Infertility Flashcards
What is primary infertility?
refers to couples who have not become pregnant after at least 1 year having sex without using birth control methods.
What is secondary infertility?
refers to couples who have been able to get pregnant at least once, but now are unable
Women 35 y/o and older are considered infertile if they have tried having sex for how many months w/o birth control?
6 months
the probability of being pregnant in a single menstrual cycle
Fecundability
T/F
- Infertility has NO association w/ race or ethnicity
True
What % of infertility is due to:
Female?
Male?
Other?
- Female: 65%
- Male: 20%
- Other: 15%
In which group of women would you consider discussing fertility w/ oocyte cryopreservation?
WWE (women w/ epilepsy)?
*No idea if this is the meaning of the acronym guys…
What recommendations would you give to prevent infertility to a couple? (4)
- Avoid weight extremes –> anovulation
- Stop using tobacco/recreational drugs
- ↓ alcohol consumption
- Avoid scrotal hyperthermia
An infertility evaluation can be performed by which 4 providers?
- Primary care providers
- OB/GYN providers
- Fertility specialists
- Reproductive endocrinologists
What are the top 3 etiologies of the “female factor” associated w/ infertility?
- Ovulatory disorders (25%)
- Endometriosis (15%)
- Pelvic adhesions (12%) –> (such as PID)
Ovulatory disorders are responsible for 25% of the female factor of infertility.
What are the 3 types of ovulatory disorders?
- Hypothalamic-pituitary failure (low body weight + excessive exercise)
- HPO axis dysfunction (PCOS, Hyperprolactinemia)
- Ovarian failure
What are the top 3 etiologies of “male factors” leading to infertility?
- Testicular defects in spermatogenesis (65-80%)
- Idiopathic (20%)
- Sperm transport disorders (5%)
Evaluation of infertility should be initiated earlier if risk of what 3 conditions??
- Premature ovarian failure
- Severe Endometriosis
- Known/suspected uterine or tubal dz
What are the 4 key aspects of fertility?
- Sperm
- Oocyte
- Transport
- Implantation
What labs should be evaluated? (8)
hCG, TSH, PRL, total Testosterone, DHEA-S, FSH, LH, estradiol
4 key physical exam components of female for infertility
•Thyroid exam
- Assess cervix
- Assess for uterine abnormalities
- Assess for adnexal masses
“TUCA”
What hormone level should be checked on day 21 to evaluate for ovulation issues?
Which phase is this?
Serum LH surge (Luteal Phase)
What 2 disorders should be evaluated for if pt is “anovulatory?”
- Thyroid
- Hyperprolactinemia
What hormone level should be evaluated on day 3?
What levels (high or low) would this indicate?
- FSH & Estradiol
- ↑ FSH and ↓ Estradiol = ovarian failure
- ↓ or normal FSH and ↓ Estradiol = Hypothalamic Pituitary Failure
How is “Ovarian Reserve” assessed? (3)
- U/S for follicular antral follicle count
- Antimullerian hormone
- Clomiphene challenge test
What 2 tests for a female can be therapeutic?
- Hysterosalpingography
- Laparoscopy / Hysteroscopy
What test is performed to evaluate for:
- Endometriosis
- Prior pelvic infection
- Prior ectopic pregnancy
Laparoscopy / Hysteroscopy w/ dye
What would a PE finding be on a male physical exam significant for infertility?
Decreased frequency of shaving (↓ testosterone levels)
What are normal results of a semen analysis?
Count: 20 million/mL +
Motility: >50%
Morphology: WHO criteria: >30% normal
Kruger Strict Criteria: >14% normal
4 labs for eval of male partner
- Testosterone
- FSH
- LH
- PRL
If semen analysis results are abnormal, when should the patient be re-tested?
4 or more weeks later
If semen count is <5 million / mL, what should be evaluated?
- Endocrine evaluation
- Possible karyotype
If a male partner has low testosterone, what follow up labs should be ordered next?
Prolactin
What do these lab values indicate in male partner?
