Infertility Flashcards
1
Q
Infertility
A
- A woman who is unable to achieve pregnancy after 12 months or more of unprotected intercourse or inseminations.
2
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. Thus women whose pregnancy spontaneously miscarries, or whose pregnancy results in a still born child, without ever having had a live birth would present with primarily infertility.”- WHO
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. Thus those who repeatedly spontaneously miscarry or whose pregnancy results in a stillbirth, or following a previous pregnancy or a previous ability to do so, are then not unable to carry a pregnancy to a live birth would present with secondarily infertile.” -WHO
4
Q
infertility: female factors, male factors, social factors, environmental factors
A
-
Female Factors
- Ovulatory status?
- Tubes open (endometriosis? Hx of PID?)
- Scar tissue?
- Egg quality?
- Uterine anatomy?
-
Male Factor
- Count, Motility, Morphology?
- Sexual dysfunction?
- Medications?
- Developmental? (XXY, cryptorchidism?)
-
Social Factors
- Timing of intercourse or ovulation?
- Use of lubricants?
- Smoking, drugs?
-
Environmental Factors
- BPA?
- Mercury?
- Chemical Exposure?
- It is the most common birth defect of the male genitalia.<a>[1]</a> In unique cases, cryptorchidism can develop later in life, often as late as young adulthood. About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis. However, about 80% of cryptorchid testes descend by the first year of life (the majority within three months), making the true incidence of cryptorchidism around 1% overall. Cryptorchidism is distinct from monorchism, the condition of having only one testicle. Reduced spermatogenesis in cryptorchid testes is due to temperature differences. high rate of anomalies of the epididymis
5
Q
sperm maturation
A
- Sperm maturation starts out in the seminiferous tubules in the testes and then completes in the epididymis. Takes around 120 days.
- A sperm cell consists of:
- Head: contains the chromosomes and is surrounded by an acrosome (contains the enzymes required to penetrate the egg)
- Mid piece: contains the mitochondria which supplies the energy to reach the egg
- Tail: propels the sperm
- If any portion of the above is compromised, it can lead to infertility.
6
Q
infertility workup/diagnosis
A
- Female Blood and Diagnostic Tests:
- FSH (Follicle Stimulating Hormone) and Estradiol (CD 2 or 3)
- AMH (Anti-Mullerian Hormone), Prolactin, RPL Panel
- TSH (Thyroid Stimulating Hormone)
- Prenatal Labs/CBC/Vit D/Prolactin
- Fasting Blood Sugar/Free and Total Testosterone
- Chromosome Analysis/Genetic Screening
- Ultrasound
- SIS (Saline Infusion Sonogram) or HSG (Hysterosalpingogram)
- Male Blood and Diagnostic Tests:
- FSH and Estradiol
- TSH
- Semen Analysis
- Chromosome Analysis
- AMH: in male fetus, activated by Sertoli cells-> inhibit dev of female repro tract=mullerian ducts. In females, produced in granulosa cells, regulating folliculogenesis in selection of single dominant follicle.
7
Q
infertility: female factor
A
- PCOS: High testosterone to estrogen ratio = random or anovulatory cycles. Increased FBG and fasting insulin.
- Hypothalamic Amenorrhea (HA): Hypothalamus does not produce GnRH = anovulatory cycles.
- Egg Quality/Decreased Ovarian Reserve (DOR): High FSH/Estradiol, low AMH levels
- Factors affecting ovulation: Elevated Prolactin, Thyroid, Stress, Fatigue….
8
Q
uterine anomalies
A
- Fibroids: Subserosal vs Intramural vs Submucosal
- Uterine Septum/Bicorneate vs Didelphus
9
Q
pelvic and fallopian tube adhesions
A
- Old Chlamydia infection
- most common cause
- “Silent infection”
- cultures negative
- Surgery unhelpful in most cases
- Surgery
- success in youngest (<34) patients
- 50% of success within 2 years
- next 50% within 11 years
- Adhesions reform!!!
- Endometriosis NEVER goes away
- Repeat surgery even less helpful
- Bottom line: IVF best option
- Chlamydia is known as a ‘silent’ infection because most infected people are asymptomatic and lack abnormal physical examination findings. It’s estimated that only about 10% of men and 5-30% of women with laboratory-confirmed chlamydial infection develop symptoms.
10
Q
infertility: male factor
A
-
Normal semen:
- 2 cc volume
- 40 million/cc count
- 40% active motility
- 60% normal shapes/morphology
-
Mild male factor:
- 5 -20 million total motile “good-looking” sperm
-
Severe male factor:
- < 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
-
Correct remediable causes:
- Scrotal Heat – illness, hot tubs, laptop, cellphone
- Cycling - bike or motorcycles
- Change medications - gout, antihypertensives, H2 blockers (Cimetidine, Ranitidine)
- Excessive alcohol, Marijuana
- Takes 3 month minimum to see changes
-
Send to urologist:
- Examination (undescended testes, varicocele)
- Hx of Vasectomy?
- Poor semen analysis result
- Patient who tried to conceive >12 months then hubby told her he had a vasectomy after kids in his previous marriage. Marijuana can lower sperm count, motility and ability to penetrate the egg. and reduce sexual performance and testosterone
11
Q
oligospermia
A
- This patient had + PMHx: mumps @ 7yo. Referred to urologist for further evaluation and management.
- Screen for testosterone use, chromosome analysis for deletions in Y, hormone panel.
12
Q
infertility: treatments
A
-
PCOS
- treat insulin resistance and elevated glucose (metformin)
- ovulation induction (Clomid, Femara, Fertility Injections)
- weight loss
- +/- IUI (Intrauterine Insemination)
- +/- IVF (In-vitro Fertilization) if sperm issues
-
HA
- ovulation induction (Clomid, Femara, Fertility Injections)
-
DOR
- IVF
- Donor Egg
-
Uterine Issues
- IVF + Gestational Carrier
-
Other Endocrine Issues
- Hyperprolactinemia: Rx Bromocriptine
- 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
- IVF + ICSI (Intracytoplasmic Sperm Injection) vs PICSI
13
Q
diet and lifestyle modification
A
-
Stop
- 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)
14
Q
acupuncture
A
- Enhanced GnRH secretion from the hypothalamus
- Cardiovascular system
- Slows heart rate
- Lowers blood pressure
- Neurological
- Reduces pain
- increases b endorphinlevels
- Uterus
- Improves endometrial thickness
- Improves uterine artery blood flow
- Improves pregnancy rates
- Results in higher implantation rates
15
Q
infertility extras
A
-
Egg quality @:
- 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)
- Complete genome screening of fetus via mom’s blood @ 9wks GA +
- 22q deletion syndrome (DiGeorge)
- 5p (Cri-du-chat syndrome)
- 15q (Prader-Willi/Angelman syndromes)
- 1p36 deletion syndrome
- 4p (Wolf-Hirschhorn syndrome)
- 8q (Langer-Giedion syndrome)
- 11q (Jacobsen syndrome)
- Complete genome screening of fetus via mom’s blood @ 9wks GA +
- PGT-A: Pre-Implantation Genetic Testing for Aneuploidy & Mitoscore
PGT-A screening of embryos for chromosomal abnormalities vs PGT-M (monogenic/single gene defects) prior to transferring embryo/s.
