infertility Flashcards
What are the types of infertility
primary: has never had a child before
secondary: has had a child prior
- both require women 35+ unable to conceive for 6+ months
What is fecundability
Likelihood you will get pregnant in any menstrual cycle
typically 20-25%
85% of couples will get pregnant with
regular, unprotected sexual intercourse
Infertility is MC
female factor (65%) male only 20%, and 15% unexplained
What are ways you can prevent infertility
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
Factors contributing to female infertility include
Ovulatory d/o: PCOS, hyperPRL, ovarian failure, low weight, excess exercise Endometriosis Pelvic adhesions Tubal blockage (STD, PID) HyperPRL
Factors contributing to male infetility include
Defects in spermatogenesis*
Idiopathic
Sperm transport d/o
hypogonadotropic hypogonadism
Initiate infertility evaluation earlier IF
FHx of premature ovarian failure, severe endometriosis, or known/suspected uterine or tubal disease
What are the 4 key aspects of fertility
Sperm
Oocyte
Transport
Implantation
Labs helpful in infertility evaluation include
hCG TSH PRL total T DHEA FSH/LH estradiol
Female infertility PE work up should include
thyroid exam
assessment of cervix, uterine abnormalities, and adnexal masses
When evaluating the female for infertility, I want to ensure
Menstrual cycle is normal (good Hx) Ovulation occurring (urine/serum LH surge test/check serum progesterone at day 21 in Luteal phase)
If a woman is anovulatory, you should
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
What tests assess ovarian reserve
US for follicular antral follicle count
Antimullerian hormone
Clomiphene challenge test
What diagnostic test has the added benefit of being therapeutic for women
Hysterosalpingography; some women get pregnant after doing this, but that’s just a plus
Laparoscopy/hysteroscopy with dye can also be therapeutic!
Laparoscopy/hysteroscopy with dye can be used to evaluate
endometriosis
prior pelvic infection
prior ectopic
Normal semen analysis results are
Count: 20+ million/mL
Motility: >50%
Morphology: >30% normal
no sex 3 days prior to test. must eval semen 1-2 hrs after collection
Male labs to get for infertility evaluation include
testosterone (if low, order PRL)
FSH/LH
PRL
If semen analysis comes back abnormal
repeat in 4 weeks
further evaluate: endocrine, urological, genetic
consider toxin exposure
If count <5 million, do an endocrine evaluation or karyotype
What do different lab levels in men indicate
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
Unexplained normal findings that require referral to infertility specialist include
normal uterine cavity
bilateral patent tubes
evidence of ovulation
normal semen analysis
What patient education can you give younger couples having difficulty conceiving
Timed intercourse! make sure they understand ovulation
Lifestyle mod- BMI, Tobacco cessation, Diet
What two meds can be taken by women to assist fertility
Comiphene (clomid)
Letrozole (femara)
What is Clomid
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!
ADE of Clomid include
hot flashes emotionally labile depression bloating visual changes -aka, estrogen s/e!
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
What are indications for using Gonadotropins to induce ovulation
when using WITH IUI (intrauterine insemination) -human Menopause Gonadotropin (hMG) Recombinant FSH (rFSH)
ADE of gonadotropins include
multiple gestation
ovarian hyperstimulation syndrome
high risk ectopic pregnancy
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
If infertility is 2/2 cerivcal factors, what can you do
IUI to bypass cervical mucus
Empiric Tx with Doxycycline
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
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
Describe ICSI
Good for severe male infertility
Used with IVF
Sperm individually injected into oocyte
20% pregnancy rate
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
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
Describe ZIFT
Zygote is placed into fallopian tube
Fertilization is in vitro, but natural implantation occurs
Rewuires laparoscopy
30% pregnancy rate
What is surrogacy
your own egg/sperm are implanted into another woman to carry.
state specific, and VERY expensive
Prognosis of infertility with UNdiagnosed etiology
60% achieve pregnancy w/in 3 years without Tx
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!