- ↓ Testosterone, ↑ FSH, ↑ LH
Primary Hypogonadism
What do these lab values indicate in male partner?
- ↓ Testosterone, ↓ Low FSH, ↓ LH
Secondary Hypogonadism
What do these lab values indicate in male partner?
- Normal Testosterone, ↓ sperm count, ↓ LH
Possible exogenous steroids
Evaluation of what 4 things need to be normal to be diagnosed w/ “unexplained infertility?”
- Normal uterine cavity
- Bilateral patent tubes
- Evidence of ovulation
- Normal semen analysis
What is the medication tx of choice for women <36 y/o w/ oligomenorrhea or amenorrhea w/ normal FSH, including PCOS?
Clomiphene citrate (Clomid)
5 SE of Clomiphene citrate (Clomid)
- Hot flashes
- Emotional lability
- Depression
- Bloating
- Visual changes
What medication is recommended for women w/ hx of estrogen dependent tumors.
What is the MOA?
Letrozole (Femara)
- Aromatase inhibitor
Ovulation is induction w/ ______
- Often used in conjunction w/ IUI (Intrauterine insemination)
- Human menopausal gonadotropin (hMG) or Recombinant FSH (rFSH)
Gonadotropins
What are 3 SE of inducing ovulation w/ Gonadotropins?
- Multiple gestation
- Ovarian hyperstimulation syndrome
- Incr. risk of ectopic pregnancy
A laparoscopy is used for patients w/ endometriosis.
- What is used for patients w/ recurrent abortions, repeated implantation failure, or distorted endometrial cavity by submucosal leiomyoma?
Myomectomy
With an IUI, cervical mucous is bypassed and therefore not an issue.
What antibiotic is given empirically with an IUI?
Doxycycline
What are the 5 types of ART? (Assisted Reproductive Technologies)
- IUI (intrauterine insemination)
- ICSI (intracytoplasmic sperm injection)
- IVF (in vitro fertilization)
- GIFT (gamete intrafallopian transfer)
- ZIFT (zygote intrafallopian transfer)
Describe IUI and the indication to do this?
Sperm is washed to remove prostaglandins, bacteria, & proteins.
Sperm transcervically injected into uterus
- Indication: mild-moderate male factor infertility
- Preg rate: 10-20%
- Cost: $350-500/attempt
What method is indicated for severe male factor infertility?
- It is used in conjunction w/ what female method?
- Preg rate?
- Cost?
Intracytoplasmic Sperm Injection
- Used in conjunction w/ IVF
- Sperm individually injected into each oocyte
Preg rate: 20%
Cost: $1500-3000
IVF
- Follicle development is monitored via US and Estradiol levels
- When follicles mature, ovulation is triggered
- How and when are oocytes retrieved from follicles?
Oocytes are retrieved from follicles before ovulation by US guided transvaginal aspiration of follicular fluid
IVF
- When are embryos transferred into uterine cavity through the cervix after the retrieval of the occytes?
On day 3-5
What hormone is supplemented thru 10 weeks gestation if conception occurs with IVF?
Progesterone
What is the preg rate and cost of IVF?
Rate: 20%
Cost: 10k-15k (30k/delivery)
Which method?
- Egg and sperm placed in fallopian tube
- Fertilization occurs in the body
- Requires laparoscopy
- Pregnancy rate: 25%
- Cost: $15,000-20,000 per attempt
GIFT: gamete intrafallopian transfer
Which method?
- Zygote placed into fallopian tube
- Fertilization occurs in vitro
- ‘Natural’ implantation into uterus
- Requires laparoscopy
- Pregnancy rate: 30%
- Cost: $10,000-20,000 per attempt
ZIFT: zygote intrafallopian transfer
3 “other options”
- Donor oocytes
- Donor sperm
- Surrogacy – own egg/sperm implanted into another woman for carrying (State specific and expensive)
What is the prognosis of infertility w/ unidentified etiology?
60% achieve pregnancy within 3 yrs in ABSENCE of tx
How many cycles of Clomiphene citrate can be given at MAXIMUM?
6
