Infertility Flashcards by Alicia Daum

Define Infertility

Failure to conceive after 1 year of unprotected intercourse in women less than 35 years of age and after 6 months in women 35+

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Lifestyle Factors Associated with Increased Risk of Infertility

Environmental &amp; occupational
Toxic effects of tobacco, marijuana
Excessive exercise
Inadequate diet (extreme weight loss or gain)
Advanced age

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Factors Associated with Infertility

Male factor
Ovulatory dysfunction
Tubal damage
Endometriosis
Coital problems
Cervical factor
Unexplained

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Female Factors Associated with Infertility

Cervical
Uterine
Ovarian
Tubal
Peritoneal

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Cervical Factors Associated with Infertility

Stenosis

Abnormality of the mucus-sperm interactions

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Uterine Factor Associated with Infertility

Congenital or acquired defects may affect endometrium or myometrium

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Ovarian Factor Associated with Infertility

Ovulatory dysfunction

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Tubal Factors Associated with Infertility

Abnormalities or damage to fallopian tube

Congenital or acquired

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Peritoneal Factors Associated with Infertility

Anatomic defects

Physiologic dysfunctions

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Types of Physiologic Dysfunctions Associated with Infertility

Infection
Adhesions
Adnexal masses
Endometriosis

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Male Factors Associated with Infertility

Pre-testicular
Testicular
Post-testicular

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Pre-testicular Factor Associated with Infertility

Congenital or acquired diseases of the hypothalamus, pituitary, or peripheral organs that alter the hypothalamic pituitary axis
Ex: prolactinoma

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Testicular Factors Associated with Infertility

Genetic: Klinefelter

Non-genetic: marijuana, radiation, varicoceles

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Post-testicular Factors Associated with Infertility

Congenital or acquired factors that disrupt normal transport of sperm through the ductal system

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Examples of Post-Testicular Factors Associated with Infertility

CF
Chlamydia
Gonorrhea
Trauma
Surgery
Lack of vas deferent on one side

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Evaluation of Infertility

Complete eval performed according to the woman’s menstrual cycle

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History in the Evaluation of Infertility

Copy of previous medical records
Complete medical history questionnaire
Details regarding type of infertility
Hx of previous pregnancies & outcomes
Hx of previous infertility eval/treatment
Female menstrual history, frequency & patterns since menarche
Male medical history of any previous semen analysis
Couple’s history of STDs
Couple’s current medical treatment, reason, & history of allergies
Complete ROS to identify endocrine or immunologic reasons

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Male Medical History in Evaluation for Infertility

Previous semen analysis results
H/O impotence
Premature ejaculation
Change in libido
Trauma
Other relationships with children

Female Medical History in Evaluation of Infertility

Previous femal pelvic surgery
PID
PCOS
Appendicitis
IUD use
Abdominal adhesions
Ectopic pregnancy history
Stress
Depression
Weight changes

Examination of Female Patients for Infertility

Obtain records of BP, pulse, &amp; temp
Calculate BMI
Perform eye exam for exophthalmos
Look for Turner's syndrome
Breast exam
Abdominal Exam
Complete female pelvic exam

Signs/Symptoms of Turner’s Syndrome

Epicanthus
Low setting ears
Webbed neck

Examination of Male Patients for Infertility

Urologist will examine if semen analysis is abnormal
Full GU exam
Testicular size
Varicose veins around testicle
Abdominal exam

Work Up of Infertility

Organized & Thorough
Diagnostics from simplest to complex & invasive
Educate couple it may take 2+ menstrual cycles to determine a cause

Male Work Up of Infertility

Semen analysis
Free & total testosterone levels
Obtain prolactin level in men with low testosterone (Prolactinoma)
Genetic testing with azoospermia (Klinefelters)
Consult to Urology

Semen Analysis

Sperm concentration Motility Morphology Viability

Female Work Up for Infertility

``` Cervical factors: stenosis Uterine factors Endometrial factors Tubal factors Peritoneal factors Ovarian factors ```

Uterine Factors for Infertility

Absence of uterus Vaginal septum Fibroids

Studies for Diagnosis Uterine Factors of Infertility

``` Hysterosalmpingogram (HSG) Pelvic ultrasound Saline infusion sonography (SIS) Hysteroscopy Endometrial biopsy ```

Hysterosalpingogram

Evaluate endometrial cavity | Performed during early follicular phase

Hysterosalpingogram Procedure

Cervix prepped with Betadine Breakaway speculum used Single tooth tenaculum used for traction of uterus Balloon HSG cath or metal cannula with plastic acorn tip

Ultrasound helps in Early Detection of

``` Uterine fibroids Endometrial polyps Ovarian cyst Adnexal masses Endometriosis PCOS Anovulation Lack of corpus luteum ```

Saline Infusion Sonography

Evaluate the uterine cavity & assess tubal potency | Perform during cycle days 6-12

Saline Infusion Sonography PRocedure

Breakaway speculum used Cervix prepped with Betadine Trans-cervical cath with acorn or ballon is placed Saline injected under US view Small amount of air bubble injected to assess tubal patency

Hysteroscope

Direct visualization of endometrial cavity | Uses glycine & sorbitol solutions under constant pressure

2 Most Frequent Tests Used for Tubal & Peritoneal Factors

Hysterosalpingogram | Laparoscopy

Ovarian Factors of Infertility

Ovulation | Ovarian Reserve

Ovulation & Infertility

Progesteron >3 ng/mL indicative of ovulation Sonographic confirmation of follicle rupture BBT charts Amenorrhea, irregular menses or galactorrhea

What labs do we check for amenorrhea, irregular menses, or galactorrhea?

FSH Prolactin Thyroid-stimulating hormone (TSH)

Most Important Prognostic Factors in Female Fertility Workup

Level of ovarian reserve | Age of the female

Treatment of the Couple

Ideal intercourse frequency Avoid lubricants & douches Avoid alcohol, tobacco, & street drugs Offer emotional support

Treatment of Female Partner with Ovulatory Dysfunction

Treat underlying cause Clomiphene citrate (Clomid) IVF & injectable ovulation-inducing agents

Underlying Causes for Ovulatory Dysfunction

Thyroid dysfunction Hyperprolactinemic anovulation: bromocriptine (Parlodel) PCOS: metformin

Treatment of Female Partner with Tubal Disease

Tubal reparative surgery (IVF alternative)

Treatment of Uterine & Pelvic Disease (Endometriosis)

Laparoscopic ablation or laparotomy | Alternatives: ovulation induction with or without intrauterine insemination OR IVF