infertility Flashcards

1
Q

What are the types of infertility

A

primary: has never had a child before
secondary: has had a child prior
- both require women 35+ unable to conceive for 6+ months

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2
Q

What is fecundability

A

Likelihood you will get pregnant in any menstrual cycle

typically 20-25%

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3
Q

85% of couples will get pregnant with

A

regular, unprotected sexual intercourse

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4
Q

Infertility is MC

A
female factor (65%) 
male only 20%, and 15% unexplained
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5
Q

What are ways you can prevent infertility

A

Discuss fertility and oocyte cryopreservation at WWE
Anovulation is associated with weight extremes
Tobacco/recreational drug cessation
decrease alcohol
avoid vaginal lubricants
avoid scrotal hyperthermia

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6
Q

Factors contributing to female infertility include

A
Ovulatory d/o: PCOS, hyperPRL, ovarian failure, low weight, excess exercise 
Endometriosis 
Pelvic adhesions 
Tubal blockage (STD, PID) 
HyperPRL
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7
Q

Factors contributing to male infetility include

A

Defects in spermatogenesis*
Idiopathic
Sperm transport d/o
hypogonadotropic hypogonadism

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8
Q

Initiate infertility evaluation earlier IF

A

FHx of premature ovarian failure, severe endometriosis, or known/suspected uterine or tubal disease

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9
Q

What are the 4 key aspects of fertility

A

Sperm
Oocyte
Transport
Implantation

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10
Q

Labs helpful in infertility evaluation include

A
hCG 
TSH
PRL
total T
DHEA
FSH/LH 
estradiol
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11
Q

Female infertility PE work up should include

A

thyroid exam

assessment of cervix, uterine abnormalities, and adnexal masses

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12
Q

When evaluating the female for infertility, I want to ensure

A
Menstrual cycle is normal (good Hx) 
Ovulation occurring (urine/serum LH surge test/check serum progesterone at day 21 in Luteal phase)
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13
Q

If a woman is anovulatory, you should

A

Evaluate for thyroid d/o, and hyperPRL
Get additional labs- day 3 serum FSH and estradiol
FSH high & Estradiol low= Ovarian failure
FSH low-norm & Estradiol low= hypo or pit failure

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14
Q

What tests assess ovarian reserve

A

US for follicular antral follicle count
Antimullerian hormone
Clomiphene challenge test

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15
Q

What diagnostic test has the added benefit of being therapeutic for women

A

Hysterosalpingography; some women get pregnant after doing this, but that’s just a plus
Laparoscopy/hysteroscopy with dye can also be therapeutic!

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16
Q

Laparoscopy/hysteroscopy with dye can be used to evaluate

A

endometriosis
prior pelvic infection
prior ectopic

17
Q

Normal semen analysis results are

A

Count: 20+ million/mL
Motility: >50%
Morphology: >30% normal
no sex 3 days prior to test. must eval semen 1-2 hrs after collection

18
Q

Male labs to get for infertility evaluation include

A

testosterone (if low, order PRL)
FSH/LH
PRL

19
Q

If semen analysis comes back abnormal

A

repeat in 4 weeks
further evaluate: endocrine, urological, genetic
consider toxin exposure
If count <5 million, do an endocrine evaluation or karyotype

20
Q

What do different lab levels in men indicate

A

Low T, High FSH/LH: Primary hypogonadism
Low T, Low FSH/LH: Secondary hypogonadism
Low LH, low sperm count, Normal T: patient may be taking exogenous steroids

21
Q

Unexplained normal findings that require referral to infertility specialist include

A

normal uterine cavity
bilateral patent tubes
evidence of ovulation
normal semen analysis

22
Q

What patient education can you give younger couples having difficulty conceiving

A

Timed intercourse! make sure they understand ovulation

Lifestyle mod- BMI, Tobacco cessation, Diet

23
Q

What two meds can be taken by women to assist fertility

A

Comiphene (clomid)

Letrozole (femara)

24
Q

What is Clomid

A

a SERM that inhibits negative feedback of estrogen and stimulates the ovaries to release more eggs
1st choice for women <36 w/ oligomenorrhea or amenorrhea w/ normal FSH (aka PCOS pts)
8% twin gestation rate!

25
ADE of Clomid include
``` hot flashes emotionally labile depression bloating visual changes -aka, estrogen s/e! ```
26
What is Letrozole
an Aromatase inhibitor; reduce estrogen conversion | Good for women with a history of estrogen dependent tumors because you get way less estrogen than clomid
27
What are indications for using Gonadotropins to induce ovulation
``` when using WITH IUI (intrauterine insemination) -human Menopause Gonadotropin (hMG) Recombinant FSH (rFSH) ```
28
ADE of gonadotropins include
multiple gestation ovarian hyperstimulation syndrome high risk ectopic pregnancy
29
If infertility is 2/2 a pelvic factor, what interventions can you apply
endometriosis: Laparoscopy | Myomectomy ONLY if: recurrent abortion, repeat implant failure, submucosal leiomyoma distorting endometrial cavity
30
If infertility is 2/2 cerivcal factors, what can you do
IUI to bypass cervical mucus | Empiric Tx with Doxycycline
31
Available ART (assisted reproductive technologies) include
``` IUI (artificial insemination) ICSI (intracytoplasmic sperm injection- w/ IVF) IVF GIFT (gamete intrafallopian transfer) ZIFT (zygote intrafallopian transfer Donor oocytes or sperm ```
32
Describe IUI
Good for mild-mod male factor infertility (less motile sperm) Sperm are washed (remove prostaglandins, bacteria, and protein) Sperm injected into uterus transcervically 10-20% pregnancy rate
33
Describe ICSI
Good for severe male infertility Used with IVF Sperm individually injected into oocyte 20% pregnancy rate
34
What is IVF
-Monitor follicle development by US and estradiol levels -When follicle is mature, retrieve oocytes before ovulation (transvaginal aspiration) -Incubate oocyte with sperm for IVF (with ICSI) -1-3 Embryos transferred to uterine cavity thru cervix on day 3-5 after getting oocyte -Supplement progesterone through 10 weeks gestation if conception happens 20% pregnancy rate
35
Describe GIFT
``` egg and sperm are placed in the fallopian tube fertilization occurs in the body requires laparoscopy 25% pregnancy rate -Good for some very religious couples ```
36
Describe ZIFT
Zygote is placed into fallopian tube Fertilization is in vitro, but natural implantation occurs Rewuires laparoscopy 30% pregnancy rate
37
What is surrogacy
your own egg/sperm are implanted into another woman to carry. state specific, and VERY expensive
38
Prognosis of infertility with UNdiagnosed etiology
60% achieve pregnancy w/in 3 years without Tx
39
What is a possible complication of infertility Tx (clomid)
Clomiphene citrate increases the rate of cervical cancer when used >12 cycles LIMIT to 6 cycles!