Infertility Flashcards
Definition of infertility
• 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)
Work up
- Medical history
- Physical examination
- Laboratory tests
- Imaging
Work up for the female partner
- Ovarian reserve
- Ovulatory function
- Structural abnormalities
Work up for the male partner
- 40-50% of couples male factor infertility is present
- Medical history
- Semen analysis
- Referral to specialist in male reproductive medicine
Prepregnancy Care
- Optimize health, address modifiable risk factors, and provide education
- Insert Opinion 762
- Educate about methods to maximize fertility (timing and frequency of intercourse)
• Assess ovarian reserve
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
• Assess Ovulatory dysfunction
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
• Assess Tubal factor
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)
• Assess Uterine factor
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%
Uterine factors associated with infertility
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.
Important points in History for infertility
• 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
Physical exam
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
Male Factor Infertilty
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
Semen Analysis
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%
PCOS
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
