Infertility

Question 1

What is primary infertility?

Answer 1

pt who has never been able to have a pregnancy

Question 2

What is secondary infertility?

Answer 2

experience infertility but has had pregnancy in the past

Question 3

In pts over 35 they are considered to be infertile if…

Answer 3

no pregnancy for 6 mos while attempting to conceive

Question 4

What is fecundability?

Answer 4

likelihood to become pregnant in any given menstrual cycle

Question 5

How many couples experience infertility?

Answer 5

25%

Question 6

Etiology for infertility?

Answer 6

Male factor – 20%
Female factor – 65%
Unexplained/other 15%

Question 7

Prevention of infertility?

Answer 7

discuss during WWE

Anovulation assoc. with weight extremes

decreased alcohol

avoid vaginal lubricants

avoid scrotal hyperthermia

Question 8

What are some female factors that can cause infertility?

Answer 8

ovulatory disorders (25%)

Endometriosis 
Pelvic Adhesions
Tubal Blockage 
Other tubal abnormalities 
Hyperprolactinemia

Question 9

What male factors can cause infertility?

Answer 9

endocrine/systemic disorders

Testicular defects in spermatogenesis**

sperm transport disorders

idiopathic

Question 10

what would make you want to eval for infertility earlier?

Answer 10

if risk of premature ovarian failure, severe endometriosis, known/suspected uterine/tubal disease

Question 11

What are the 4 key aspects of fertility?

Answer 11

Sperm
Oocyte
Transport
Implantation

Question 12

What labs should you consider when evaluation for infertility?

Answer 12

hCG, TSH, PRL, total Testosterone, DHEA-S, FSH, LH, estradiol

Question 13

What should be included in female PE when evaluating for infertility?

Answer 13

Thyroid exam

Assess cervix

Assess for uterine abnormalities

Assess for adnexal masses

Question 14

What labs can you order to check to see if a woman is ovulating?

Answer 14

Urinary or Sr LH surge assessment

Luteal phase Sr progesterone (day 21)

if anovulatory: thyroid disorder, hyperprolactinemia -day 3 FSH & estradiol

Question 15

tests to asses ovarian reserve?

Answer 15

U/S for follicular antral follicle count

Antimullerian hormone

Clomiphene challenge test

Question 16

what other tests can be done to asses female partner?

Answer 16

pelvic US

hysterosalpingography

Laparoscopy/hysteroscopy with dye

Question 17

What should be included in male partner H&P?

Answer 17

congenital abn.
prior paternity
freq. of intercourse
exposure to toxins

Question 18

eval of male partner?

Answer 18

semen analysis:

• Count: > 20 mil
• Motility: >50%
• Morphology: >30%

Labs: testosterone, FSH, LH, PRL

Question 19

Interpretation of semen analysis?

Answer 19

repeat abn. in >4 wks

if repeat abn, refer to: endo, urology, genetic, consifer exposure to toxins

Question 20

What should you do if semen count is <5 mil?

Answer 20

endocrine eval

possible karyotype

Question 21

Pt lab results reveal:

Low T, High FSH, High LH, you suspect?

Answer 21

primary hypogonadism

Question 22

Pt lab results reveal:

Low T, Low FSH, Low LH, you suspect?

Answer 22

secondary hypogonadism

Question 23

Pt lab results reveal:

Low LH, low sperm count, normal testosterone, you suspect?

Answer 23

possible exogenous steroids

Question 24

When should you suspect unexplained infertility?

Answer 24

Normal uterine cavity

Bilateral patent tubes

Evidence of ovulation

Normal semen analysis

Question 25

Tx for infertility in younger couples?

Answer 25

pt education- timed intercourse

lifestyle: BMI, tobacco cessation, diet

Question 26

Medication options for female factor infertility?

Answer 26

Clomiphene citrate: tx of choice for women <36

Letrozole

Gonadotropins

Question 27

ADEs of clomiphene citrate?

Answer 27

hot flushes, emotional lability, depression, bloating, visual changes

Question 28

Letrozole is preferred in women with….

Answer 28

hx of estrogen dependent tumors

Question 29

ADEs of ovulation induction with gonadotropins?

Answer 29

multiple gestation, ovarian hyperstimulation syndrome, increased risk of ectopic pregnancy

Question 30

Tx options for women with pelvic factors?

Answer 30

Laparoscopy for endometriosis

Myomectomy in select patients only

Question 31

Tx options for pts with cervical factors contributing to infertility?

Answer 31

Bypass cervical mucus with IUI

Empiric tx with doxycycline

Question 32

What are some assisted reproduction technologies?

Answer 32

Intrauterine insemination (IUI)

Intracytoplasmic sperm injection (ICSI)

In vitro fertilization (IVF)

Gamete intrafallopian transfer (GIFT)

Zygote intrafallopian transfer (ZIFT)

Donor oocytes/sperm

Question 33

indication for IUI?

Answer 33

mild to moderate male factor infertility

preg rate: 10-20%

Question 34

indication for Intracytoplasmic sperm injection?

Answer 34

severe male factor infertility

(used with IVF)

Sperm individually injected into each oocyte

preg rate: 20%

Question 35

Describe IVF?

Answer 35

Follicle development monitored by u/s and estradiol levels > oocyte incubated with sperm > embryos transferred into uterine cavity

preg rate: 20%

Question 36

Describe Gamete intrafallopian transfer?

Answer 36

Egg and sperm placed in fallopian tube

Fertilization occurs in the body

preg rate: 20%

Question 37

Describe zygote intrafallopian transfer?

Answer 37

Zygote placed into fallopian tube

Fertilization occurs in vitro

‘Natural’ implantation into uterus

preg rate: 30%

Question 38

What are some other options for infertility?

Answer 38

donor oocytes, donor sperm, surrogacy

Question 39

___ achieve preg. within 3 yrs in absence of tx

Answer 39

60%