Infertility and ART Flashcards
Risk of heterotopic pregnancy in IVF
The risk of heterotopic pregnancy among women with a naturally achieved pregnancy is estimated to range from 1 in 4,000 to 1 in 30,000, whereas the risk among women who have undergone in vitro fertilization is estimated to be as high as 1 in 100
The criteria for normal semen parameters (WHO 2010) are:
Volume (mL): ≥1.5
Concentration (x 106 mL): ≥15
Total sperm number (x 106 mL): ≥39
Total motility (%): ≥40
Progressive motility (%): ≥32 Normal morphology (%): ≥4
WBC (x 106 mL): ≤1.
PCOS has increased risk of
1) endometrial Ca
PET
RPL
When the infertility cycle cancelled ?
If
-there is no response to injections
- high estradiol levels
Micro-flare (short) protocol
For low-reserve ovarian Pt
Or who is not responding
Diffuse adenomysosis associated with
Infertility 20% and miscarriages 50%
Common side effects of CC
Hypoestrogeniemia S&S
Double vision > you have to stop medication right away associated with underlying pituitary tumor
Multiple gestational rate 8%
Usual dose: 50-150 mg
The minimum endometrial thickness for successful embryo implantation
7 mm
The rate of multiple gestation with letrozole
4% ( near the normal percent)
When did you consider removing endometrioma in infertility ?
If the size > 5 cm
When the amount measured in the circulation in the nonpregnant woman exceeds a certain level, usually —- ng/ mL (=— to —) , the condition is called hyperprolactinemia.
When the amount measured in the circulation in the nonpregnant woman exceeds a certain level, usually 20 to 25 ng/ mL (=425 to 531) , the condition is called hyperprolactinemia.
if elevated above 100 ng/mL, imaging of the sella turcica should be performed to determine whether a macroadenoma is present.
The incidence of galactorrhea in women with hyperprolactinemia has been reported to range from —- to– % and these differences probably reflect variations in the techniques used to detect mammary excretion.
The incidence of galactorrhea in women with hyperprolactinemia has been reported to range from 30% to 80%, and these differences probably reflect variations in the techniques used to detect mammary excretion.
Causes of Hyperprolactinemia
Pituitary Disease: (Prolactinomas,Acromegaly,Empty sella syndrome,Lymphocytic hypophysitis, Cushing disease)
Hypothalamic Disease:(Craniopharyngiomas,Meningiomas,Dysgerminomas,Nonsecreting pituitary adenomas, Other tumors, Sarcoidosis,Eosinophilic granuloma, Neuraxis irradiation, Vascular, Pituitary stalk section)
Medications:(tricyclic antidepressants block dopamine uptake and pro-pranolol, haloperidol, phentolamine, and cyproheptadine block hypothalamic dopamine receptors)
Neurogenic:(Chest wall lesions,Spinal cord lesions,Breast stimulation)
Other:(Pregnancy,Hypothyroidism,Chronic renal failure,Cirrhosis, Pseudocyesis, Adrenal insufficiency, Ectopic, Polycystic ovary syndrome, Idiopathic)
Pharmacologic Agents Affecting Prolactin Concentrations
Stimulators: Anesthetics, including cocaine
Psychoactive drugs Phenothiazines Tricyclic antidepressants Opiates Chlordiazepoxide Amphetamines Diazepam Haloperidol Fluphenazine Chlorpromazine SSRIs
Hormones Estrogen Oral-steroid contraceptives Thyrotropin-releasing hormone
Antihypertensives α-Methyldopa Reserpine Verapamil
Dopamine receptor antagonists Metoclopramide
Antiemetics Sulpiride Promazine Perphenazine
Others Cimetidine Cyproheptadine
Protease inhibitors Inhibitors l-Dopa Dopamine Bromocriptine Pergolide Cabergoline Depot bromocriptine
Primary hypothyroidism can also produce hyperprolactinemia and galactorrhea because of decreased negative feed-back of thyroxine (T4) on the hypothalamic-pituitary axis. The resulting increase in TRH stimulates PRL secretion and thyroid-stimulating hormone (TSH) secretion from the pituitary.
3% to 5% of individuals with hyperprolactinemia have hypothyroidism. Therefore TSH, the most sensitive indicator of hypothyroidism, should be measured in all individuals with hyperprolactinemia.
Hyperprolactinemia has been reported to occur in approximately 25% of those with acromegaly and 10% of those with Cushing disease, indicating that these pituitary adenomas, which mainly secrete growth hormone (GH) and adrenocorticotropic hormone (ACTH), frequently also secrete PRL.
Various types of pituitary tumors, lactotroph hyperplasia, and the empty sella syndrome can be associated with hyperprolactinemia. It has been estimated that as many as 80% of all pituitary adenomas secrete PRL.
Functional hyperprolactinemia
the term used for the clinical diagnosis of cases of elevated PRL levels without imaging evidence of an adenoma.
primary empty sella syndrome
describes a clinical situation in which an intrasellar extension of the subarachnoid space results in compression of the pituitary gland and an enlarged sella turcica. The cause is believed to result from a congenital or acquired (by radiation or surgery) defect in the sella diaphragm that allows the subarachnoid membrane to herniate into the sella turcica.
The best modality for diagnosing empty sella syndrome is ……….. It is important to establish the diagnosis because the syndrome has a benign course.
magnetic resonance imaging (MRI)
Several studies have reported that pregnancy is beneficial for women with functional hyperprolactinemia or PRL-secreting microadenomas. Following pregnancy, PRL levels decrease in approximately 50% of women.
