Infertility And Assited Reproductive Fertility Techniques Flashcards
Infertility definition
Inability of a couple to conceive after 12 months of unprotected regular sexual intercourse without the use of contraceptive
- if women is > 35 = 6 months
- if women < 35 = 12 months
Primary = have never been able to get pregnant
Secondary = has gotten pregnant before, but now cant
Infertility rates are lower with nulliparous women and rates get higher with age
Pathophysiology behind infertility
Can occur at multiple different places
Males
- azzospermia or non functional sperm
Females
- ovaries = anovulation/oligoovulation
- Fallopian tubes = ashermann syndrome, adhesions, PID, etc
- uterus = mullerian anomalies of the uterus or distorted anatomy (cancers, fibroids, etc)
- vagina and cervix = vaginal septum or cervical stenosis
Idiopathic (most common cause)
Male infertility
Usually is idiopathic but can be
- primary testicular defect in spermatogenesis
- hypogonadatropic hypogonadism
- sperm transport anomalies
Types of tubal infertility
Adhesive diseases (ashermann) via
- infections
- surgery
- endometriosis
Previous sterilization (ligation of tubes)
Impaired ciliary transport via CF or excessive smoking
Mullerian anomalies in utero
Work up and clinical evaluation of infertility
Is initiated via PCP or BOGYN specialist
Risk factors: STI, Puerperal infections, surgery, unsafe abortions, TB, female genital cutting, environmental factors, genetic/anatomical/hormonal/immunological issues
History
- sexual history
- menstrual history
- molinminal symptoms (evidence of ovulation actually occurring (breast tenderness, blue changes of cervix, etc))
- medical/surgery Hx
- smoking, paternal history, trauma, sexual dysfunction, etc.
Lab values evaluation
- males = semen analysis
- females = urine LH, progesterone- Day 3 serum FSH, Anti-Mullerian hormone, TSH and prolactin levels
Semen analysis
collect after 2-7 days of ejaculatory abstinence
Volume needed = at least 1.5 mL
Normal sperm concentration = 15 million spermatozoa/mL
Total sperm number = 39 million spermatozoa/mL
Vitality = 58% live
Progressive motility = 32%
Total motility = 40%
Morphology = 4% need to be normal
Ovulatory function evaluation
Mid luteal phase progesterone = 1 week prior to normal menses onset
- should be very high if the women is actually ovulating (if it is not high = no corpus luteum = no ovulation)
Ovulation predictor kits (OPK) for urinary LH surge rough 2 weeks before normal menses Onset
TSH and prolactin levels at any point
- high prolactin = no LH surge
- low TSH = less LH and FSH due top elevated prolactin
Ovulatory reserve evaluation
1) Antrial follicle count = hard to do accurately
- need to use ultrasound (transvaginal) on 3rd day of cycle and count follicles in the ovary
- this can estimate primordial follicle pool
2) Anti-mullerian hormone level (AMH)
- this is released by the preantral and early natural follicles which can be used as a marker of ovarian functions
- **this doesn’t fluctuate with cycle changes so its a better lab test to dot halt can be done at anytime
- **does decline with age and is undetectable at menopause
3) day 3 FSH and estradiol
- stimulates growth and recruitment of ovarian follicles
- subject to negative feedback with estrogen
- poor follicle levels = low estrogens = high levels of FSH
4) Clomiphrane challenge test
- blocks estrogen at hypothalamus as a SERM
- day 3 of period = look at FSG/E2
- day 5-8 of period = use Clomiiphrane
- day 10 = measure FSH again
- poor ovulation = high FSH at day 3 or 10 in the CCCT (overactive axis since there is no estrogen being produced by follicles = primary ovarian failure)
Education for patients who are coming in for infertility
Ovulation is 14 days before period
- fertile window = 5 days before -> 1 day after
Timed inter course is required at this time in order to best increase risks of getting pregnant
In PCOS = loss of 5-10% of body weight alone = restores ovulation in over 60% of them
In males = medications for ER if present
- other wise IVF or IU implantation
Ovulation induction
ONLY used for ovulatory infertility
Clomphene citrate (SERM)
- antagonist at hypothalamus pituitary and uterus for estrogen
- blocks estrogen feedback = excessive GnRH and FSH/LH = increases ovarian follicular development
- **10% risk of multiple gestation rates
- dont use more for 6-12 months (50mg daily for 5 doses starting on day 5 of cycle -> day 10 of cycle
- have unprotected sex every other day for 1 week after day 10 (last pill used)
Letrozole (aromatase inhibtor)
- superior outcomes in PCOS
- decreases risk of multiple gestation
- blocks estrogen = increases GnRH = increases FSH and LH = increases ovarian follicular development
- take 2.5 mg daily for 5 days starting on day 3 (can increase to 7.5 mg max)
- have unprotected sex every other day for 1 week after last pill
What to give if no menstrual cycle for ovulation?
Oral provera 10 mg daily for 10 days
- you need to start a menstrual cycle normally before putting on Clomid or letrozole
Letrozole is better but not FDA approved compared to clomiphene citrate
- durg of choice for PCOS
Indications for IVF
Tubula factors, severe male facotr of infertility, diminished ovary reserve, ovarian failure with donor eggs
Idiophitic reasons
