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Women's Health > infertility > Flashcards

infertility Flashcards

1
Q

infertility

A

no conception (pregnancy) after 1 year of frequent unprotected intercourse.

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2
Q

incidence of infertility

A

15% of couples, increases with age, peak fertility is before/ at age 27, then starts to decline. male contributes 20%. 1 or more causes in 90% of the cases. adherence to therapy will result in pregnancy 85% of time.

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3
Q

etiology of infertility

A

delayed childbearing, environmental/occupational exposures, STI (decrease production of sperm), genital tract problems, lack of successful sexual interactions, ovulation, anatomy

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4
Q

female history

A

HPI: duration of time without conception. efforts to obtain pregnancy (frequency and timing of intercourse, correlation with ovulation, contraceptives/douches/lubricant use.
GYN/OB: previous pregnancies, menstrual cycles & pattern, length duration and amount of bleeding, dysmenorrhea, puberty and menarche, prior STIs
PMH: Rx, OTC, herbal meds, surgery, h/o endocrine disorders
SH: exercise/diet/sleep habits (caffeine intake) tabacco/etoh/drugs, work atmosphere, stress
FH: DES usage, multiple abortions.
ROS: excessive hair growth, breast discharge, weight change

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5
Q

male history

A

HPI: prior fertility, general health
Sexual: Libido, prior STIs
PMH: genital surgery/trauma/infections, medications (colchine, methotrexate)
SH: Tobacco, ETOH & drug use, vitamin C intake (1000 mg), hot tub, baths, or constricting underwear, excessive physical or mental stress, too frequent ejaculation
FH: generally not relevant
ROS: chronic fatigue (testosterone deficiency, hypogonadism)

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6
Q

4 concepts when thinking of infertility

A

prove ovulation, eval sperm, the right chemicals, the right environment

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7
Q

Physical exam females (R/O virilism)

A
  • adequacy of bodyweight
  • acne, oily skin, skin pigmentation
  • hirsutism (increased androgens)
  • thyroid enlargement
  • galactorrhea
  • abdominal striae
  • surgical scars
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8
Q

GYN exam females

A
  • presence of pink, moist, rugated vaginal mucosa as evidence of good estrogen
  • quality and quantity of cervical mucus
  • cervix for surgery/cryocautery/laser
  • cervical, uterine, and adnexa for masses, mobility and tenderness, size, contour
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9
Q

Physical exam males (R/O hypogonadism)

A

degree of secondary sexual development, gynecomastia

GU: hypospadias, cryptorchidism, varicocele, hydrocele

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10
Q

methods to prove ovulation

A

history, ovulation predictor kits, basal body temp, serum progesterone, progesterone challenge

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11
Q

History

A

regular, cyclic and predictable menses with some degree of “phase change” assess through careful history and patient log of menses/symptoms

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12
Q

ovulation predictor kits

A

assist in montioring mid-cycle LH surge that precedes ovulation. rise in urine LH indicates ovulation-test in the am. follow intercourse guidelines as with basal body temp.
Alternative: endometrial bx to determine hormonal development

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13
Q

Basal body temp

A

core body temp taken first thing in the am (prior to rising). use a basal body thermometer; range 97-99. During follicular phase T

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14
Q

charting temp should include

A

fever, illness, intercourse, spotting

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15
Q

Serum progesterone

A

mid luteal phase (1 week prior to menses)

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16
Q

Progesterone challenge

A

10 mg medroxy-progesterone aceate PO qd-BID x 5-10 days. Result: if estrogen levels are appropriate and outflow tract is intact, bleeding should occur within 1 week after cessation of progesterone. if successful, assessment=chronic anovulation usually PCOS. if no withrdrawal bleeding occurs, check ovualtion hormones. LH elevated do CTor MRI of pituitary. LH normal measure FSH level, if FSH elevated then suspect primary ovarian failure, If FSH is normal then determine hypothalamic-pituitary vs. outflow disorder

