Infertility Flashcards
definition of infertility by insurance companies
inability to achieve pregnancy after one year of unprotected intercourse
infertility statistics
- 8 mil couples in the US affected
- 1 in 8
- 12% of reproductive age pop
what causes infertility? in a general sense
-disruption of any of the developmental steps between gametogenesis and implantation
ratio of male to female infertility problems
1:1
causes of ovulation defects 5
- changes in GnRH from the hypothalamus
- reduced FSH and LH from the anterior pituitary
- stress and extreme athletic activity
- eating disorders
- thyroid and adrenal hormonal imblances
Polysistic Ovary Syndrome
- symptoms
- problems
- statistics
- excessive growth of face and body hair due to increased androgen hormones
- irregular ovulation and involution
- increased LH relative to FSH
- most common hormonal disturbance in women of child bearing age (1 in 10 in this age group)
abnormalities of the female reproductive tract
- anatomical abnormalities can interfere with transport of the gametes or embryos or blastocyst implantation
- common examples include: endometriosis, chronic pelvic inflammatory disease, tubal obstruction, uterine abnormalities, usually fibroids
types of uterine abnormalities
- uterine fibroids (leiomyomas)
- congenital uterine developmental anomalies (mayer-rokitansky-kutser-hauser syndrome)
- excessive scar tissue (ashermans syndrome)
- excessive scar tissue from STI’s
most male infertility causes
- azoospermia: no sperm cells
- oligospermia: few sperm cells
causes of abnormally low sperm number and low sperm function
- hormonal abnormalities (HPT axis)
- abnormally high testis temperature caused by varicocele in the scrotum (dilated internal spermatic veins)
Aging and infertility in women
- advanced age is the leading risk for infertility in women in the US (over 35)
- by age 40, over half of the ovulated oocytes are aneuploid and unable to support normal embryonic development
- in some women, these losses occur earlier and cause premature ovarian failure (menopause before age 40)
aging and infertility in men
-recent data suggests that men over 50 are more likely to have children with autism and certain other conditions
success rate of IVf is
similair to normal fertile population until mid 30’s
unexplained infertility
-approximately one third of couples go through infertility treatment and are diagnosed with this
first step in treating/diagnosing infertility
-determining whether it is explained or unexplained
when do you do surgery?
- endodetriosis
- ashermann’s
- fibroids
- fallopian tube defects
- varicoceles in males
when do you prescribe FSH?
-if its PCOS
if the sperm are immotile, what do you do?
IVF using ICSI
if the couple has no trouble getting pregnant but the woman has miscarriages, what do you do?
-prescribe progesterone
When do you prescribe GnRH therapy?
-if a defect in GnRH production is found
-if the woman has gone throuhg menopause, what do you do?
-donor egg IVF and adoption
if the infertility is unexplained…
- consider the age of the women first
- if she is young, you would ideally start with clomiphene treatment, probably with IUI, and go on from there to add in more complex, expensive, and invasive treatments if it does not work
- if she is over 35 then going straight to IVF would be the best choice as the fertility of your patient will rapidly decline with time
fertility drugs
- colmiphene citrate
- human menopausal gonadotropins (FSH and LH)
- FSH
- GnRH
- hCG (LH mimetic)
clomiphene citrate
- inexpensive, orally administered
- blocks estrogen receptors in the hypothalamus
- used to regulate ovulation or induce ovulation in women who are anovulatory
human menopausal gonadotropins
- given by daily injection and contains LH and FSH
- requires monitoring of follicle size by ultrasound and blood estrogen levels
- mimis LH surge
- FSH and LH stimulate the ovaries to produce multiple dominant follicles in one cycle
- used for anovulatory women who have have not had success with clomiphene citrate
- used for women with amenorrhea who do not produce enough FSH and LH
FSH
administered by subcutaneous injection
-used for PCOS patients (high LH, low FSH)
GnRH
- can be administered at 90 minute intervals by a special drug delivery pump system
- used for patients that are anovulatory because of abnormalities in both FSH and LH
hCG
- administered by subcutaneous injection at the end of ovulation induction treatment
- monitoring with US and serum estrogen levels are used
- hCG mimics LH
- used to trigger multiple ovulations
intrauterine insemination (IUI)
- used for couples with unexplained infertility, minimal male infertility factors, and women with cervical mucus abnormalities
- usually done in conjunction with ovulatory induction, in which case monitoring is essential
- sperm are first washed to removed surface glycoproteins and seminal proteins - this mimics capacitation
-IVF overview
- ovulation induction using gonadotropins is done to produce multiple eggs
- mature eggs are removed from the ovary and fertilized in vitro by incubation with sperm
- fertilization and early embryonic cleavages are observed in the lab for 2-3 days using a microscope
- embryos that appear healthy with 8 blastomeres are placed into the uterus, unless PGD has been performed, in which case a 5-day embryo (blastocyst) will be implanted
fertilization and embryo culture
- after washing sperm to mimic capacitation, sperm are mixed with oocyte and incubated
- embryologist looks for fertilized oocyte that have two pronuclei, indicating that normal fertilization has occurred
- 2-3 days after mixing sperm and oocyte, the embryos are examined and assessed for the number of blastomeres present (hopefully 8) and overall embryo symmetry and morphology
ICSI
intra cytoplasmic sperm injection
IVF follow up
- smallest number of embryos are transferred to avoid multiple gestations
- if the women is under 35, only one or two high quality embryos are transferred
- if the women is over 40 and has a history of failed IVF cycles, up to 4-5 high quality embryos are transferred
- extra embryos are cryopresevered and saved for future IVF cycles for the same couple - these are the source of major ethical/social/political controversy surrounding stem cell research
key points of IVF
- invasive
- expensive
- produces many more embryos than are used, kept frozen
- ICSI gives highest take-home baby rate but is more expensive and by-passes important steps in fertilization
- ICSI is not the most commonly performed IVF procedure in most US clinics
what comes after normal IVF
- IVF with donor eggs
- adoption
problems/risk with infertility treatments
- multiple births, this increases nearly all medical risks for pregnancy an abnormal fetal development, particularly when delivery is premature
- reduction of multiple pregnancies created ethical issues
- limited access due to high cost (limited to upper middle class couples)
- unknown medical risks, especially for ICSI: too early to have much data, some data shows greatly increased risk of type 2 diabetes
