infertility

Question 1

infertility

Answer 1

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

Question 2

incidence of infertility

Answer 2

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.

Question 3

etiology of infertility

Answer 3

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

Question 4

female history

Answer 4

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

Question 5

male history

Answer 5

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)

Question 6

4 concepts when thinking of infertility

Answer 6

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

Question 7

Physical exam females (R/O virilism)

Answer 7

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

Question 8

GYN exam females

Answer 8

• 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

Question 9

Physical exam males (R/O hypogonadism)

Answer 9

degree of secondary sexual development, gynecomastia

GU: hypospadias, cryptorchidism, varicocele, hydrocele

Question 10

methods to prove ovulation

Answer 10

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

Question 11

History

Answer 11

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

Question 12

ovulation predictor kits

Answer 12

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

Question 13

Basal body temp

Answer 13

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

Question 14

charting temp should include

Answer 14

fever, illness, intercourse, spotting

Question 15

Serum progesterone

Answer 15

mid luteal phase (1 week prior to menses)

Question 16

Progesterone challenge

Answer 16

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

Question 17

Normal volume of sperm

Answer 17

> 1.5 mL

Question 18

normal pH sperm

Answer 18

> 7.2

Question 19

normal sperm concentration

Answer 19

> 15 million/mL

Question 20

normal motility of sperm

Answer 20

> 40%, >32% with rapid forward progession

Question 21

normal morphology of sperm

Answer 21

> 4%

Question 22

WBCs

Answer 22

fewer than 1 million cells/mL

Question 23

Testing sperm

Answer 23

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

Question 24

Other lab tests

Answer 24

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

Question 25

testing for the right environment

Answer 25

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).

Question 26

HSG

Answer 26

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

Question 27

endometrial bx

Answer 27

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.

Question 28

Huhner's test

Answer 28

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

Question 29

treatment options

Answer 29

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

Question 30

Clomid

Answer 30

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

Question 31

hcG

Answer 31

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)

Question 32

progesterone

Answer 32

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

Question 33

assisted reproductive technology

Answer 33

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

Question 34

intrauterine insemintation

Answer 34

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

Question 35

in-vitro fertilization

Answer 35

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

Question 36

GIFT

Answer 36

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

Question 37

TET

Answer 37

in-vitro fertilization of embryo per laproscopy or mini laparotomy