Infertility Flashcards
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+
Lifestyle Factors Associated with Increased Risk of Infertility
Environmental & occupational Toxic effects of tobacco, marijuana Excessive exercise Inadequate diet (extreme weight loss or gain) Advanced age
Factors Associated with Infertility
Male factor Ovulatory dysfunction Tubal damage Endometriosis Coital problems Cervical factor Unexplained
Female Factors Associated with Infertility
Cervical Uterine Ovarian Tubal Peritoneal
Cervical Factors Associated with Infertility
Stenosis
Abnormality of the mucus-sperm interactions
Uterine Factor Associated with Infertility
Congenital or acquired defects may affect endometrium or myometrium
Ovarian Factor Associated with Infertility
Ovulatory dysfunction
Tubal Factors Associated with Infertility
Abnormalities or damage to fallopian tube
Congenital or acquired
Peritoneal Factors Associated with Infertility
Anatomic defects
Physiologic dysfunctions
Types of Physiologic Dysfunctions Associated with Infertility
Infection
Adhesions
Adnexal masses
Endometriosis
Male Factors Associated with Infertility
Pre-testicular
Testicular
Post-testicular
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
Testicular Factors Associated with Infertility
Genetic: Klinefelter
Non-genetic: marijuana, radiation, varicoceles
Post-testicular Factors Associated with Infertility
Congenital or acquired factors that disrupt normal transport of sperm through the ductal system
Examples of Post-Testicular Factors Associated with Infertility
CF Chlamydia Gonorrhea Trauma Surgery Lack of vas deferent on one side
Evaluation of Infertility
Complete eval performed according to the woman’s menstrual cycle
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
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, & 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
