Infertility Flashcards
What is primary infertility?
pt who has never been able to have a pregnancy
What is secondary infertility?
experience infertility but has had pregnancy in the past
In pts over 35 they are considered to be infertile if…
no pregnancy for 6 mos while attempting to conceive
What is fecundability?
likelihood to become pregnant in any given menstrual cycle
How many couples experience infertility?
25%
Etiology for infertility?
Male factor – 20%
Female factor – 65%
Unexplained/other 15%
Prevention of infertility?
discuss during WWE
Anovulation assoc. with weight extremes
decreased alcohol
avoid vaginal lubricants
avoid scrotal hyperthermia
What are some female factors that can cause infertility?
ovulatory disorders (25%)
Endometriosis Pelvic Adhesions Tubal Blockage Other tubal abnormalities Hyperprolactinemia
What male factors can cause infertility?
endocrine/systemic disorders
Testicular defects in spermatogenesis**
sperm transport disorders
idiopathic
what would make you want to eval for infertility earlier?
if risk of premature ovarian failure, severe endometriosis, known/suspected uterine/tubal disease
What are the 4 key aspects of fertility?
Sperm
Oocyte
Transport
Implantation
What labs should you consider when evaluation for infertility?
hCG, TSH, PRL, total Testosterone, DHEA-S, FSH, LH, estradiol
What should be included in female PE when evaluating for infertility?
Thyroid exam
Assess cervix
Assess for uterine abnormalities
Assess for adnexal masses
What labs can you order to check to see if a woman is ovulating?
Urinary or Sr LH surge assessment
Luteal phase Sr progesterone (day 21)
if anovulatory: thyroid disorder, hyperprolactinemia -day 3 FSH & estradiol
tests to asses ovarian reserve?
U/S for follicular antral follicle count
Antimullerian hormone
Clomiphene challenge test
what other tests can be done to asses female partner?
pelvic US
hysterosalpingography
Laparoscopy/hysteroscopy with dye
What should be included in male partner H&P?
congenital abn.
prior paternity
freq. of intercourse
exposure to toxins
eval of male partner?
semen analysis:
- Count: > 20 mil
- Motility: >50%
- Morphology: >30%
Labs: testosterone, FSH, LH, PRL
Interpretation of semen analysis?
repeat abn. in >4 wks
if repeat abn, refer to: endo, urology, genetic, consifer exposure to toxins
What should you do if semen count is <5 mil?
endocrine eval
possible karyotype
Pt lab results reveal:
Low T, High FSH, High LH, you suspect?
primary hypogonadism
Pt lab results reveal:
Low T, Low FSH, Low LH, you suspect?
secondary hypogonadism
Pt lab results reveal:
Low LH, low sperm count, normal testosterone, you suspect?
possible exogenous steroids
When should you suspect unexplained infertility?
Normal uterine cavity
Bilateral patent tubes
Evidence of ovulation
Normal semen analysis
Tx for infertility in younger couples?
pt education- timed intercourse
lifestyle: BMI, tobacco cessation, diet
Medication options for female factor infertility?
Clomiphene citrate: tx of choice for women <36
Letrozole
Gonadotropins
ADEs of clomiphene citrate?
hot flushes, emotional lability, depression, bloating, visual changes
Letrozole is preferred in women with….
hx of estrogen dependent tumors
ADEs of ovulation induction with gonadotropins?
multiple gestation, ovarian hyperstimulation syndrome, increased risk of ectopic pregnancy
Tx options for women with pelvic factors?
Laparoscopy for endometriosis
Myomectomy in select patients only
Tx options for pts with cervical factors contributing to infertility?
Bypass cervical mucus with IUI
Empiric tx with doxycycline
What are some assisted reproduction technologies?
Intrauterine insemination (IUI)
Intracytoplasmic sperm injection (ICSI)
In vitro fertilization (IVF)
Gamete intrafallopian transfer (GIFT)
Zygote intrafallopian transfer (ZIFT)
Donor oocytes/sperm
indication for IUI?
mild to moderate male factor infertility
preg rate: 10-20%
indication for Intracytoplasmic sperm injection?
severe male factor infertility
(used with IVF)
Sperm individually injected into each oocyte
preg rate: 20%
Describe IVF?
Follicle development monitored by u/s and estradiol levels > oocyte incubated with sperm > embryos transferred into uterine cavity
preg rate: 20%
Describe Gamete intrafallopian transfer?
Egg and sperm placed in fallopian tube
Fertilization occurs in the body
preg rate: 20%
Describe zygote intrafallopian transfer?
Zygote placed into fallopian tube
Fertilization occurs in vitro
‘Natural’ implantation into uterus
preg rate: 30%
What are some other options for infertility?
donor oocytes, donor sperm, surrogacy
___ achieve preg. within 3 yrs in absence of tx
60%
