INFERTILITY Flashcards
definition of infertility
failure to conceive (regardless of cause) after 1 year of unprotected intercourse in women less than 35 years of age, and after 6 months in women 35 years and older
Infertility = failure to conceive (regardless of cause) after ______ of unprotected intercourse in women less than _________ of age, and after _______ in women older than _____
1 year in women < 35 years
6 months in women 35+
the probability of achieving a pregnancy in one menstrual cycle
fecundability
Studies demonstrate that the large majority (80 to 90 percent) of apparently normal couples will conceive within the
first year of attempted conception
LIFESTYLE FACTORS ASSOCIATED WITH INCREASED RISK OF INFERTILITY
- Environmental and occupational (radiation, exposure to heavy metals)
- Toxic effects of
⦁ Tobacco
⦁ Marijuana - Excessive exercise
- Inadequate diet
- Extreme weight loss or gain – increased BMI
- Advanced age
- also with work shift fluctuations
FACTORS ASSOCIATED WITH FERTILITY
⦁ Male factor—26% ⦁ Ovulatory dysfunction—21% ⦁ Tubal damage—14% ⦁ Endometriosis—6% ⦁ Coital problems—6% ⦁ Cervical factor—3% ⦁ Unexplained—28%***
most common factor associated with fertility
unexplained**
then male factor….
⦁ Fecundability rates ________ in younger women
⦁ Fecundability rates _______ in older women
higher in younger women
lower in older women
Counseling a 40 y/o women to wait a year before seeking fertility services is inappropriate
she already doesn’t have much time; don’t waste more time by telling her to try another few months to a year…go ahead and refer to fertility clinic
FEMALE FACTORS CAUSING INFERTILITY
- Cervical: stenosis, scarring or abnormality of mucus-sperm interaction
- Uterine: congenital or acquired defects may affect the endometrium or myometrium
- Ovarian: ovulatory dysfunction = an alteration in frequency & duration of menstrual cycle
- Tubal: abnormalities or damage to fallopian tube; congenital or acquired
- Peritoneal: anatomic defects or physiologic dysfunctions (ex: infection, adhesions, adnexal masses)
oligoovulation =
anovulation =
infrequent ovulation
absent ovulation
Infrequent ovulation (oligoovulation) or absent ovulation (anovulation) results in infertility because an oocyte is not available every month for fertilization.
WHO CLASS I
low FSH & low estradiol
due to decreased hypothalamic secretion of GnRH or pituitary unresponsiveness to GnRH
WHO CLASS II
normogonadotropic normoestrogenic anovulation = normal amounts of GnRH and estrogen, but FSH secretion is subnormal.
PCOS is class II - some ovulate occasionally
WHO CLASS III
hypergonadotropic hypoestrogenic anovulation = premature ovarian failure - either due to early menopause –> absence of ovarian follicles, or ovarian resistance. GnRH is high, estrogen is low
Hyperprolactinemic Anovulation
hyperprolactinemia inhibits GnRH and therefore estrogen secretion is inhibited.
