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OB > infertility > Flashcards

infertility Flashcards

1
Q

Primary Infertility

A

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.

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2
Q

definition of infertility

A

A woman who is unable to achieve pregnancy after 12 months or more of unprotected intercourse or inseminations.

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3
Q

secondary infertility

A

“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

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4
Q

Female Factors that can play into infertility

A
  1. Ovulatory status?
    (Think PCOS)
  2. Tubes open (endometriosis? Hx of PID?)
    Fertilization happens in the fallopian tubes
    Think lovers lane (emergency appendectomy can cause this
  3. Scar tissue?
  4. Egg quality? –> evaluate family hx
  5. Uterine anatomy?
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5
Q

male factors that influence fertility

A
  1. Count, Motility, Morphology?
  2. Sexual dysfunction?
  3. Medications?
  4. Developmental? (XXY, cryptorchidism?)
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6
Q

social factors that influence

A
  1. Seen in different ethnicities where sex is a taboo
  2. Timing of intercourse or ovulation?
  3. Use of lubricants?
  4. Smoking, drugs?
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7
Q

what can affect ovulation status

A

high stress in sxs nervous system

PCOS

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8
Q

Tubes open

A

emergency appendectomy can lead to issues with fallopian tubes

hx of STI

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9
Q

what lifestyles can affect sperm

A

firefighters
heavy equipment
thinking about circadian rhythms

having intercourse outside of ovulatory cycle

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10
Q

environmental factors that can affect fertility

A
  1. BPA?
  2. Mercury?
  3. Chemical Exposure? Agent orange
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11
Q

most common birth defect that can lead to infertility in males

A

Cryptorchidism = most common birth defect

also more likely to devlope testicular cancer

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12
Q

formal semen analyses involves

A

dissecting the sperm and looking at the different components

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13
Q

head of the sperm contains

A

contains the chromosomes and is surrounded by an acrosome (contains the enzymes required to penetrate the egg)

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14
Q

mid piece of the sperm contains

A

contains the mitochondria which supplies the energy to reach the egg

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15
Q

cycle day three labs

A

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

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16
Q

AMH what does it mean

A

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

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17
Q

what other tests should be done in a work up for infertility

A
  1. TSH (Thyroid Stimulating Hormone)
  2. Prenatal Labs/CBC/Vit D/Prolactin
  3. Fasting Blood Sugar/Free and Total Testosterone
  4. Chromosome Analysis/Genetic Screening
  5. Ultrasound –> look at lining of the uterus
  6. SIS (Saline Infusion Sonogram) or HSG (Hysterosalpingogram)
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18
Q

Chromosome Analysis/Genetic Screening

A

looking for micro deletions that can effect sperm

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19
Q

SIS (Saline Infusion Sonogram) or HSG (Hysterosalpingogram)

can be used for

A

done in office with saline, pushed into the uterine cavity to make sure there are no fibroids or polyps and checking for fallopian patency

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20
Q

male diagnostic tests for infertility

A
  1. FSH and Estradiol
  2. TSH
  3. Semen Analysis
  4. Chromosome Analysis
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21
Q

what would we see in tests for PCOS

in labs or ULS

A

High testosterone to estrogen ratio = random or anovulatory cycles. Increased FBG and fasting insulin.
1. String of pearls seen on US

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22
Q

Hypothalamic Amenorrhea (HA) is seen in this population and with a decrease in this hormone

A

Hypothalamus does not produce GnRH = anovulatory cycles.

1. Seen in female athletes

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23
Q

Egg Quality/Decreased Ovarian Reserve (DOR) is reflected in these tests

A

High FSH/Estradiol, low AMH levels

24
Q

uterine anomalies that can cause infertility

A

Fibroids

uterine anomaly

25
Q

types of fibroids

A

Subserosal vs Intramural vs Submucosal

1. Polyp present?

26
Q

uterine abnormalities that can affect infertility

A
  1. Septums can be repaired

2. Diagnosed on HSG, can confirm on MRI if needed

27
Q

MCC of pelvic & Fallopian Tube Adhesions

A

Old Chlamydia infection

28
Q

other causes of pelvic & Fallopian Tube Adhesions

A

Old PID, previous surgery, or endometriosis

Old Chlamydia infection

Surgery unhelpful in most cases

29
Q

surgery for pelvic and fallopian tube adhesion surgery success

A
  1. Success in youngest (<34) patients
  2. 50% of success within 2 years
  3. Next 50% within 11 years

