Infertility Flashcards
__ of couples will conceive within the first 6 months of trying
80% of couples will conceive within the first 6 months of trying
Monthly fecundability
Probability of becoming pregnant per month
When fecundability starts to drop off for men and women
- Women: Age 35
- Men: Age 50
Clinical definition of infertility
1 year of trying to conceive without becoming pregnant
Or
6 months of ^ in someone above the age of 35 (this is so this population gets extra attention, since they have less “time” to conceive)
Post-coital supine lying
Many patients will come in thinking that this increases the likelihood of pregnancy, but this is a myth
In reality, there is no evidence that the coital position affects fecundability
Vaginal lubricants and infertility
Many water-based lubricants decrease the viability and motility of sperm and lessen fecundability, as do K-Y jelly, olive oil, and saliva.
Canola oil, mineral oil, and hydroxymethylcellulose do not have this property and may be used as a lubricant during sex without these effects.
Diet and infertility
Generally speaking, diet has no direct effects on fertility.
However, extremes of BMI can both lessen fertility, and dietary mercury from heavy seafood consumption can reduce fertility as well.
Common substances and fertility
- Smoking: Significant reduction in female fertility, not male
- Alcohol: There appears to be no relationship. Heavily conflicting data. However, of course, we recommend that you do not drink if you are attempting to become pregnant since it can affect early fetal development even before a pregnancy test would be positive.
- Caffeine: Significant reduction in fertility and increased risk of miscarriage, but not of congenital anomalies. Only w/ high levels (>3 cups/day), and only in women.
Sauna bathing and fertility
Contrary to common belief, sauna bathing has no effect on fertility for for women. However, it DOES reduce fertility in men (remember the importance of the scrotum!)
However, elevated body temperature for prolonged periods in women in the first trimester of pregnancy is teratogenic. Generally speaking, we don’t make this recommendation until we know that the woman is pregnant (as with avoiding alcohol, large fish, cat litter, and unpatseurized dairy products)
Occupation and fertility
Agricultural workers exposed to pesticides and some laboratory workers exposed to lab chemicals may have a reduced fertility as a result of exposure.
Similarly, those who work in the proximity of industrial microwaves have been shown to have reduced fertility.
“Fertile window”
6 day interval ending on the day of ovulation
Correlates with volume and quality of cervical mucous
Frequency of intercourse and fecundability
Highest fecundability is associated with intercourse every 1-2 days during the fertile period, however results achieved with intercourse every 2-3 days are nearly equivalent
Graph showing probability of at least one live birth by age and # of oocytes frozen
Note: This is a conservative model due to an assumption made underestimating blastocyst viability. True probabilities are likely higher. It also has a lower sample size for older individuals, and so its power is weak for patients above age ~38.
Basic categories of testing for male and female factor infertility
- Female factor:
- Ovarian reserve
- Ovulatory function
- Anatomical abnormalities
- Male factor:
- Semenalysis
Relative prevalence of male and female factor infertility in couples struggling to conceive
It’s close to 50:50, suprisingly
Table summarizing basic infertility testing options
Clinical pathology results consistent with diminished ovarian reserve
- AMH < 1 ng/mL
- Antral follicle count < 5
- FSH < 10 IU/L (order w/ estradiol, usually >80 pg/mL when FSH is low) ie, low FSH, high estradiol like in PCOS.
- History of poor response to IVF stimulation (<4 oocytes at time of retrieval)
Definition of ovulatory dysfunction
A history of oligomenorrhea or amenorrhea or as luteal progesterone levels repeatedly less than 3 ng/mL, or both
Anovulation Ddx
- PCOS
- Thyroid disease
- Hyperprolactinemia
- Obesity
- Starvation
- Primary HPO axis dysfunction
- Functional (as in athlete’s triad)
Hysterosalpingography may need to be. . .
. . . confirmed if demonstrating patency
The NPV for patency is high, but the PPV is relatively low.
