Infertility Flashcards
Definitions in infertility
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%
Types of fertility
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
factors involved in fertility
SCOOFN
Spermatogenesis
Coitus - mechs of sex
Ovulation
Oocyte competentency
Fallopian tube patency
Normal uterine cavity and vaginal outflow tract
factors causing infertility
(Usually mx causes)
METOOCUU
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%
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
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
ovulatory dysfunction definitions
Normal ovulation requires an intact
hypothalamic-pituitary-ovarian axis
Ovarian dysfunction= loss of cyclic release of oocytes by the ovaries (menoII)
Oligo-ovulation is occasional ovulation
Anovulation is lack of ovulation
causes of oligo ovulation/ anovulation
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)
how is ovulatory dysfunction diagnosed
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
rx of ov dys
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
incompetent oocyte/ ovarian ageing
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
markers of reduced ovarian reserve
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
rx of reduced ovarian reserve
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
function of fallopian tube
transfer of gametes and dividing embryo to the uterine
cavity
site of fertiization, and early development of the
embryo
tubal factors of infertility
causes of tubal ligation
Tubal disease or blockage (PID, Myoma, adhesions from endometriosis/ asherman) can impair the ability to conceive
Common causes
PID
tubal ligation
endometriosis
dg of tubal factors causing infertility (3)
func of HSG
func of laparoscopy
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
what things can’t a HSG visualise
external part of the fallopian tubes and possible external adhesions of the tubes in the pelvis
when can tubal patancy be assed w/ laparsocopy
if an indigo carmine dye is injected through the cervix and is allowed to spill into the pelvic cavity under direct visualization
rx of infertility d2 tubal factors
(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
function of the uterus in fertility and uterine factors that reduce the chances
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
cervical factor in infertility
dg and rx are part of uterine factors
multiple cone biopies and LEEP procedures cause miscarriage
male fertility factors
abmornal: semen vol, sperm count & mobility
paternal age over 40 have 20% greater chance of birth defects
def and causes of azoospermia
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),
-
dg of male factors causing infertility
semen analysis is FIRST test
2 mastubatory samples after 2 to 5 days abstinence
WHO standards of semen samples
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
rx of male factor infertility
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
assisted reproductive techniques steps (IVF)
follicular stim and US retrieval of oocyte
lab fertilization of oocyte w/ sperm
reimplantation of the embryo into uterus
3 groups of female factors in infertility
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
Male factors in infertility
Kallman syndrome, klinefelters, alcohol, varicocele, ED
physical exam for men in infertility
Testical size and consistency
- Length4cm min
- 20ml min vol
- soft non tender
Physical exam for women in infertility
Mobility of cervix &nodules- endometriosis
size of uterus- enlarged (adenomyosis) irreg- fibroids
anatomy- bicornuate etc
Dg tests for ovaries in infertility
Mid luteual serum progesterone test
-check for ovulation
hormone lvls
FSH, Estradiol,TSH, AMH
Clomifen citrate challenge test
Tube dg in infertility
Hysterio saloingogram
- check for abnormalites
Hydteroscopy
Uterine tests in infertility
Saline infusion US
Hysterosaloingogram
Dg tests for other
Endometrial biopsy 1-3 days before ovulation to check thickness
If flat then there’s defected
Female rx in infertility
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
Male dg in infertility
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
Rx for male infertility
Sperm aspiration
Lifestyle- smoking, drinking,
History in infertility
Ovulation Contraception Fam histort Social history Surgial histort Co morbidities
Men_ same minus cycle
Obesity causes infertility why
Fat cells produce more estrogen,=> excess endo prolif and anovulation
