premature ovarian failure
Day 3 FSH & estradiol (high FSH mean decreased ovarian function)
Clomiphene citrate challenge test (CCCT)
ULS by day 10
day 3 inhibin B (falls in women with decreased ovarian reserve prior to increasing FSH)
CCCT
100mg clomid on cycle day 5-9, measure FSH levels day 3 & 10
an abnormal result w/ either test virtually confirms tx failure
ovarian function eval in women w/ amenorrhea &/or androgen excess signs
progesterone challenge test
testosterone level, DHEA-S
ovarian function eval in women w/ irregular menses & anovulation or h/o SABs
LH predictor kit
midluteal progest level (3rd wk of cycle)
PRL, TSH
Progesterone challenge test
10 mg PO x5 days
bleeding a week after indicates sufficient estrogen & patent outflow tract
Pelvic factors that may cause infertility
abnormal uterus, fallopian tubes or ovaries 2/2 PID, appendicitis, IUD, endometriosis, septic AB, ectopic, fibroids, Asherman’s syndrome DES exposure
DES
diethylstilbestrol- given to pregnant women from 1948-1971 to tx certain high risk conditions
hystero-salpingogram (HSG)
radioactive dye ejected into uterus to observe contours, tubal patency
often curative
invasive- risk of peritonitis, can give prphylactic doxycycline
chlamydia antibodies
simple inexpensive test that can predict the presence of tubal dz
unexplained infertility
often d/t combined factors
often worst case dx
30-80% will achieve preg in 3 yrs
varicocele & infertility
can cause decreased semen quality b/c of elevated scrotal temp
“wear boxers”
you can use what to tx sperm autoantibodies
steroids
ICSI
intracytoplasmic sperm injection
insert single sperm into oocyte cytoplasm
possible risk of chromosomal abnormalities
female therapies
wt modulation/ lifestyle modification pulsatile GnRH x 3-6 cycles if all else fails correct endocrine d/o's, iatrogenic causes clomid or other SERM (tamoxifen) gonadotropin therapy aromatase inhibitors laparoscopic ovarian diathermy bromocriptine or other DA agonist ART
Clomid
clomiphene citrate
PO med that competes w/ estrogen receptors as agonist/antagonist in hypothalamus to block estrogenic neg FB effects, thus promoting increased follicular development/ hyperovulation
Aromatase inhibitors
decrease estradiol levels
laparoscopic ovarian diathermy
induce ovulation by wedge resection & drilling by laser or diathermy
reserved for special cases
bromocriptine or other DA agonist
elevated PRL results in decreased estradiol & anovulation