Drugs that induce ovulation
- Letrozole: Aromatase inhibitor. Especially good in PCOS since hyperestroginemia is the main problem. Becoming first-line agent for all patients. Reduces estrogen, allowing for FSH to build up and stimulate ovulation.
- Clomiphene citrate: A type of SERM, like tamoxifen and raloxifene. Poor function in obese patients.
- Pulsatile GnRH
- hMG and FSH (direct gonadotropin therapy)
-
Special populations:
- Metformin: Improves likelihood of ovulation in women with insulin resistance (PCOS or DM)
- Dopamine agonists: Improves ovulatory HPO axis function in women with hyperprolactinemia.
Major things a woman should stop avoiding once she is known to be pregnant, but not necessarily while she is trying to become pregnant
- Moderate alcohol consumption
- Large fish consumption (mercury)
- Soft cheeses and unpausteurized dairy products (Listeria)
- Cat litter (Toxoplasma)
- Saunas/warm baths (heat teratogenicity)
Standard infertility workup
- Female partner:
- Blood draw on follicular day 2-4 (numerous tests including AMH, LH, FSH, estradiol)
- Hysterosaplingogram
- Transvaginal ultrasound w/ follicle count
- Male partner:
- Semenalysis
AMH correlates to . . .
. . . pre-antral follicles
Ovarian follicle cycle
Folliculogenesis histology
Primary oocytes are arrested in ___
Secondary oocytes are arrested in ___
Primary oocytes are arrested in prophase I
Secondary oocytes are arrested in metaphase II
Optimal age to recommend egg freezing
~34-37
Before this, the patient is unlikely to ever need cryopreservation.
After this, egg quality starts to decline.
Ovarian hyperstimulation syndrome
- Ascites, pleural effusions, and hypercoagulability
- Caused by vasoactive molecules (VEGF) and hyperestrogenemia induced by stimulatory IVF hormones
Normal AMH
A normal AMH is ~1.0 to 3.5
An AMH above 5 is highly suggestive of PCOS
Implantation rate for euploid embryos
~55%
Programmed cycles for IVF have higher rates of. . .
. . . multiple gestation, abnormal placentation, and preeclampsia
Quetiapine-induced ovulatory dysfunction
Quetiapine’s mild antidopaminergic effects can result in a mild hyperprolactinemia, which can in turn impair HPO-axis function at the level of GnRH.
Indications for endometrial polypectomy
- Polyp size > 1.5 cm
- Associated infertility
- Associated dysmenorrhea or menorrhagia not controlled by progestin therapy
First-line for endometriosis-associated infertility
These patients are excellent candidates for ovarian stimulation with or without intrauterine insemination
This should be attempted prior to moving to IVF, unless there is another indication for IVF.
If a young patient presents with symptoms (but no diagnosis) of endometriosis and a history of infertility, the first thing to do is. . .
. . . laporoscopy to confirm diagnosis, remove ectopic endometrial tissue, and assess tubal patency
Even in the absence of tubal occlusion, the presence of endometrial tissue outside of the uterus decreases fertility, and endometrial ablation often restores fertility.
First-line therapy for individual with Athlete’s triad who wishes to become pregnant following advice about diet and exercise
In someone with BMI over 18.5, pulsatile GnRH is usually what is recommended.
In someone who is below this level, we would recommend increasing BMI to 18.5 or 19 and then beginning pulsatile GnRH.
Cervical factor infertility
Rare cause of infertility
Essentially cervical mucous is too thick for sperm to get in. Also kind of how the progesterone IUD works (in addition to thin endometrium)
Since in these cases the whole problem is that the sperm can’t get in, intrauterine insemination is the obvious therapy
Isolated infertility without associated symptoms is highly likely to be. . .
. . . endometriosis
So, the next step for these patients is exploratory laporoscopy
Easiest, cheapest way to tell if someone is ovulating
Basal body temperature! Take it in the morning every morning before getting out of bed for one month
Temperature shoots up by ~0.5oF following ovulation
Abnormal hysterosalpingograms without “fill and spill” require. . .
. . . confirmation laparoscopically
