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O&G > Infertility > Flashcards

Infertility Flashcards

1
Q

Definitions in infertility

A

Infertility= no conception after 1 year of unprotected regular intercourse

Fecundability= monthly probability of pregnancy, is 20% among fertile couples

The cumulative probability of pregnancy after 1 year approaches 85%

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2
Q

Types of fertility

A

Primary infertility= individuals who have never established a pregnancy

Secondary infertility= individuals who have conceived previously (including miscarriages) but are currently unable to establish a subsequent pregnancy

15% of couples are infertile, using the
criteria of at least 1 year of unprotected coitus

The longer the period of time that a couple attempts
pregnancy without success, the more likely that they
will have infertility

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3
Q

factors involved in fertility

SCOOFN

A

Spermatogenesis

Coitus - mechs of sex

Ovulation

Oocyte competentency

Fallopian tube patency

Normal uterine cavity and vaginal outflow tract

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4
Q

factors causing infertility

(Usually mx causes)

METOOCUU

A

Male factor: 40%

Endometriosis: 35%

Tubal factor: 35%

Ovulatory dysfunction: 25%

Ovarian aging: incidence varies with age

Unexplained: 10%

Uterine and vaginal outflow tract abnormalities: 3%

Coital problems: 5%

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5
Q

indications for early evaluation (of sex tekkers) of infertility

EVAL of women w.o these are at risk of unecessary rx when spontaneous pregnancy s possible

A

over age 35 after 38 it significantly decreases

irregular or absent menses;

a history of PID

STD

pelvic/abdominal surgery;
significant history in the male partner

Hyperthyroidism

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6
Q

ovulatory dysfunction definitions

Normal ovulation requires an intact
hypothalamic-pituitary-ovarian axis

A

Ovarian dysfunction= loss of cyclic release of oocytes by the ovaries (menoII)

Oligo-ovulation is occasional ovulation

Anovulation is lack of ovulation

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7
Q

causes of oligo ovulation/ anovulation

A

hypothalamic amenorhhea

  • Weight loss
  • Excessive exercise
  • Malnutrition
  • stress

excess androgens

  • Polycystic ovarian syndrome
  • Androgen-secreting tumors (SCLC, cushings)
  • Nonclassic congenital adrenal hyperplasia (l8 onset)**

hyperprolactinemia

  • haloperidol(dopamine antag)
  • Pit adenoma
  • Increased thyrotropin-releasing hormone (hypothyroidism)

hypothyroidsm

reduced ovarian reserve (meno II)

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8
Q

how is ovulatory dysfunction diagnosed

A

1) LH kits to detect preovulatory LH elevation
- day 10, test urine till colour changes=> ovulation w/in 24hrs

Luteal phase biopsy:: confirms ovulation and checks if endometrium is ready for implantation
-progesterone changes endometrium from secretory to prolif but no longer used d/2 normal fertile variablility

2) serum progesterone testing
- greater than 4 ng/mL suggests ovulation,
- 10 ng/mL in the midluteal phase (7 days from ovulation) shows replacement of endometrial biopsy for luteal-phase adequacy

3)hormonal tests if absence of ovulation in previous tests
- FSH, LH, TSH, prolactin, total & free testosterone,
17 di-hydroxyprogesterone, and

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9
Q

rx of ov dys

A

correct endocrine disorgers

ovulation induction
1)Clomiphene citrate!! =estrogen antagonist in
-women w/ functioning hypo-pit-ovarian axis
=>triggers
endogenous release of FSH by reducing estrogen mediated suppression =>stimulates follicular
development

2)IV gonadotropins
-women with hypothalamic amenorrhea
=> failed to ovulate with clomiphene as the issue is w/ the HPA
=>Direct stim of ovary

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10
Q

incompetent oocyte/ ovarian ageing

A

there is finite number of oocytes in women w/ a steady depletion throughout their lives independent of ovulation

leads to “reduced ovarian reserve” that defines Ovarian ageing and correlates with a decrease in fertility

older women have higher spontaneous loss of fertility d/2 increased risks of aneuploidy

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11
Q

markers of reduced ovarian reserve

A

hormonal markers

  • FSH/estradiol elevation on day 3 = reduced ovarian count
  • definition of ovarian failure= FSH >40 mIU/mL plus amenorrhea
  • ————————–PREMATURE OVARIAN FAILURE= any of these under 40———————————

-Anti Mullerian Hormone in plasma= mentrual cycle independant premature ovarian failure

antral follicle count - determines response to rx
-U.S ovary visualisation & count follicular no. betw 2 and 5mm.
Low count predicts diminished response to fertility treatment

clomiphrine citrate challenge
FSH bioassay showing follicular ability of ovary

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12
Q

rx of reduced ovarian reserve

A

IVF: donor oocyte fertilized w/ partner sperm, embryo(s) can be transferred to and carried
by the woman

Adoption

aggressive rx required for low ovarian reserve

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13
Q

function of fallopian tube

A

transfer of gametes and dividing embryo to the uterine
cavity

site of fertiization, and early development of the
embryo

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14
Q

tubal factors of infertility

causes of tubal ligation

A

Tubal disease or blockage (PID, Myoma, adhesions from endometriosis/ asherman) can impair the ability to conceive

Common causes
PID
tubal ligation
endometriosis

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15
Q

dg of tubal factors causing infertility (3)

func of HSG

func of laparoscopy

A

Hysterosalpingography (HSG) is a fluoroscopy : radiopaque
dye injected through the cervix so you can see
1)uterine cavity
2)fallopian tube lumen and patency
done prior to laparoscopy as its cheap and less invasive

Laparoscopy lets you see the external
surface of the fallopian tube so
-abnormalities in struc/loc and peritubal or pelvic adhesions can be identifiedbut not patency

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16
Q

what things can’t a HSG visualise

A

external part of the fallopian tubes and possible external adhesions of the tubes in the pelvis

17
Q

when can tubal patancy be assed w/ laparsocopy

A

if an indigo carmine dye is injected through the cervix and is allowed to spill into the pelvic cavity under direct visualization

18
Q

rx of infertility d2 tubal factors

A

(IVF) bypasses the fallopian tube and is
the most successful !!!!

