Infertility

Question 1

Infertility

Answer 1

multifactorial with mied etiologies

Question 2

infertility- black and white definition

Answer 2

failure of a couple to conceive after 12 months of regular intercourse without use of contraception in women less than 35yo OR failure to conceive after 6 months of regular intercourse in women 35 years or older

Question 3

fecundability

Answer 3

the probability of achieving pregnancy in one menstrual cycle; it is a more accurate descriptor because it recognizes varying degrees of infertility

Question 4

etiology of infertility diff in each sex?

Answer 4

believed to be roughly equally divided between male and female causes- approx 1/3 of affected couples experience a combined problem

Question 5

fecundability teaches that:

Answer 5

• the possibility of infertility may be suspected after only 6 mos of unprotected intercourse without conception
• decreases over time and with increasing age of the female partner

Question 6

decrease in fecundability with aging likely d/t

Answer 6

decline in both the quantity and quality of the ooctyes

Question 7

Absolutes: infertility occurs when there is a:

Answer 7

• azoospermia (no sperm cells in ejaculate)
• longstanding amenorrhea
• bilateral tubal obstruction

Question 8

Not so absolutes: infertility occurs when

Answer 8

• reduced # of sperm compare to absolute absence (from testicular atrophy, could be the consequence of taking testosterone)
• oligomenorrhea with some ovulatory cycles
• partial tubale obstruction
• intermittent ovulation

Question 9

biggest caveat aside from absolute when’s

Answer 9

an abnormal test result cannot be said to be the cause of infertility in all couple

Question 10

when to start evaluating who

Answer 10

• initiate evaluation after 12 mos of unprotected frequent intercourse in women under 35 w/o risk factors
• initiate eval after 6 mos for women 35- 40
• initiate eval upon presentation despite less than 6 mos for women 40+ years, women with oligomenorrhea/ amenorrhea, women w/ h/o chemo, raditation, or advanced endometriosis, women w/ known or suspected uterine/ tubal dx, and women whose male partner has a h/o groin or testicular surgery, adult mumps, impotence or other sexual dysfunction, chemo/ radiation or h/o subfertility wi/ another partner

Question 11

initial diagnostic eval should include:

Answer 11

complete h&p and PE, eval of both partners performed concurrently, same approach used in both primary and secondary infertility

Question 12

primary infertility

Answer 12

when a woman has never had a successful birth of a child- potentially more ominous dx than secondary

Question 13

secondary infertility

Answer 13

difficulty conceiving after any prior conception with a successful birth

Question 14

infertility eval- what history to ask about (male)

Answer 14

duration of infertility, fertility in other relationships, medical and surgical hx, including testicular surgery and h/o mumps or adult chicken pox, meds, h/o chemo/ radiation, smoke cigs or weed, ETOH use, environmental/ occupational exposures, sexual dysfunction or impotence, frequency of sex, use of lubricants, previous infertility testing/ therapies, and family hx of birth defects, mental retardation or reproductive failure

Question 15

infertility eval- what history to ask about (female)

Answer 15

duration, # and outcome of any prior pregnancies (including ectopic and miscarraiges) with the same or diff partner, any and all gyn hx, menstual hx, changes in hair growth/ body weight/ breast discharge, other medical and surgical hx, meds, h/o chemo/ radiation, smoke cigs or weed, ETOH use, environmental/ occupational exposures, exercise/ dietary hx, frequency of sex and use of lub, previous infertility testing/ therapies, family hx of birth defects, mental retardation or reproductive failure, and any pelvic/ abdominal pain or sx of thyroid dx

Question 16

when do women have the highest chance of getting pregnant?

