Infertility and Assisted Reproductive Technologies

Question 1

Normal fecundity (ability to get pregnant in one cycle)

Answer 1

20-25% in first 3 mo
15% in next 9 mo
80-90% within 12 mo
Start workup after one year

Question 2

Female factor in infertility (45-55%)

Answer 2

Ovulatory disorders
Tubal factors
Uterine/cervical factors
Endocrine factors
Other

Question 3

Ovulatory disorders affecting infertility

Answer 3

PCOS / advanced maternal age most common
Track menstrual cycle with basal body temp chart, mid-luteal progesterone
Clomiphine citrate challenge test: give clomiphine on days 5-9, then measure FSH on days 3 and 10. If FSH high, suggests that ovarian reserve diminished (not making estrogen, so FSH increased

Question 4

Tubal factors affecting infertility

Answer 4

PID → adhesions, hx ectopics, endometriosis, previous surg → adhesions
May need HSG for tubal patency and/or laparoscopy to look for adhesions / endometriosis
GC/CT cx and Pap smears as well

Question 5

Uterine / cervical factors affecting infertility

Answer 5

Asherman’s, DES exposure, cervical stenosis (after conization, 4+ mechanical dilations, cauterization - also cause inadequate mucous production)
Progestin challenge test & combined estrogen / progesterone challenge to look for endometrial suitability
Pelvic U/S to look for fibroids, adenomyosis, cancer, polyps, etc.
Hysteroscopy is next step

Question 6

Endocrine factors affecting infertility

Answer 6

Hypothyroid, hyperPRL, Cushing’s, CAH, etc Get appropriate labs

Question 7

Others factors affecting infertility

Answer 7

Luteal phase defect (controversial), Turner’s syndrome / translocations, etc.

Question 8

Treatment options: clomiphine citrate

Answer 8

SERM, estrogen antagonist at hypothalamus, stimulates GnRH production → increasedLH/FSH surges → ramps up follicular development

Question 9

Treatment options: Letrozole

Answer 9

Aromatase inhibitor, decreases peripheral estrogen production → more GnRH → more LH/FSH→ more follicles, etc.
Decreases peripheral estrogen (good for fertility in breast cancer pts, etc)

Question 10

Treatment options: Metformin

Answer 10

Insulin sensitizer (biguanide), but some studies suggest it doesn’t help in PCOS

Question 11

Treatment options: Human menopausal gonadotropins

Answer 11

Purified FSH/LH, next line after Clomiphine

Question 12

Treatment options: Follistatins (Follistim)

Answer 12

Recombinant FSH, stimulates follicular development

Question 13

Treatment options: Recombinant hCG

Answer 13

Similar to LH, used to trigger ovulation after follicle stimulation

Question 14

Treatment options: Pulsatile GnRH

Answer 14

Can be used to increase FSH/LH release. Often used for HPA axis failure (e.g. low wt)

Question 15

Treatment options: surgery

Answer 15

For endometriosis, or tuboplasty with reanastamosis (although many go straight to IVF), or uterine factors (cut synechiae, remove polyps, etc)

Question 16

Male factor infertility (35%)

Answer 16

Check semen analysis.

Avoid tight underwear, saunas, hot tubs, excess radiation / heat / some meds /steroids / marijuana /etc.

Question 17

Normal semen

Answer 17

> 2mL, pH 7.2-7.8, > 20 million / mL sperm with > 30% normal forms, > 50% with forward progression (motility), < 1 million WBC / mL

Question 18

Treatment for low sperm density or impaired motility

Answer 18

Can use ICSI (intracytoplasmic sperm injection) if low sperm density or impaired motility

Question 19

Unexplained etiology of infertility (10%)

Answer 19

Often try IVF → ICSI → donor sperm
If no cause found, some studies suggest that therapy has no higher success than no treatment at all - 60% eventually become pregnant over 3-5 years no matter what.

Question 20

Treatment for: absent or infrequent ovulation (PCOS, mild hypothalamic amenorrhea)

Answer 20

Clomid

Letrozole

Question 21

Treatment for: Pituitary gland not making LH/FSH, or fails

Answer 21

Human menopausal gonadotrophin

Question 22

Treatment for: Really bad hypothalamic amenorrhea

Answer 22

Recombinant GnRH

Question 23

Treatment for: Poor sperm motility, low sperm count

Answer 23

ICSI

Question 24

Treatment for: Azoospermia

Answer 24

Donor sperm

Question 25

Treatment for: Ovarian failure (advanced maternal age or PMOF)

Answer 25

Donor egg

Question 26

Complications of assisted reproductive technologies:

Answer 26

Multiple gestations

Ovarian hyperstimulation syndrome (OHSS)

Question 27

Ovarian hyperstimulation syndrome (OHSS)

Answer 27

Ovarian enlargement, can lead to torsion / rupture, can be complicated by ascites / pleural effusion / hemoconcentration / hypercoagulability / renal failure / even death

Question 28

Preimplantation genetic diagnosis:

Answer 28

Evaluate embryo for genetic abnormalities before implanting into uterus
E.g. for pt with hx of Huntington’s, sickle cell, etc

Question 29

Preimplantation genetic screening:

Answer 29

Screen for conditions, usually chromosomal, screening for aneuploidy
E.g. for advanced maternal age, etc.