infertility Flashcards
Primary Infertility
When a woman is unable to ever bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth she would be classified as having primary infertility.
definition of infertility
A woman who is unable to achieve pregnancy after 12 months or more of unprotected intercourse or inseminations.
secondary infertility
“When a woman is unable to bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous ability to carry a pregnancy to a live birth, she would be classified as having secondary infertility
Female Factors that can play into infertility
- Ovulatory status?
(Think PCOS) - Tubes open (endometriosis? Hx of PID?)
Fertilization happens in the fallopian tubes
Think lovers lane (emergency appendectomy can cause this - Scar tissue?
- Egg quality? –> evaluate family hx
- Uterine anatomy?
male factors that influence fertility
- Count, Motility, Morphology?
- Sexual dysfunction?
- Medications?
- Developmental? (XXY, cryptorchidism?)
social factors that influence
- Seen in different ethnicities where sex is a taboo
- Timing of intercourse or ovulation?
- Use of lubricants?
- Smoking, drugs?
what can affect ovulation status
high stress in sxs nervous system
PCOS
Tubes open
emergency appendectomy can lead to issues with fallopian tubes
hx of STI
what lifestyles can affect sperm
firefighters
heavy equipment
thinking about circadian rhythms
having intercourse outside of ovulatory cycle
environmental factors that can affect fertility
- BPA?
- Mercury?
- Chemical Exposure? Agent orange
most common birth defect that can lead to infertility in males
Cryptorchidism = most common birth defect
also more likely to devlope testicular cancer
formal semen analyses involves
dissecting the sperm and looking at the different components
head of the sperm contains
contains the chromosomes and is surrounded by an acrosome (contains the enzymes required to penetrate the egg)
mid piece of the sperm contains
contains the mitochondria which supplies the energy to reach the egg
cycle day three labs
third day of the period looking at FSH and estradiol
brain is secreting and if it is ver loud (high) it is trying to scream at the ovaries
AMH what does it mean
Anti-Mullerian Hormone
present in all of us
this is the chatter at the ovarian level
the higher the AMH the better (1-2)
levels at 3 think too much chatter–> PCOS
.8 or .5 think not enough chatter, perhaps this is a older patient
what other tests should be done in a work up for infertility
- TSH (Thyroid Stimulating Hormone)
- Prenatal Labs/CBC/Vit D/Prolactin
- Fasting Blood Sugar/Free and Total Testosterone
- Chromosome Analysis/Genetic Screening
- Ultrasound –> look at lining of the uterus
- SIS (Saline Infusion Sonogram) or HSG (Hysterosalpingogram)
Chromosome Analysis/Genetic Screening
looking for micro deletions that can effect sperm
SIS (Saline Infusion Sonogram) or HSG (Hysterosalpingogram)
can be used for
done in office with saline, pushed into the uterine cavity to make sure there are no fibroids or polyps and checking for fallopian patency
male diagnostic tests for infertility
- FSH and Estradiol
- TSH
- Semen Analysis
- Chromosome Analysis
what would we see in tests for PCOS
in labs or ULS
High testosterone to estrogen ratio = random or anovulatory cycles. Increased FBG and fasting insulin.
1. String of pearls seen on US
Hypothalamic Amenorrhea (HA) is seen in this population and with a decrease in this hormone
Hypothalamus does not produce GnRH = anovulatory cycles.
