Infertility and Abortion Flashcards
Fertility
Capacity to conceive and produce offspring
Fecundability
Probability or achieving a pregnancy in one menstrual cycle
More accurate descriptor b/c recognizes varying degrees of infertility
Infertility
Diminished capacity to conceive despite frequent coitus
Subfertility
More appropriate description of most infertile couples
Sterility
Inability to conceive offspring, usually used after sterilization procedure or specific illness, exposure or genetic condition (mumps, chemo, klinefelter)
Why does fecundability decrease?
As woman ages due to declining quantity and quality of oocytes (first 3 cycles of unprotected intercourse=.25 and decreased over next 9 months of cycles)
How to define infertility
Inability to conceive after 12 mos of unprotected intercourse for women 35 or younger
Inability to conceive after 6 mos of unprotected intercourse for women 35+
Primary and secondary infertility
Primary: individuals who have never conceived (higher 40-44 YO)
Secondary: infertility after prior fertility
Causes of infertility
Male factor
Female factor (37%)
Combned
Unknown
Categories of male factor infertility
Endocrine and systemic disorders
Primary testicular defects in spermatogenesis
Sperm transport disorders
Idiopathic male infertility
Clinical semen findings in male factor infertility
Low sperm conc
Absent sperm
Motility issues
Morphology issues
How to obtain semen analysis
Masturbation sample at office or lab
2-7 days of sexual abstinence
2 samples taken 1-2 wks apart
Serum analysis WHO criteria
Vol: 1.5 ml
Sperm conc: 15 mil spermatozoa/mL
Total sperm number: 39 mil spermatazoa per ejaculate
Morphology: 4% normal forms, strict Tygerbergmethod
Vitality: 58% live
Progressive motility: 32%
Total (progressive and nonprogressive motility)- 40%
Most common congenital abnormality causing primary hypogonadism
Klinefelters (47 XXY)
Main contributing factors of female factor infertility
Ova
Patent oviduct
Anatomic abnormalities of uterua
What to consider with ova
Quantity and quality: age and surgeries/injury to ovary
Ovulation: discharge of ova or ovules from ovary
Complications of ovulation
Polycystic ovarian syndrome Thyroid dysfunction (hyper and hypo) Hyperprolactinemia
Presentation of polycystic ovarian syndrome
Cutaneous signs of hyperandrogenism
Oligomenorrhea or amenorrhea
Obesity and insulin resistance
Causes of oligomenorrhea and amenorrhea in PCOS
Lack of progesterone (no corpus luteum) causing unopposed estrogen exposure–hyperplastic growth
Irregular sloughing of endometrium–oligomenorrhea
High prolactin states
Breastfeeding Breast stimulation/intercourse Extreme exercise Meds (risperidone) If persistently elevated look for pituitary adenoma on MRI
Tx of PCOS
Diet and exercise
Provera cycling
Metformin
Clomiphene
Tx of thyroid def
PTU or levothyroxine
Tx of prolactinemia
Bromocriptine (Safe in pregnancy but stop when get + pregnancy test)
What is clomiphine?
SERM
Serious short term complication of ovarian hyperstimulation (lead to thromboembolic events)
Tubal factors leading to infertility
Occluded oviducts (proximal or distal, from untreated STDs or PID, mucous or anatomic abnormalities)
Injury/surgery to oviduct
r/o with hysterosalpingogram
Limitations of HSG
Not covered by insurances
Maybe painful
Evaluates for tubal patency not function
Txs for tubal factors
Surgical tubal repair
IVF
Surgical tubal repair
Rarely performed
High failure rates
Increased risk of ectopic pregnancy
2 most important questions for fertility HPI
Regular menstrual cycles?? (21-35 days and varying 2-7 days in length)
How often are they having intercourse??- recommend every other day around ovulation
Other pertinent history questions for fertility
Dysmenorrhea?
History of irregular menses?
Signs of regular ovulation?
Signs of regular ovulation
Evaluate cervical mucous (spinnbarkeit or egg white)
Breast tenderness resolves with menses onset
Mittelschmerz (pain with ovulation)
Swelling or bloating that subsides with menses
Day 21 progesterone lab draw
Important HPI for female
Age, medical history, meds, social history review, surgical history
Important HPI for male
Medical history (mumps)
Meds
Social history (anabolic steroids, EtOH, chemo, psychotropic meds, chemicals)
Surgical history (vasectomy, hernia repair, orchiectomy)
Developmental history
Combo HPI
Primary vs secondary infertility (successful, abortions and miscarriages too)
How long trying
Contraceptives previously?
When to start fertility tx if know there is specific cause for infertility?
No need to wait 6-12 mos so refer early
Reasons for elective abortion
Unplanned pregnancy
Fetal anomalies
Maternal health
Meds for elective abortion
Misoprostol or mifepristone
May have risk of retained products of infection (prophylactic abx)
FDA approved to 70 days gestation
Surgical way for elective abortion
Depending on gestational age:
Suction D&C
Dilation and evacuation
Stimulation of labor
Definition of spontaneous abortion
Miscarriage
Pregnancy loss which occurs prior to 20 wks gestation
Most common complication of pregnancy
Work up for spontaneous abortion
CBC
Rh type
HCG quantitative
Pelvic and transvaginal u/s
Important things to remember for spontaneous abortion
Most common cause is abnormal karyotype (>50%)
Usually in first trimester (<8 wks)
Genetic studies rarely performed for isolated SAB
Rh neg women need rhogram injection
Complete spontaneous abortion
Complete passage of products of conception
Incomplete spontaneous abortion
Retention of part/all products of conception
Threatened spontaneous abortion
Closed cervical os- bleeding with + urine pregnancy test
Inevitable spontaneous abortion
Open cervical os (presents with bleeding)
Missed abortion
Absent heartbeat without bleeding, cervix is closed
Septic spontaneous abortion
Any above abortion with infected POC (products of conception) or endometrial lining
Recurrent abortion
Three or more consecutive losses prior to 20 wks (SABs)
“Habitual aborter”
Risk increases with each subsequent SAB
Refer to reproductive endocrinology
Causes of recurrent abortion
Abnormal karyotype Uterine malformations Antiphospholipid antibody (Antiphospholipid syndrome)-lupus common co-presentation Chronic uncontrolled med conditions Insufficient progesterone levels
Work up for recurrent abortion
History (age, chronic disease) Karyotype of both parents Karyotype of aborted embryo Luteal phase progesterone Antiphospholipid Ab Lupus work up Uterine cavity eval
First thing to always check with fertility and pregnancy!!!
BMI
