Infertility and ART Flashcards
Causes of female factor infertility in descending order?
1) Ovulatory disorders
2) Fallopian tube abnormalities (including adhesions)
3) Endometriosis
Ovulatory disorders
1) Hypogonadotrophic hypogonadal anovulation
2) Normogonadotropic normoestrogenic anovulation
3) Hypergonadotropic hypoestrogenic anovulation
4) Hyperprolactinemic anovulation
1) Hypothalamic amenorrhea
2) PCOS
3) Premature ovarian failure, advanced maternal age
Most common ovulatory disorders leading to infertility?
PCOS and advanced maternal age
What happens with oocytes after aging?
Accelerated loss after mid-30s. Decline in quantity and quality.
The problems with conception in AMA are NOT with her body, it’s with her eggs. She could easily carry a donor egg pregnancy!
Mechanism of PCOS?
Genetics affecting the regulation of gonadotropin, androgen, or insulin secretion and action.
Hyperandrogenism leads to disruption of the HPGA axis and leads to chronic anovulation.
How does endometriosis cause adhesions?
It can invade local tissues thus causing severe inflammation and adhesions
How could LEEP, mechanical dilations, etc. cause problems with fertility?
Can result in stenosis and destruction of the endocervical epithelium, leading to inadequate mucous production so sperm then have a hard time making it in.
Luteal phase defect?
Could result in inadequate production of progesterone by corpus luteum
How can you test for ovulatory factor infertility?
Tracking menstrual cycle, measuring basal body temperature, monitoring cervical mucus, measuring the mid-luteal progesterone
What is the test to detect decreased ovarian reserve?
Clomiphine citrate challenge test (CCCT)- give it on days 5-9 of menstrual cycle, measure FSH level on days 3 and 10.
Day 3 FSH should be low (<10mIU/mL) bc a woman with good ovarian reserve will make enough ovarian hormones early in menstrual cycle to INHIBIT FSH and keep it LOW.
Even small elevations in FSH levels correlate with decreased ovarian reserve
Newer battery of tests instead of CCCT?
Basal FSH/estradiol testing
Antral follicle count
Anti-Mullerian hormone assay
Day 3 estradiol should be 0.5 ng/mL) when the primordial follicle pool is good.
Use of saline sonohysterogram?
Complements u/s for better visualization of uterine cavity.
PCOS treatment?
weight loss, metformin
OI with clomid or letrozole
Improving fertility in endometriosis?
You can’t. You can try cutting through the adhesions and endometrial implants…
Improving fertility in primary ovarian insufficiency?
You can’t because there aren’t eggs to work with
Prior tubal ligation treatment?
Tuboplasty with tubal reanastomosis
BUT MOST COUPLES UNDERGO IVF
Treatment for synechiae, septa, polyps, submucosal fibroids?
Operative hysteroscopy
Treatment for cervical stenosis?
Intrauterine insemination
Surgical or mechanical dilation
Normal semen analysis
Volume >2 mL pH 7.2-7.8 Concentration >20 million/mL Morphology >30% normal forms Motility >50% with forward progression WBC <1 million/mL
What is ICSI used for?
Intracytoplasmic sperm injection for low sperm density or impaired motility
Next, transfer it back to the uterine cavity via IVF.
What is clomiphene citrate (Clomid)? Who gets it?
SERM that competitively binds to estrogen receptors in the hypothalamus, thus blocking the negative feedback effect of endogenous estrogen.
This increases GnRH pulsatile frequency, which inc FSH and LH production.
First line for PCOS and unexplained fertility.
NO USE IN PRIMARY OVARIAN INSUFFICIENCY.
What is letrozole?
Aromatase inhibitor that decreases the conversion of androgens to estrogens.
(bc too much estrogen decreases GnRH pulsations)
OFF LABEL USE FOR OI.
What should you do to track someone with OI?
Serial estrogen levels, pelvic u/s (to look at number of follicles, size, etc.)
You did OI. What should patient make sure to do?
HAVE INTERCOURSE or do IUI.
Or, the oocyte has descended and you can try to take it out via transvaginal aspiration then fertilize it with ICSI or IVF.
Selected embryos are then transferred to uterus with u/s guidance. Progesterone is often used to promote endometrial receptivity to the introduced embryo.
Save remaining embryos with cryopreservation.
Complications of ART?
- Multiple gestation pregnancy MC
- Antiestrogen effects like hot flashes, bloating, depression, visual changes
- Ovarian hyperstimulation syndrome: LIFE THREATENING AND IATROGENIC. Range of minimal to scary sx.