1. Seen in female athletes
Egg Quality/Decreased Ovarian Reserve (DOR) is reflected in these tests
High FSH/Estradiol, low AMH levels
uterine anomalies that can cause infertility
Fibroids
uterine anomaly
types of fibroids
Subserosal vs Intramural vs Submucosal
1. Polyp present?
uterine abnormalities that can affect infertility
- Septums can be repaired
2. Diagnosed on HSG, can confirm on MRI if needed
MCC of pelvic & Fallopian Tube Adhesions
Old Chlamydia infection
other causes of pelvic & Fallopian Tube Adhesions
Old PID, previous surgery, or endometriosis
Old Chlamydia infection
Surgery unhelpful in most cases
surgery for pelvic and fallopian tube adhesion surgery success
- Success in youngest (<34) patients
- 50% of success within 2 years
- Next 50% within 11 years
Adhesions reform!!! (in anyone who has had abdominal surgery)
best option for a pt with endometriosis
- Tell her to freeze her eggs b/c endometriosis is toxic
normal semen
volume, active motility
i. 2 cc volume
ii. 40 million/cc count
iii. 40% active motility
iv. 60% normal shapes/morphology
Mild male factor
count of good sperm
5 -20 million total motile “good-looking” sperm
Severe male factor
Good looking” sperm =
< 5 million total motile “good-looking” sperm
Good looking” sperm = Volume x Count x Active x Normal shapes
Goal ≥ 20 “good-looking” million in sample
how much of the sperm are lost in the vagina
Half of the sperm are lost in the vagina itself. Then they have to make their trek up 8-10 cm further and then pick door 1 or 2 depending on which side is ovulating
remediable causes of sperm decrease
Scrotal Heat – illness, hot tubs, laptop, cellphone
Cycling - bike or motorcycles
Change medications - gout, antihypertensives, H2 blockers (Cimetidine, Ranitidine)
iv. Excessive alcohol, Marijuana
v. Takes 3 month minimum to see changes
what can you do for males with low sperm count
Dr. Turek urologist in SF
i. Examination (undescended testes, varicocele)
ii. Hx of Vasectomy?
PCOS treatments
i. Treat insulin resistance and elevated glucose (metformin)
ii. Ovulation induction (Clomid, Femara, Fertility Injections)
iii. Weight loss
iv. +/- IUI (Intrauterine Insemination)
v. +/- IVF (In-vitro Fertilization) if sperm issues
HA treatment
Ovulation induction (Clomid, Femara, Fertility Injections)
DOR – decreased ovarian reserve
i. IVF
ii. Donor Egg
uterine issues treatment options
i. IVF + Gestational Carrier
ii. IVF created to bypass sperm issues
Other Endocrine Issues treatment
i. Hyperprolactinemia: Rx Bromocriptine
ii. Thyroid: Tx underlying issue (REIs like TSH between 1-2)
sperm issues
IVF + ICSI (Intracytoplasmic Sperm Injection) vs PICSI (Physiological Intracystoplasmic Sperm Injection)
Donor Sperm
ICSI
intracytoplasmic sperm injection
isolates healthy sperm and injects it into the egg
lifestyle modifications
- Tobacco, ETOH, recreational drugs
- Exercise (if d/t HA)
start
- Eating healthy
- Sperm friendly foods (Spinach, liver, broccoli, almonds, citrus fruits, beef, lamb, pumpkin seeds, sesame seeds, yogurt, shrimp, and other iron and zinc rich foods.)
- Exercise, decrease BMI (if warranted)
- Vitamins (Folic Acid, DHEA, Fish Oil, CoQ10)
v. Improves pregnancy rates
vi. Results in higher implantation rates
how can acupuncture help with IVS cycles
Enhanced GnRH secretion from the hypothalamus
Cardiovascular system with acupuncture
- Slows heart rate
2. Lowers blood pressure
neurological target with acupuncture
- Reduces pain
2. Increases b endorphin levels
uterus targets with acupuncture
- Improves endometrial thickness
2. Improves uterine artery blood flow
egg quality at age
30
35
40
42
30 YO = 50% chromosomally abnormal
35 YO = 75% chromosomally abnormal
40 YO = 90% chromosomally abnormal
42 YO = 98% chromosomally abnormal
NIPT (Non-Invasive Pre-ntatal Testing)
this is a blood test done at 9 weeks pregnant
this is a blood test that can seperate fetal
PGT-A
(Pre-Implantation Genetic Screening/Diagnosis for anaploydi
can test embryos to see if they are chromosomal normal
PGT-M
monochromal single defects anomalies
mito score
mitochondria score
only inherit maternal
looking for mitochondrial activity
if you have more than it is indicative that they require more not necessarily good
should be 20 and below
Fertilome
Multigene test for genetic factors that may predispose to female infertility (ie. DOR, RPL, endometriosis)
ii. Blood test for women – genes that can cause infertility in women (like genes that will flag endometriosis, PCOS, etc)
if you have a gene that may predispose you to pregnancy lost consider freezing eggs or if a lot consider gestational carrier
High FSH and low AMH
High FSH and low AMH
this is normal for older women
AMH > 3, high testosterone/estrogen ratio
high FBG
high fasting insulin.
think PCOS
Hypothalamic amenorrhea
hypothalamus not producing enough GnRH. Women who exercise a lot can get this.