Answer 16

1- 2 days before ovulation or on the day of ovulation**

Question 17

to get pregnant what has to happen

Answer 17

woman must have sex with a man around the time she ovulates (releases egg from the ovary), then the man’s sperm must swim up the vagina, into the uterus and up the fallopian tubes (they connect the ovaries to the uterus). when the sperm reaches the egg, at least one sperm must eat through the outer casing of the egg and make it inside AKA fertilize this is fertilization. then the egg must secure itself to the wall of the uterus which is called implantation

Question 18

factors affecting fertility (age & weight)

Answer 18

maternal age (biological age more important than chronological age) generally women's fertility begins to decline at 34- risks after: gestational DM, preg- insuced HTN, premature labor, stillbirth and placenta problems
body weight- extremes are associated with altered ovarian function

Question 19

consider ovarian function

Answer 19

• ovulatory dysfunction in 15% of infertile couples and 40% of infertile women
• ovulatory dysfunction can result in mentrual disturbances (oligo/amenorrhea, dysfunctional uterine bleeding) or more subtle disturbances (polumenorrhea, short luteal phase)
• important to discover underlying cause (hyperandrogenism, pituitary tumor, eating disorders, extreme weight loss or exercise, hyperprolactinemia, obesity)

Question 20

consider normal semen analysis parameters

Answer 20

• volume > 1.5 mL
• pH 7.2- 7.8
• count: 15 million per mL or greater
  motility: 32% or greater
• forward progression: greater than 2 (on a scale of 0 to 4, 0 being no movement, 4 being excellent)
• morphology: 30% or greater have normal oval heads, midpiece and tail

Question 21

abnormal semen analysis requires

Answer 21

the test to be repeated in 4- 6 weeks; if time is not critical 3 mos should be allowed to complete a sperm cycle

Question 22

if semen parameters are normal

Answer 22

no further male evaluation is necessary unless infertility persists

Question 23

factors affecting infertility (smoking)

Answer 23

• shown to be reproductive toxin in men and women
• reduces fertility in women, increases rate of spontaneous abortion, and increases incidence of abruptio placentae, placenta previa, bleeding during pregnancy, and premature rupture of placental membranes
• women who smoke generally go through earlier menopause by 1- 5 years
• tobacco decreases sperm motility and density

Question 24

factors affecting infertility (alcohol)

Answer 24

• ETOH- known human teratogen, embryotoxic
• any degree of etoh intake can decrease chances of conception
• shown to reduce ability to conceive in dose- dependent fashion
• 2+ drinks per day associated with spontaneous abortion

Question 25

factors affecting fertility ( caffeine, recreational drugs)

Answer 25

caffeine- dose dependent relationship of more than one serving of caffeine has been confirmed to be detrimental fertility
recreational drug use- combined effects of substances of abuse may be additive with those related to etoh consuption and cig smoking

Question 26

factors affecting fertility (environmental hazards and psychological stess)

Answer 26

environmental hazards- many toxins (lead, mercury, organic solvents) encountered by women may affect reproductive health by decreasing fertility or lead to spontaneous abortion, fetal malformation, or developmental abnormalities
psychological stress- no adequate studies proving stress causes infertility

Question 27

medications causing ovulatory dysfuntion

Answer 27

• estrogen- progestin contraceptives
• progestins
• antidepressant and antipsychotic drugs
• corticosteroids
• chemo agents

Question 28

WHO classification of anovulation*

Answer 28

class 1-  hypogonadotropic hypogonadal anovulation (hypothalamic amenorrhea) (low) these women have low or low- normal serum follicle stimulating hormon (FSH) concentrations and low GnRH or pituitary unresponsiveness to GnRH
class 2- normogonadotrpic normoestrogenic anovulation (normal) these women secrete normal amts of gonadotropins and estrogens. BUT FSH secretion during follicular stage of cycle is subnormal- this includes women with PCOS
class 3- hypergonadotropic hypoestrogenic anovulation (high) the primary cases are premature failure (absence of ovarian follicles d/t early menopause) and ovarian resistance (follicular form)
hyperprolactinemic anovulation- these women re anovulatory bc hyperprolactinemia inhibits gonadotropin and therefore estrogen secretion; they may have regular anovulatory cycles but more have oligomenorrhea or amenorrhea. Serum gonadotropins usually normal