Adhesions reform!!! (in anyone who has had abdominal surgery)

30
Q

best option for a pt with endometriosis

A
  1. Tell her to freeze her eggs b/c endometriosis is toxic
31
Q

normal semen

volume, active motility

A

i. 2 cc volume
ii. 40 million/cc count
iii. 40% active motility
iv. 60% normal shapes/morphology

32
Q

Mild male factor

count of good sperm

A

5 -20 million total motile “good-looking” sperm

33
Q

Severe male factor

Good looking” sperm =

A

< 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

34
Q

how much of the sperm are lost in the vagina

A

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

35
Q

remediable causes of sperm decrease

A

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

36
Q

what can you do for males with low sperm count

A

Dr. Turek urologist in SF

i. Examination (undescended testes, varicocele)
ii. Hx of Vasectomy?

37
Q

PCOS treatments

A

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

38
Q

HA treatment

A

Ovulation induction (Clomid, Femara, Fertility Injections)

39
Q

DOR – decreased ovarian reserve

A

i. IVF

ii. Donor Egg

40
Q

uterine issues treatment options

A

i. IVF + Gestational Carrier

ii. IVF created to bypass sperm issues

41
Q

Other Endocrine Issues treatment

A

i. Hyperprolactinemia: Rx Bromocriptine

ii. Thyroid: Tx underlying issue (REIs like TSH between 1-2)

42
Q

sperm issues

A

IVF + ICSI (Intracytoplasmic Sperm Injection) vs PICSI (Physiological Intracystoplasmic Sperm Injection)

Donor Sperm

43
Q

ICSI

A

intracytoplasmic sperm injection

isolates healthy sperm and injects it into the egg

44
Q

lifestyle modifications

A
  1. Tobacco, ETOH, recreational drugs
  2. Exercise (if d/t HA)

start

  1. Eating healthy
  2. Sperm friendly foods (Spinach, liver, broccoli, almonds, citrus fruits, beef, lamb, pumpkin seeds, sesame seeds, yogurt, shrimp, and other iron and zinc rich foods.)
  3. Exercise, decrease BMI (if warranted)
  4. Vitamins (Folic Acid, DHEA, Fish Oil, CoQ10)

v. Improves pregnancy rates
vi. Results in higher implantation rates

45
Q

how can acupuncture help with IVS cycles

A

Enhanced GnRH secretion from the hypothalamus

46
Q

Cardiovascular system with acupuncture

A
  1. Slows heart rate

2. Lowers blood pressure

47
Q

neurological target with acupuncture

A
  1. Reduces pain

2. Increases b endorphin levels

48
Q

uterus targets with acupuncture

A
  1. Improves endometrial thickness

2. Improves uterine artery blood flow

49
Q

egg quality at age

30

35

40
42

A

30 YO = 50% chromosomally abnormal

35 YO = 75% chromosomally abnormal

40 YO = 90% chromosomally abnormal

42 YO = 98% chromosomally abnormal

50
Q

NIPT (Non-Invasive Pre-ntatal Testing)

A

this is a blood test done at 9 weeks pregnant

this is a blood test that can seperate fetal

51
Q

PGT-A

A

(Pre-Implantation Genetic Screening/Diagnosis for anaploydi

can test embryos to see if they are chromosomal normal

52
Q

PGT-M

A

monochromal single defects anomalies

53
Q

mito score

A

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

54
Q

Fertilome

A

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

55
Q

High FSH and low AMH

A

High FSH and low AMH

this is normal for older women

56
Q

AMH > 3, high testosterone/estrogen ratio

high FBG

high fasting insulin.

A

think PCOS

57
Q

Hypothalamic amenorrhea

A

hypothalamus not producing enough GnRH. Women who exercise a lot can get this.

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