age & ovaries
- female age = important factor in infertility; as the quantity & quality of oocytes decreases with age
- females are born with 1-2 million viable ovarian follicles. These follicles decrease with age; by puberty, about 300,000 follicles remain
- as the woman ages, the remaining oocytes left are of poorer quality
primary cause of tubal factor infertility
PID**
Salpingitis Isthmica Nodosa
diverticulosis of the fallopian tube
Leiomyomata
uterine fibroids
- most common cause for hysterectomy
- 5x more common in African americans
most are asymptomatic, but most common presentation = bleeding - menorrhagia, dysmenorrhea
abdominal pressure/pain
PRIMARY TESTICULAR DEFECTS IN SPERMATOGENESIS
- majority =
idiopathic dysspermatogenesis = defect in spermatogenesis without an identifiable cause
- the majority of infertile men who have abnormalities in sperm number, morphology, and/or motility = there is no identifiable cause
Diagnostic testing is unnecessary if a couple has not attempted to conceive for at least
1 year
Tests done sooner if women >35 years old
Complete infertility evaluation is performed according to the _______________
woman’s menstrual cycle
urologist will examine male patient if the
semen analysis is abnormal
Educate couple that may take up to ______ menstrual cycles before a cause is found
2
SEMEN ANALYSIS
⦁ Looks at sperm concentration, motility, morphology, and viability
- WHO semen analysis parameters
⦁ Volume – 2-5 ml
⦁ pH level – 7.2-7.8
⦁ Sperm concentration – 20 million or greater
⦁ Motility – 50% forward progression
⦁ Morphology – Normal sperm (>4%)
⦁ White blood cells – Fewer than 1 million cells/μL
Obtain prolactin level in men with low
testosterone
in men with low testosterone levels = obtain
prolactin levels
cervical factors
cervical stenosis = diagnosed during speculum exam
uterine factors
absence of uterus, vaginal septum, fibroids = diagnosed with physical exam
⦁ vaginal septum - which is indicative that they probs have a uterine septum
Most frequently used tool to evaluate endometrial cavity
hysterosalpingogram
HYSTEROSALPINGOGRAM
Most frequently used tool to evaluate endometrial cavity
- Should be performed during early follicular phase
- Procedure
⦁ Cervix is prepped with Betadine
⦁ A breakaway speculum is used
⦁ Single tooth tenaculum is used for traction of the uterus
⦁ A balloon HSG cath or a metal cannula with a plastic acorn tip
- insert dye into uterus - see if any obstructions are preventing dye from going to fallopian tubes or ovaries
downsides = exposure to radiation & contrast
HSG can help find:
Structural abnormalities of the uterus
Blockage in the fallopian tube(s)
Scar tissue in the uterus or fallopian tubes
Uterine fibroids, tumors, polyps, or adhesions
PELVIC ULTRASOUND
- allows a more precise evaluation of the position of the uterus within the pelvis
- helps with early detection of ⦁ uterine fibroids ⦁ endometrial polyps ⦁ ovarian cysts ⦁ adnexal masses ⦁ endometriomas
positives = easy, cheap, and no radiation!
saline infusion sonography
- inexpensive way to evaluate the uterine cavity & assess tubal patency
- should be performed during cycle days 6-12
- procedure
⦁ Breakaway speculum is used
⦁ Cervix is prepped with Betadine
⦁ Transcervical cath with acorn or balloon is placed
⦁ Saline is injected under ultrasonic view
⦁ Small amount of air bubbles are injected to assess tubal patency
hysteroscopy
- gives direct visualization of endometrial cavity
- can be done in office under local anesthesia
- uses glycine & sorbitol solutions under constant pressure using an automatic pump
- operative hysteroscopies are done in the OR - use scissors, cautery, lasers
Patients 35 years and older a ______________challenge test is most commonly used
clomiphene citrate
2 most frequent tests used for tubal & peritoneal factors
⦁ Hysterosalpingogram
⦁ Laparoscopy = not part of routine infertility evaluation; only used when abnormalities are found on ultrasound or HSG
________ and ________ are the most important prognostic factors in fertility workup
Level of ovarian reserve
age of the female
⦁ hyperprolactinemic anovulation = treat with
bromocriptine
rx treatment for infertility
Clomiphene citrate (clomid) = estrogen modulator - induces ovulation by stimulating GnRH.
azospermia
semen has no sperm
men with azoospermia, treatment =
none!
first test for men
sperm analysis
can then do blood tests & ultrasounds, etc.
INITIAL TESTS FOR WOMEN
⦁ Ovulation kits = Urine LH test
⦁ FSH, Prolactin, TSH
⦁ Hysterosalpingogram
- Hysteroscopy and laparoscopy only used if abnormalities or no identifiable cause is found
