Infertility Flashcards
What is the definition of infertility?
- Inability of a couple to achieve a clinical pregnancy within 12 months of beginning regular unprotected sexual intercourse
What is primary infertility?
No previous pregnancies
What is secondary infertility?
A couple have previously had a child but now can not
What is fecundability?
The percentage of women exposed to the risk of pregnancy for one menstrual cycle who will subsequently produce a live born infant (Normal 15-28%)
At what age do fecundity rates begin to decrease?
- Small but noticeable decrease at age 31, more pronounced at age 36 and very steep at 40
What are the main categories for the causes of infertility?
- Ovulation disorders (25%)
- Male factors (25%)
- Tubal factors (15%)
Different book says
- Female (65%)
- Male (20%)
- Other (15)
In men who have had infection to the testis or epididymis or who have had reversed vasectomies what may you be more concerned about regarding fertility?
- Antisperm antibodies
What is the chromosomal abnormality found in Turner syndrome?
- 45,XO
What is the pathophysiology behind weight-related anovulation
a) low weight
b) high weight
a) A minimum percentage of body fat is required to maintain ovulatory cycles (typically 22%ish)
- weight reduction leads to disappearance of normal 24h secretory pattern of GnRH resulting in anovulation
b) Overweight - likely due to excess androgen from adipose tissue converting androgens.
- Interferes with normal feedback mechanism in pituitary
What is luteinized unruptured follicle syndrome?
- occurs when the oocyte is retained following the luteinizing hormone surge
- No studies have been done longitudinally to show if this is longstanding or recurring or if affects fertility
What are some symptoms that would make you concerned about hyperprolactinemia?
- Galactorrhea (10-15%)
- Bitemporal hemianopia (if pituitary adenoma)
What are the gonadotrophins?
- Luteinizing hormone
- Follicle stimulating hormone
What is the mechanism behind anovulation in hyperprolactinemia?
- High levels of prolactin inhibit the release of gonadotrophins (LH and FSH) which are required for ovulation to occur
Name 3 methods of determining if ovulation is occuring in a female
1) History: over 90% of women with regular menstrual cycles will ovulate spontaneously
2) Urine LH kit: Urine test which can pick up the mid-cycle LH surge that leads to ovulation
3) Mid-luteal (7-10 days before next cycle) progesterone level: Progesterone is produced by corpus luteum. Therefore levels over 28
Explain how basal body temperature can be used to test for ovulation? What temperature change are you expecting?
- After ovulation the corpus luteum produces progesterone
- Progesterone is pyrogenic and increases body temperature which can be monitored
- 0.5 degree Celsius change after ovulation and during luteal phase
What is a progesterone challenge? What does it test?
- 5 days of oral progesterone, followed by withdrawal
- A bleed following shows that the patient is well estrogenized (estrogen causing endometrial growth) and progesterone inducing it to shed.
How can you induce ovulation in patients with hyperprolactinemia? What is the mechanism?
- You can use a dopamine agonist (bromocriptime, carergoline)
- Dopamine inhibits the secretion of prolactin allowing for ovulation to occur
How can you treat anovulation in patients with polycystic ovarian syndrome?
- First line pharmacologic treatment is with anti-estrogen therapy
- Decreased estrogen -> stops it’s negative feedback on hypothalamus -> higher FSH levels
- Weight loss should be acheived or attempted prior in younger women with ovarian reserve *
- Many will ovulate spontaneously following and increases live-birth rate
How do you treat anovulation in estrogen-deficient women?
- Exogenous gonadotrophins (LH, FSH)
- Monitor follicle growth with U/S
- Exogenous hCG to induce ovulation mid cycle (replaces LH surge)
- Start w low dose to decrease change of multiple pregnancy
What treatment options exist for those with tubal disease looking to become pregnant?
- Tubal surgery
- In vitro fertilization (used more often due to advances in technique)
What is one of the major risks of pregnancy after tubal surgery?
- Higher incidence of ectopic tubal pregnancy
What is azoospermia?
- Medical condition of a man where the semen contains no sperm
Why do you test FSH in a man with azoospermia? What do the results tell you?
1) High FSH: FSH encourages speratogenesis in males, if this is not occurring it will continue to produce more
- This indicates non-obstructive azoospermia
2) Low FSH: Signifies an obstructive azoospermia from a block of the vas deferens or epididymis. Most common in those who have had vasectomy
What is in-vitro fertilization?
- In vitro: performed in test tube, culture plate or elsewhere outside of a living organism
- In this context mixing of egg and sperm occurs outside of the body
What is intracytoplasmic sperm injection? What advantage does it have over IVF?
- Sperm is injected directly into the oocyte.
- In IVF the two are just mixed
- Advantage in being able to treat most male factor infertility problems
When do you start investigating someone for infertility? What can change this?
1) Age under 35: 1 year
2) Age 35+: 6 months
3) Symptoms suggestive of underlying cause: right away
(ex: signs of PCOS, Endometriosis, etc..) you would investigate for suspected cause
