Infertility Flashcards

1
Q

Definition of infertility

A

• Failure to achieve pregnancy within 12 months of unprotected intercourse (or therapeutic donor insemination) in women younger than 35 yo
• Failure to achieve pregnancy within 6 months in women older than 35 years old
• Affects 15% of couples
• If a woman has a condition known to cause infertility or over the age of 40, efforts at immediate evaluation and treatment should be made
o Oligomenorrhea or amenorrhea
o Known or suspected uterine tubal or peritoneal disease
o Stage III or stage IV endometriosis
o Known or suspected male infertiltiy
• Unexplained infertility occurs in 30% of couples (after ovulation, tubal patency, and semen analysis have been found to be normal)

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2
Q

Work up

A
  • Medical history
  • Physical examination
  • Laboratory tests
  • Imaging
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3
Q

Work up for the female partner

A
  • Ovarian reserve
  • Ovulatory function
  • Structural abnormalities
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4
Q

Work up for the male partner

A
  • 40-50% of couples male factor infertility is present
  • Medical history
  • Semen analysis
  • Referral to specialist in male reproductive medicine
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5
Q

Prepregnancy Care

A
  • Optimize health, address modifiable risk factors, and provide education
  • Insert Opinion 762
  • Educate about methods to maximize fertility (timing and frequency of intercourse)
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6
Q

• Assess ovarian reserve

A

o Decreased ovarian reserve predicts response to ovarian stimulation
o Measure FSH/Estradiol on cycle day #2-5
o AMH (antiullerian hormone) – diminished if less than 1 ng/mL
 Produced by granulosa cells of antral follicles
 May be assessed on any day of the cycle
o FSH – basal follicle stimulating hormone - diminished if greater than 10 IU/L due to less than ideal response to stimulation
o Estradiol – should be less than 60-80 pg/mL
 Elevated estrogen may suppress FSH and indicate decreased reserve
o Transvaginal ultrasound with antral follicle count – diminished if less than 5-7
 Number of follicles that measure 2-10 mm in both ovaries
 May be elevated in PCOS
 May be depressed in hypothalamic amenorrhea or with hormonal contraception
o H/O poor response to IVF with fewer than 4 oocytes at egg retrieval
o **If ovarian insufficiency/failure and elevated FSH prior to 40; screen for fragile X carrier
 FMR1 premutation

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7
Q

• Assess Ovulatory dysfunction

A

o Ovulatory function test
 Oligomenorrhea or amenorrhea or luteal progesterone less than 3 ng/mL
 Most women have cycles every 21-35 days with moliminal symptoms
 Up to 1/3 of women with normal cycles are annovulatory
 Midluteal progesterone measurement greater than 3ng/mL shows +ovulation
• Produced by corpus luteal cyst following LH surge
o Serum progesterone measurement

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8
Q

• Assess Tubal factor

A

o Hysterosalpingography
 Injection of radiopaque contrast throught the cervix during fluoroscopy
 Determines tubal patency (PPV 38% and NPV 94% - occlusion may require further evaluation)
 May see proximal/distal occlusions of tube, peritubal adhesions, salpingitis
o Hysterosalpingo-contrast sonography
 Ultrasound with infusion of fluid (contrast agent with air bubbles) through a transcervical catheter
 No FDA approved agents (perflutren lipid microspheres, sulfur hexafluoride lipid type A microsphere, agitated saline)

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9
Q

• Assess Uterine factor

A

o Transvaginal ultrasound – 16% of infertility and 40% of AUB have abnormalities on US
 If uncertain may consider 3D US or pelvic MRI
o Sonohysterography
o Hysteroscopy – most definitive method to diagnose polyps, synechiae, and submucousal fibroids
o Hysterosalpingoraphy
 Not great at seeing changes within the cavity unless a mass effect is seen
 Sensitivity of 50%

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10
Q

Uterine factors associated with infertility

A

o Endometrial polyps
o Synechiae
o Mullerian anomalies
o Leiomyomas
o Submucosal or endometrial cavity distorting fibroids may affect fertility
o Myomectomy is not advised in asymptomatic women with noncavity-distorting myomas.

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11
Q

Important points in History for infertility

A

• Duration of infertility, prior eval and tx
• Menstrual history
o Menarche, cycle interval, cycle length, molimina, dysmenorrhea, ovulation signs, cervical mucus change, basal body temps
• Contraception history
• Coital timing and frequency
• Past medical history (hospitalizations, illnesses, injuries)
• Past surgical history
• Medications (supplements, teratogenic meds)
• Allergies
• Social history (use of nicotine products, alcohol or drugs)
o Work – occupation and exposure to environmental/chemical hazards
• Family history (birth defects, developmental delay, early menopause or reproductive issues)
• Obstetric history/ Pregnancy history (G/Ps, route of delivery, complications, fertility treatments, outcomes)
• Gynecologic history (STI, PID, endometriosis, leiomyomas)
o Pap
o Menses
o Contraception
• Review of systems (complete)
o Focus on thyroid, hirsutism, pelvic/abdominal pain, dyspareunia, galactorrhea

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12
Q

Physical exam

A
o	Vital signs
o	Weight, BMI, BP, pulse
o	Signs of androgen excess
o	hirsuitism
o	Thyroid
o	Enlargement or nodules
o	Breast
o	Secretions or other abnormalities
o	Tanner staging
o	Axillary hair
o	Pelvic
o	External
	Pubic hair
o	Vaginal
	vaginal or cervical abnormality
	Abnormal secretions or discharge
o	Uterine
	Size, shape, position, mobility
	Adnexal masses or tenderness
	Cul-de-sac masses, tenderness or nodularity
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13
Q

Male Factor Infertilty

A

o 40-50% of cases
o History
o PMH – childhood illness, developmental, systemic medical illness, gonadal trauma or toxins
o PSH – any cryptorchidism with or without surgery
o Meds – any anabolic steroid use, testosterone, supplements
o Allergies
o Sexual dysfunction – erectile or ejaculation issues
o Coital frequency and timing

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14
Q

Semen Analysis

A

o Abstinence/no ejaculation for 2-5 days prior to testing
o Must be received by the lab within 1 hour and at body temp
o Best obtained at the lab collection room
o Abnormalities should be re-tested
o Semen Volume (should be over 1.5 mL)
o pH (should be >7.2)
o Sperm Concentration (should be 15 X10^6 per mL)
o Total sperm number (should be 39 X 10^6 per ejaculate)
o Total motility (should be 40%)
o Progressive motility (should be 32%)
o Sperm agglutination (should be absent)
o Sperm morphology (%normal forms) WHO says 4% Excellent prognosis if >14%

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15
Q

PCOS

A
o	Diagnosis (no universal diagnosis)
o	NIH, Rotterdam, Androgen Excess, PCOS Society
o	Most common cause of ovulatory infertility
o	Increased risk of metabolic syndrome
o	Waist circumference
o	Blood pressure
o	Fasting lipid panel
o	Glucose tolerance testing
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16
Q

Annovulation

o Associated factors:

A
o	Obesity
o	PCOS
o	Pituitary dysfunction
	Thyroid function and hyperprolactinemia
o	Hypothalamic dysfunction