Infertility and ART

Question 1

Causes of female factor infertility in descending order?

Answer 1

1) Ovulatory disorders
2) Fallopian tube abnormalities (including adhesions)
3) Endometriosis

Question 2

Ovulatory disorders

1) Hypogonadotrophic hypogonadal anovulation
2) Normogonadotropic normoestrogenic anovulation
3) Hypergonadotropic hypoestrogenic anovulation
4) Hyperprolactinemic anovulation

Answer 2

1) Hypothalamic amenorrhea
2) PCOS
3) Premature ovarian failure, advanced maternal age

Question 3

Most common ovulatory disorders leading to infertility?

Answer 3

PCOS and advanced maternal age

Question 4

What happens with oocytes after aging?

Answer 4

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!

Question 5

Mechanism of PCOS?

Answer 5

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.

Question 6

How does endometriosis cause adhesions?

Answer 6

It can invade local tissues thus causing severe inflammation and adhesions

Question 7

How could LEEP, mechanical dilations, etc. cause problems with fertility?

Answer 7

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.

Question 8

Luteal phase defect?

Answer 8

Could result in inadequate production of progesterone by corpus luteum

Question 9

How can you test for ovulatory factor infertility?

Answer 9

Tracking menstrual cycle, measuring basal body temperature, monitoring cervical mucus, measuring the mid-luteal progesterone

Question 10

What is the test to detect decreased ovarian reserve?

Answer 10

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

Question 11

Newer battery of tests instead of CCCT?

Answer 11

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.

Question 12

Use of saline sonohysterogram?

Answer 12

Complements u/s for better visualization of uterine cavity.

Question 13

PCOS treatment?

Answer 13

weight loss, metformin

OI with clomid or letrozole

Question 14

Improving fertility in endometriosis?

Answer 14

You can’t. You can try cutting through the adhesions and endometrial implants…

Question 15

Improving fertility in primary ovarian insufficiency?

Answer 15

You can’t because there aren’t eggs to work with

Question 16

Prior tubal ligation treatment?

Answer 16

Tuboplasty with tubal reanastomosis

BUT MOST COUPLES UNDERGO IVF

Question 17

Treatment for synechiae, septa, polyps, submucosal fibroids?

Answer 17

Operative hysteroscopy

Question 18

Treatment for cervical stenosis?

Answer 18

Intrauterine insemination

Surgical or mechanical dilation

Question 19

Normal semen analysis

Answer 19

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

Question 20

What is ICSI used for?

Answer 20

Intracytoplasmic sperm injection for low sperm density or impaired motility

Next, transfer it back to the uterine cavity via IVF.

Question 21

What is clomiphene citrate (Clomid)? Who gets it?

Answer 21

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.

Question 22

What is letrozole?

Answer 22

Aromatase inhibitor that decreases the conversion of androgens to estrogens.
(bc too much estrogen decreases GnRH pulsations)
OFF LABEL USE FOR OI.

Question 23

What should you do to track someone with OI?

Answer 23

Serial estrogen levels, pelvic u/s (to look at number of follicles, size, etc.)

Question 24

You did OI. What should patient make sure to do?

Answer 24

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.

Question 25

Complications of ART?

Answer 25

• 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.