Infertility Flashcards
Define infertility.
no pregnancy after 1 year of frequent unprotected sex
What are possible causes of infertility?
- delayed childbearing (incidence increases w/ age)
- environmental/occupational exposures
- increased incidence of STIs, PID
- genital tract problems like endometriosis
- lack of successful sexual interactions
When should infertility evaluation be done?
after 1 year of failure to conceive OR in the case of:
- age > 35
- male factor infertility
- previous infx, dz, or surgery (PID, endometriosis)
- DES exposure in utero
- previous infertility work-up, now wanting 2nd pg
What HPI is important to collect?
- female: duration of time w/o conception, efforts to obtain pregnancy (frequency and timing of sex, correlation w/ ovulation, contraceptives)
- male: prior fertility
What GYN/OB or sexual hx is important to collect?
- female: previous pg, menstrual cycle patterns, puberty and menarche, prior STIs
- male: libido and prior STIs
What PMH is important to collect?
- female: Rx, OTC, herbal meds, gyn/abd surgery, h/o endocrine disorders
- male: genital surgery/trauma/infx, medications
What SH is important to collect?
- female: exercise, diet, sleep, tobacco, EtOH, work, stress
- male: tobacco, EtOH, vitamin C, hot tub, baths, constricting underwear, stress, too frequent ejaculation
What FH is important to collect?
-female: DES usage or exposure, hx of multiple abortions
What ROS is important to note?
- female: excessive hair growth, breast d/c, weight change
- male: chronic fatigue
What are possible findings on female physical exam?
- adequacy of body weight (more problems BMI 27)
- acne, oily skin, hirsutism
- thyroid enlargement
- galactorrhea
- abdominal striae
- cervix, uterus and adnexa for masses, tenderness
- presence of pink, moist rugated vaginal mucosa
What are possible findings on male physical exam?
- degree of secondary sexual development
- gynecomastia
- GU: hypospadias, cryptorchidism, varicocele, hydrocele
What methods can be used to prove ovulation?
- history: regular, cyclic, predictable menses
- ovulation predictor kits (test in AM)
- basal body temp: core body temp taken before rising in AM
- serum progesterone: >3 ng/mL evidence of recent ovulation
- progesterone challenge: bleeding w/in 1 wk of stopping progesterone
Semen Analysis - What are normal values for the following:
- volume
- pH
- sperm concentration
- motility
- morphology
- WBCs
- volume: > 1.5 mL
- pH: > 7.2
- sperm concentration: > 15 million/mL
- motility: 40%, 32% with rapid forward progress
- morphology: normal > 4%
- WBCs:
What lab tests should be done in infertility work-up to R/O other problems?
-STI screen
-UPT
-TSH
-prolactin (assess pituitary fx)
+/- LH and FSH to assess ovary and feedback loop
Why would a pelvic US be done in infertility work-up?
-rule out anatomic abnormality: fibroids, ovarian cysts, endometrial lining
What is a HSG test?
- tests patency of uterine and fallopian structures
- radiopaque dye injected into uterus under fluoroscopy; normal test will show filling of uterus and tubes with dye
Why would a laparoscopy be used in infertility work-up?
-identify adhesions, endometriosis, structural problems
How is endometrial biopsy used?
- histological criteria are used to date the endometrium within the cycle
- endometrium that lags behind cycle indicates luteal insufficiency
- does not distinguish fertile/infertile
What does the postcoital/Huhner’s test do?
-test quality and receptiveness of ovulatory cervical mucus and sperm tolerance
What is clomid (clomiphene citrate) and how does it work?
- antiestrogenic drug
- increases FH and LSH, which promotes maturation and release of egg (ovulation)
Clomid Dosage
50 mg PO qd x5 days
How does human chorionic gonadotropin work?
- given IM when follicles reach appropriate size for ovulation
- hCG mimics LH surge and causes egg release
How does progesterone work?
-indicates to endometrial lining to stop growth and prepare for implantation
Psychosocial Needs of Couple for Infertility
- counseling
- financial
- adoption
- miscarriage/stillbirth support
What is intrauterine insemination?
- collect semen
- sperm is washed and placed in uterus via catheter
What are the indications for intrauterine insemination?
- male factor
- cervical factor
- unspecified infertility
What is in vitro fertilization?
-eggs fertilized in vitro with embryos transferred to the uterine fundus
What is GIFT (gamete intra-fallopian transfer)?
- placement of both egg and sperm in uterine tube by laparoscopy
- more invasive than IVF
When is GIFT not indicated?
- women with tubal dz
- male factor infertility
What is TET (tubal embryo transfer) or ZIFT (zygote intra-fallopian transfer)?
-in vitro fertilization of embryo via laparoscopy
What are causes of cervical factor infertility?
- infections
- cervical mucus
- hostility toward sperm
What are management options for cervical factor infertility?
- treat infection
- timing of sex
- IVF
- anti-sperm antibody
- conjugated estrogens for inadequate mucus
What are causes of uterine or tubal factor infertility?
- congenital: physical malformation, genetic abnormality, DES exposure in utero
- acquired: endometritis, endometriosis, fibroids/polpys
What are the management options for uterine/tubal factor infertility?
-surgical correction if possible
What are causes of endometrial factor infertility?
- endometritis
- menstrual cycle irregularities
- trauma
What are the management options for endometrial factor infertility?
- treat infx
- surgical
- medication
What are causes of peritoneal factor infertility?
- endometriosis
- adhesions
- distal tubal occlusions
- ovarian cysts
What are the management options for peritoneal factor infertility?
-surgical correction if possible
What are the causes of ovarian/ovulatory factor infertility?
- PCOS
- weight extremes
- hypothalamic
- hypo/hyperthyroidism
- hyperprolactinemia (lactation, tumor, dopamine blocking drugs
What are the management options for ovarian/ovulatory factor infertility?
- mainly pharmacologic
- clomiphene citrate (Clomid)
- menotrophins (hCG)
- metformine/thiazolidinediones (can try for pts with PCOS)
What are causes of male factor infertility?
- varicocele
- azoospermia (no sperm detected)
- oligospermia (decreased sperm count)
- testicular temp
- trauma
What are the management options for male factor infertility?
- azoospermia is untreatable
- surgical correction if indicated
- lifestyle mods (boxer underwear)