Surgical
1)Tubal reanastomosis for reversing tube ligation (sterilization)

2) removal of peritubal adhesions
3) Neosalpingostomy fimbrioplasty (opening of the fallopian tube and recunstruction of the fimbrae aftwewards) for occluded fallopian tubes

19
Q

function of the uterus in fertility and uterine factors that reduce the chances

A

uterine fertility func

1) suitable for sperm transport, 2)embryo dev b4 implantation
3) carriage of the pregnancy

uterine factors
Leiomyomas (fibroids): especially submucosal in location**

Uterine polyps

Asherman syndrome/ Synechiae: scar tissue from prior uterine procedures

Congenital anomalies
uterine septum
bicornuate uterus
unicornuate uterus

20
Q

cervical factor in infertility

A

dg and rx are part of uterine factors

multiple cone biopies and LEEP procedures cause miscarriage

21
Q

male fertility factors

A

abmornal: semen vol, sperm count & mobility

paternal age over 40 have 20% greater chance of birth defects

22
Q

def and causes of azoospermia

A

azoospermia: absence of sperm in the ejaculate

Obstructive azoospermia:

  • vasectomy,
  • congenital bilateral absence of vas deferens (CBAVD)
  • postsurgical obstruction

Nonobstructive azoospermia:

1) hypogonadotropic hypogonadism:
- idiopathic;
- Kallmann syndrome,
- pituitary tumors;

2) testicular failure:
- chemotherapy/radiation, trauma, mumps, infection

3)chromosomeabnormalities:
-Klinefelter syndrome (47,XXY),
-

23
Q

dg of male factors causing infertility

A

semen analysis is FIRST test

2 mastubatory samples after 2 to 5 days abstinence

24
Q

WHO standards of semen samples

A

Volume: 1.5 to 5.0 mL

Concentration: greater than 20 million sperm/mL

Total sperm number: greater than 40 million per ejaculate as min vol is 1.5

Percent motility: greater than 50%

Progression: greater than 2 (scale 0 to 4)

Morphology: more than 30% with normal, oval heads and a single tail

White blood cells: less than 1 million/mL

25
Q

rx of male factor infertility

A

medical
-Correction of underlying hormonal disorders(FSH for testosterone
-hCG to stimulate spermatogenesis in cases of
hypothalamic dysfunction

surgical

  • Varicocele repair
  • Vasectomy reversal

intrauterine insemination
wash the semen specimen to concentrate actively motile
sperm=> place the specimen high in the reproductive tract, closer to the fallopian tubes, at the time of ovulation

26
Q

assisted reproductive techniques steps (IVF)

A

follicular stim and US retrieval of oocyte

lab fertilization of oocyte w/ sperm

reimplantation of the embryo into uterus

27
Q

3 groups of female factors in infertility

A

Ovulatory
-PCOS, primary ovarian failure, hyperthyroidism, turners, hyperprolactinemia
Rf: smoking, alcohol

Tubal
-PID, surgery, previous ectopic, asherman syndrome
Uterus
-fibroids, polyps,

Other : endometriosis, obesity, underweight, extreme excercise, cervical anomalies

28
Q

Male factors in infertility

A

Kallman syndrome, klinefelters, alcohol, varicocele, ED

29
Q

physical exam for men in infertility

A

Testical size and consistency

  • Length4cm min
  • 20ml min vol
  • soft non tender
30
Q

Physical exam for women in infertility

A

Mobility of cervix &nodules- endometriosis
size of uterus- enlarged (adenomyosis) irreg- fibroids
anatomy- bicornuate etc

31
Q

Dg tests for ovaries in infertility

A

Mid luteual serum progesterone test
-check for ovulation

hormone lvls
FSH, Estradiol,TSH, AMH

Clomifen citrate challenge test

32
Q

Tube dg in infertility

A

Hysterio saloingogram
- check for abnormalites
Hydteroscopy

33
Q

Uterine tests in infertility

A

Saline infusion US

Hysterosaloingogram

34
Q

Dg tests for other

A

Endometrial biopsy 1-3 days before ovulation to check thickness

If flat then there’s defected

35
Q

Female rx in infertility

A

Clomifen- stimulates ovulation by increasing FSH follicle receptors and stim development and recruitment if follicle production

Tamoxifen
-increases oestrogen

GNRH analog: buserelin

Rx underlying cause

Surgical

  • ART: IVF/ICSI/
  • surgical removal of any adhesions but last resort caude it can damage
36
Q

Male dg in infertility

A

Semen analysis to examine amount and morph

Check for autoab’s against sperm from blood
-tests barrier loss post trauma

Sperm cervical mucus interaction test

Endocrine tests

Genetic tests

37
Q

Rx for male infertility

A

Sperm aspiration

Lifestyle- smoking, drinking,

38
Q

History in infertility

A 
Ovulation
Contraception
Fam histort
Social history 
Surgial histort 
Co morbidities

Men_ same minus cycle

39
Q

Obesity causes infertility why

A

Fat cells produce more estrogen,=> excess endo prolif and anovulation

O&G (43 decks)

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