Infertility

Question 1

Within 24 hrs the zygote will go to the 4 cell stage, and then to the 8 cell stage by day 3, then to a proliferative morula stage, and then to a blastocyte by day 5

Question 2

What must happen to a blastocyst for implantation (attachment to the endometrium) to occur?

Answer 2

It must lose its zona pellcuida, aka hatching. The blastocyt attaches from the inner cell mass in humans

Question 3

The embryo heart starts beating at age 5 when the embryo is still in the form of a disc

Question 4

When does an embryo start to be called a fetus?

Answer 4

10 weeks gestation

Question 5

Question 6

What is infertility defined as?

Answer 6

1 yr of unsuccessful attempts to conceive when younger than 35. After 35, 6 months of intercourse without conception defines infertiity

Affects 10-15% couples in the US

Question 7

How much sperm is destoryed in the vagina?

Answer 7

Up to 95% due to the acidity (It takes about 5 minutes for sperm to ascend to the fallopian tubes once in the vagina)

Question 8

How much sperm is destroyed in the cervical canal?

Answer 8

Not much because the cervix produces mucus to protect sperm

Question 9

Where does fertilization most commonly occur?

Answer 9

ampulla of the fallopian tubes

Question 10

What are the most common factors for infertility?

Answer 10

Female factors (60%)

Male factors (40%)

Combined M-F (20%)

Question 11

Where are the most common problems in women?

Answer 11

Tubal and peritoneal (30-40%)- arise primarily from infections, including *Chlymidia* and Gonorrhea

Ovulatory (15%)- PCOS is a big factor

Cervical and Uterine/endometrial (5-10%)

Question 12

What are the main effects of DES?

Answer 12

T-shaped uterus and a small cervical opening that does not have many glands so it cant produce as much mucus

Question 13

How could TB lead to infertility?

Answer 13

It can lead to inflammation of the cervix, causing constriction

Question 14

What are some ways to test for cervical factor?

Answer 14

Cultures to look for infection and protozoa including uroplasma and microplasma (these can cause miscarriages) and vaginosis can cause pre-term delivery

Question 15

What are some types of uterine/endometrial factor?

Answer 15

Anatomical changes (Congenital malformations, (submucosal) fibroids, adhesions)- can lead to miscarriages as well as infertility

Functional abnormalities (endoemtritis, decreased receptivity)

Question 16

What other symptoms are submucosal fibroids associated with besides infertility?

Answer 16

menorrhagia and miscarriages

Question 17

Why would endomterial/uterus/peritoneal inflammation lead to infertility?

Answer 17

Inflammation makes the endometrium/uterus/etc. release some cytokines that pre-activate the sperm to switch its motility from forward motion to side-to-side motion before it reaches the egg and because it doesnt have much energy source (only some mitochondrial in the neck of the tail), will tire the sperm and prevent fertilization

Question 18

T or F. Endometritis is a cause of recurring miscarriages

Answer 18

T. It is still inflammation so it decreases receptivity of the endometrium

Question 19

How is uterine/endometrial factor evaluated?

Answer 19

• transvaginal ultrasound or sonohysterography (insert a catheter TV and inject normal saline to help open up the uterine cavity and outline the contours) for the presence of any abnormalities of fibroids
• Hysteroscopy (surgery with a camera to visualize the cavity)
• Hysterosalpingography (inject radioopaque medium through the medium and look under floroscopy at the uterus). Stops from visualizes any muscle, can only see the contour of the cavity or tubes
• Endometrial biopsy (more rare for fertility purposes, more so for recurrent prgenancy loss related to endometritis)

Question 20

What uterine abnormalities are related to infertility?

Answer 20

Septate and arcuate uterus

dont have infertility in bicornate and unicornate (but may see recurrent miscarriages or pre-term delivery)

Question 21

What are some tubal/peritoneal factors?

Answer 21

Mainly anatomical changes due to DES exposure (causing coarctation of the fimbrial part, raising the risk of ectopic pregnancy), tubal ligation, adhesions (infections, mainly Chylmdia), and endometriosis)

Question 22

Why would endometriosis be disadvantageous to the tubes?

Answer 22

they are cyclically active and can result in bleeding, inflammation, and scarring of the tubes leading to infertility (mild endometriosis can also lead to ectopic pregnancy)

Question 23

How are tubal/peritoneal factors evaluated?

Answer 23

• Hysterosalpingography to show contours of the tubes
• Laparoscopy (camera through the belly-button) with chromospertubation (inject blue-dye to see if the fimbriae are patent are not)
• Sonohysteography has limited use

Question 24

What are some causes of ovarian factor?

Answer 24

• oligo/anovulation
• luteal phase deficiency

Question 25

Why do women with PCOS have luteal phase duration deficiencies?

Answer 25

Because there is crowding of the follicles in the ovarian cortex (some of the follicles are still primary while others are closer to tertiary phase because estrogen is not as high and these older follciles tend to linger and not produce as much progesterone), the lack of progesterone can lead to miscarriage and the lack of early estrogen can lead to inferitlity

The eggs are not to blame, its the follicle!

Question 26

How would you evaulate for ovulatory dysfunction?

Answer 26

Make sure to take an accurate menstrual history (account for age- older and younger are more likely to have variable periods), basal body temp, serum progesterone at about 7 days prior to menses

Or can use urinary LH execretion kits (threshold of 40units/ml indicates that ovulation will occur within 48 hrs),

basal FSH/clomiphene challange test (low FSH is good=good ovarian reserve; high FSH means that estrogen is not being made by the ovaries; most commonly seen in older women or younger women exposed to chemo). Can also test AMH (high AMH= good ovarian reverse)

Oligo-amenorrhea testing

Question 27

Conc might want to be closer to 50mil/Ml

The round cells are white cells. They should not be present and are indicative of male infection (most likely male prostatitis)

Question 28

What pts typically get prostatis?

Answer 28

Either very active or very sedentary men

Question 29

When is retrograde ejaculation most common?

Answer 29

Men who have diabetes because the neck of the bladder will not constrict at the time of ejaculation due to neuropathy

Question 30

What can cause duct obstruction besides vasectomy?

Answer 30

inflammation

Question 31

What causes congential bilateral absence of the vas deferens?

Answer 31

cystic fibrosis- these men will ONLY have prostatic secretions, but will not sperm or seminal vesicle contributions (fructose)

Question 32

Question 33