Infertility Flashcards
Who warrants a fertility referral?
• Known PCOS
• Women < 35 trying for up to a year of regular
unprotected intercourse
• Women > 35 trying for 6 months of regular
unprotected intercourse
• Hx of pelvic infections or endometriosis
• Donor with known semen analysis problem
Important components of history for a patient presenting with fertility concerns?
o Good menstrual hx: symptoms like breast tenderness/fatigue (symptoms of ovulation)
o Hx of prior pregnancy (primary vs secondary fertility
issues)
o Hx of STDs and tx
o Surgery
o Smoking/drinking/drugs
o Thyroid
o Occupation
o Pelvic pain
o Nipple d/c
o Signs of excess androgens (hirsutism)Male infertility lab work up
Semen analysis (abstinence 2-5 days before test): volume, sperm count, motility, morphology. If anything abnormal refer to reproductive endocrinologists or a urologist
What percentage of infertility is solely male factor and what percentage does male factor contribute?
Male factor solely responsible: 20%
Male factor contributes: 30 - 40 %
Female infertility lab work up
- Ovarian reserve: Day 3 FSH and estradiol (FSH < 10 or estradiol < 80 → indicates good ovarian reserve. If either is elevated should refer to R.E.)
- AMH levels (secreted by early follicles → elevated in PCOS, may be reduced in poor ovarian reserve)
- Progesterone one week prior to menses.
- Thyroid testing – TSH, Free T4 and T3
- Prolactin level
- Total Testosterone
- Pelvic ultrasound
What is ovarian reserve and how is it measured?
Reproductive potential as a function of the number and quality of remaining oocytes.
Measured by:
- Day 3 FSH and estradiol
- Chlomiphene citrate challenge test
- Early follicular phase antral follicle count (via TVS)
- Serum anti mullarian hormone (AMH) level
What is a chlomiphene citrate challenge test (CCCT)?
Clomiphene citrate 100 mg q day during Day 5 - 9
Measures serum FSH before and after (typically Day 3 and Day 10)
Elevated Day 10 FSH suggests decreased ovarian reserve (DOR)
What is an antral follicle count (AFC)?
Sum of the number of follicles in both ovaries as measured by TVS during the early follicular phase
Low AFC is 3 - 10 follicles, associated with poor response to ovarian stimulation and failure to get pregnant
What is serum antimullerian hormone (AMH)>
Gonadotrophin independent, can be measured any day of cycle
Overall lower AMH levels (< 1ng/dL) are associated with poor response to ovarian stimulation, poor embryo quality, and poor pregnancy outcome
What is the post-coital test on cervical mucus?
Cervical mucus checked under a microscope shortly after sex to see if there are sperm
Rarely changes clinical management, so no longer recommended
How are uterine and tubal abnormalities assessed in a fertility work-up?
Hysterosalpingography (HSG) - assesses size and shape of uterine cavity and can show developmental (ie bicornuate uteri) or squired anololoes (ie polyps).
* when used with water or lipid based contrast media can evaluate tubal patency and may provide therapeutic benefit
Sonohysterography - TVS with saline instilled into uterus. Is more accurate in identifying pathology
Transvaginal ultrasonography (TVS) - evaluate for endometriosis
Laparoscopy - direct visualization of reproductive anatomy. Rarely done to assess peritoneal factors of infertility (ie complications from endometriosis).
First step of infertility workup?
Evaluate ovulation
If menstrual hx is grossly abnormal, no further workup needed to diagnose anovulation
Most common causes of ovulatory dysfunction
PCOS Obesity Weight gain or loss Strenuous exercise Thyroid dysfunction Hyperprolactinemia
Serial basal body temperature measurements (BBT)
Record temperature 1st thing every morning (thermometer must go to 1/10th a degree).
Follicular phase expect 97 – 98 degrees typically, then 0.4 – 0.8 degree increase during luteal phase
Period of highest fertility is in the 7 days before the rise in BBT
Need months of data. Tedious. Unreliable.
What serum progesterone level would indicate ovulation and when in the cycle do you draw it?
Progesterone > 3 ng/mL indicates recent ovulation occurred
Draw level 7 days before period expected