Therefore if women with hyperprolactinemia desire to become pregnant, they should be encouraged to do so, because pregnancy is likely to result in normal or lowered PRL levels.
IMAGING STUDIES Current recommended for central causes of hyperprolactinemia
CT scan with intravenous contrast or an MRI with gadolinium enhancement. T he latter provides better soft tissue definition, without radiation
Those with hyperprolactinemia, with or without microadenomas, who have adequate estrogen levels and who do not wish to conceive should be treated with
periodic progestogen withdrawal (e.g., medroxyprogesterone acetate, 5 to 10 mg/day for 10 days each month) or with combination oral contraceptives to prevent endometrial hyperplasia.
Post-op complications of micro/macroadenomas removal
T he risk of temporary postoperative diabetes insipidus is 10% to 40%, but the risk of permanent diabetes insipidus and iatrogenic hypopituitarism is less than 2%. The initial cure rate, with normalization of PRL levels and return of ovulation, is relatively high for microadenomas (65% to 85%) but less so with macroadenomas (20% to 40%). Vision can return to normal in 85% of patients with loss of acuity and visual field defects.The initial cure rate is related to the pretreatment PRL levels. T hose tumors with PRL levels less than 100 ng/mL have an excellent prognosis (85%), and those with levels higher than 200 ng/ mL have a poor prognosis (35%).
breastfeeding and hyperprolactinemia
Breastfeeding may be initiated without adverse effects on the tumors and may be initiated after delivery unless there have been visual field defects during pregnancy
The commonest cause of anovulation is
Polycystic Ovarian Syndrome (PCOS)
is the first drug of choice used in management of anovulatory infertility.
Clomiphene Citrate (CC)
Congenital bilateral absence of the vas deferens is associated with
Cystic fibrosis
lnfertilityTesting of ovulatory function/ ovarian reserve
Ovulation predictor kit
Early follicular FSH ± estradiol level
Antimullerian hormone (AMH)
Endocrine disorders (TSH, prolactin)
Ovarian sonography (antral follicle count)
lnfertilityTesting of Tubal/pelvic disease
Hysterosalpingography Laparoscopy + chromotubation
Probable ovulation is also suggested by mittelschmerz, which is
midcycle pelvic pain associated with ovulation, or by moliminal symptoms such as breast tenderness, acne, food cravings, and mood changes.
the midluteal progesterone level (serum is obtained on cycle day number 21 following the first day of menstrual bleeding, or 7 days following ovulation) is best regarded as an acceptable test for
ovulation but not an absolute indicator of adequate: luteal function.
With PID, tubal infertility has been estimated following one, two, or three cases of PID,
to follow in 12 percent, 23 percent, and 54 percent of women
Salpingitis isthmica nodosa
is an inflammatory condition of the fallopian tube, characterized by nodular thickening of its isthmic portion. Histologically, smooth muscle proliferation and diverticula of tubal epithelium contribute to this thickening. This uncommon condition typically develops bilaterally and progressively leads to ultimate tubal occlusion and infertility
Causes of male infertility can roughly be categorized as
abnormalities of sperm production, sperm function, or obstruction of the ductal outflow tract.
The seminiferous tubules contain
developing sperm and support cells called Sertoli cells or sustentacular cells
The Sertoli cells form tight junctions that produce a
blood-testis barrier. This avascular space within the seminiferous tubules protects sperm from anti-bodies and toxins but also makes these cells dependent on dif-fusion for oxygen, nutrients, and metabolic precursors.
Located between the seminiferous tubules are Leydig cells, also called interstitial cells, which are responsible for
steroid hormone production.
Oligospermia means
Sperm concentration 10-15 million sperm/ml (mild-moderate) or <5-1O million/ml (severe)
Asthenospermia
Greater proportion of immotile sperm or sperm with decreased motility
Teratospermia
Increased proportion of morphologically abnormal sperm
Azoospermia VS. Aspermia
Azoospermia Semen present but lacks sperm
Aspermia Sperm and seminal plasma lacking (anejaculation)
Leukocytospermia
Increased white blood cell count
Necrospermia
All sperm nonviable or immotile
Low semen volume can indicate
incomplete specimen collection or short abstinence interval.
partial vas deferens obstruction or retrograde ejaculation.
Partial or complete vas deferens obstruction may be caused by
infection, tumor, prior testicular or inguinal surgery, or trauma.
Retrograde ejaculation follows
failed closure of the bladder neck during ejaculation and allows seminal fluid to flow backward into the bladder. Retrograde ejaculation is sus-pected in men with diabetes mellitus, spinal cord damage, or prior prostate or other retroperitoneal surgery that may have damaged nerves, Medications, particularly f3-blockers, may contribute to this problem.
Retrograde ejaculation diagnosis
A postejaculatory urinalysis can detect sperm in the bladder and confirm the diagnosis. If urine is properly alkalinized, these sperm are viable and can be retrieved to achieve pregnancy.
In any patient with POi, what karyotype testing for ….. should be considered?
trisomy 21/ Turner syndrome
Fragile X premutation carrier screening should be discussed with any woman with a family or personal history of POi or family history of intellectual disability.
For anovulatory infertility in women with PCOS , ESRE/ASRM guidelines recom-mend first-line treatment with
letrozole or clomiphene citrate
Biopsy of PGD can be taken from :( each option mention pros and cons)
