Infertility Flashcards
infertility definition
no pregnancy after 1 year of unprotected well timed intercourse
fecundability
probability of pregnancy in a single menstrual cycle
fecundity
probability of live birth in a single menstrual cycle
fertile window
6-day interval ending on the day of ovulation
when is the highest fecundity?
w/i 2 days of ovulation
what can maximize the likelihood of conception?
increasing frequency of intercourse beginning soon after cessation of menses and continuing to ovulation
home ovulation monitoring is only recommended for who?
- pts w/ regular cycles
- only accurate 50% of the time
fecundability (prob. of pregnancy per month for fertile couples planning to conceive) for
- daily intercourse
- alternate days
- once a week
- daily: 37%
- alternate: 33%
- once/week: 15%
optimal frequency of intercourse
- every 1-2 days but factor in patient stress
- cycles days 10-20 probably hit the fertile window in most cases
lubricants that are ok
- mineral oil
- canola oil (WUT??)
- hydroxyethylcellulose - based lubricants (Pre-seed, ConveivEase)
lubricants that are not ok
- olive oil
- salive
- astroglide
- KY
how does BMI effect fertility?
- BMI > 35 can double time to pregnancy
- BMI < 19 can quadruple time to pregnancy
lifestyle factors that effect fertility
- smoking increases infertility by 60%
- alcohol > 2 drinks/day increases infertility by 60%
- drugs can increase infertility 70%
- toxins at work can increase infertility 40%
- caffeine > 250mg daily can decrease pregnancy rates (controversial)
recommended folic acid
400 mcg to reduce NTDs
effects of smoking
- OR of infertility is 1.6
- menopause occurs 1-4 yrs earlier
- increases risk of miscarriage
- decreases sperm density, motility and morphology - but no definite decrease in male fertilty
what factors make up fertility evaluation?
- H&P
- assessment of ovulation
- ovarian reserve testing
- uterine abnormalities
- tubal patency
- male fertility testing
- optimization of medical conditions and medications
H&P for fertility
- duration
- menstrual hx
- pregnancy hx
- gyn hx
- previous method of contraception
- coital frequency and sexual dysfunction
- PSH
- PMH
- meds
- fam and social hx
PE for fertility
- vitals
- thyroid
- breasts
- signs of androgen excess
- pelvic exam
what accounts for 40% of infertility in women?
-ovulatory dysfunction (MC is PCOS)
evaluation of ovulation
- hx: regular periods is a good indication of ovulation
- are they using home-checking methods?
lab test for ovulation
- serum progesterone
- get 1 week before expected onset of menses
- if > 3ng/mL presumed ovulation
meds that can induce ovulation
- clomiphene citrate (clomid)
- letrozole (femara)
- gonadotropins (follistim, gonal-F)
MoA of clomiphene citrate
- selective E receptor modulator
- interrupts the negative feedback b/w estradiol and FSH
- FSH increases, facilitating follicle growth and ovulation
MoA of letrozole
- aromatase inhibitor, blocks production of estradiol
- also interrupts the negative feedback b/w estradiol and FSH
- off label
tx for pts resistant to meds
- gonadotropins
- ovarian drilling
what is ovarian reserve
- reproductive potential as a function of the number and quality of remaining oocytes
- gives a sense of how quickly a pt is reproductively aging
evaluation of ovarian reserve
- cycle day 3 FSH and estradiol
- day 3 antral follicle count by US
- serum AMH level
when is the only time you can interpret FSH?
if estradiol is low
what is the antral follicle count
- sum of antral follicles in both ovaries
- low count is associated w/ poor response to ovarian stimulation
serum AMH level
- AMH is produced by granulosa cells of early follicles
- relatively consistent levels during menstrual cycle
low AMH (< 1-2 nl/ml) is associated with what?
- poor response
- poor embyro quality
- poor pregnancy outcomes in IVF
tx for low ovarian reserve
- not possible to reserve process
- worse response to all types of tx offered
- therapy aimed at increasing chance of pregnancy each month
- donor oocyte or embry
tubal disease
-obstructed fallopian tubes block egg and sperm from ever meeting
RFs for tubal disease
- hx of STI (esp. chlamydia)
- hx of pelvic surgery
- hx of ectopic pregnancy
- hx of appendicitis
processes to check for tubal patency
- hysterosalpingogram
- laparoscopy w/ chromopertubation
tx for tubal obstruction
- rarely gets surgery
- more often use in vitro
evaluation to check for uterine abnormalities
- HSG to look at size and shape of uterine cavity, developmental or acquired anomalies
- sonohysterography to look for polyps or fibroids
- hysteroscopy: definitive for diagnosis and tx of intrauterine pathology
male factor is responsible for infertility how often?
about 20% of cases but is a contributor to about 30-40% of cases
factors of a semen analysis
- volume
- concentration
- motility
- morphology
- total motile count
tx for male factor infertility
- referral to urology
- hormone testing
- if counts are minimally decreased: intrauterine insemination
- counts very low: IVF
indications to refer
- trying over 12 mos
- trying over 6 mos if female > 35
- abnl semen analysis
- irregular periods
- suspect PCOS or tubal blockage
- no success after 3 cycles of clomid