17
Q

Normal volume of sperm

A

> 1.5 mL

18
Q

normal pH sperm

A

> 7.2

19
Q

normal sperm concentration

A

> 15 million/mL

20
Q

normal motility of sperm

A

> 40%, >32% with rapid forward progession

21
Q

normal morphology of sperm

A

> 4%

22
Q

WBCs

A

fewer than 1 million cells/mL

23
Q

Testing sperm

A

must be obtained 48-72 hourse after abstaining from intercourse. must be kept at body temp and delivered to lab 1 hour after collection. repeat if abnormal

24
Q

Other lab tests

A

STI screen->R/O disease/infection
UPT-> R/O pregnancy
TSH-> assess thyroid function
Prolactin-> assess pituitary function
+/- LH and FSH-> assess ovary and feedback loop.
antimullerian hormone-> assess ovarian reserve

25
Q

testing for the right environment

A

vaginal cultures to rule out infections
pelvic US to rule out anatomic abnormality (fibroids, ovarian cysts, endometrial lining, T shaped uterus.)
HSG, laproscoy, endometrial bx, postcoital test (huhner’s test).

26
Q

HSG

A

tests the patency of the uterine and fallopian structures, should be obtained between day 3-6 after the completion of menses. radio opaque dye is injected into the uterus under fluoroscopy oil>water. normal test will show prompt fillin the uterus and tubes with spilling of dye into peritoneum

27
Q

endometrial bx

A

obtained 2-3 days prior to menses. progesterone in the luteal phase stimulates secretory changes in the endometrium. histological criteria are used to “date” the endometrium within the cycle. Endometrium that lages behind cycle dates indicates luteal phase insufficiency.

28
Q

Huhner’s test

A

tests the quality and receptibility of ovulatory cervical mucus as well as sperm tolerance. test 1-3 days prior to expected ovulation. examine mucus 2-12 hours after intercourse. mucus being examined for quality (spinnbarkeit/ferning) and semen (many and motile). fallen out of favor

29
Q

treatment options

A

clomiphene citrate (clomid or serophene): antiestrogenic drug-ovulation induction. Human chorionic gonadotropin (hcG) given IM triggers ovulation. Progesterone to stabalize endometrium.

30
Q

Clomid

A

pituitary recognizes a decreased level of estrogen, and increases the secretion of LH and FSH, which promote maturation and release of the egg. Usual dose: 50 mg PO QD x 5 days increasing if ovulation doesn’t occur. possibility of ovarian cyst formation is increased, an exam +/- US to R/O cyst must be obtained prior to another cycle of medication. 10% chance of twin pregnancy; multiple births beyond is

31
Q

hcG

A

given when follicles reach appropriate size for ovualtion. follicle studies (a series of US) are necessary to monitor the growth; 25% chance of multiples. hcG mimics the LH surge, stimulating release of the egg. (usually within 24-36 hours)

32
Q

progesterone

A

usually is produced by the corpus luteum after ovulation. it also indicates to the endometrial lining to stop growth and prpare for implantation. progesterone suppositories or oral (25 mg BID) on days 7-10 after ovulation

33
Q

assisted reproductive technology

A

intrauterine insemination, in-vitro fertilization, gamete intra-fallopian transfer, tubal embryo trasfer or zygote intra-fallopian transfer

34
Q

intrauterine insemintation

A

indicated for male factor, cervical factor (stenosis), or unspecified infertility. Collection of semen, maintained at body temp, and in clinic within 20 minutes. sperm is wasehd and placed via catheter into uterus

35
Q

in-vitro fertilization

A

eggs fertilized in vitro, with embryos transferred to the uterine fundus. embryos not utilized can by cryo preserved for subsequent cycles.

36
Q

GIFT

A

placement of both egg and sperm in the uterine tube by laproscopy. more invasive, not appropriate for tuabl disease of indicated for male factor

37
Q

TET

A

in-vitro fertilization of embryo per laproscopy or mini laparotomy

Women's Health (7 decks)

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