Infertility and polycystic ovarian syndrome Flashcards
definition: infertility
inability to conceive despite regular, unprotected intercourse without conception for 12 months (6 months if woman is over 35)
definition: fecundability
ability to conceive within a given month / cycle
infertility affects what % of reproductive age couples?
10-15%
what are the etiologies of infertility?
- male factor
- female factors (endometriosis, tubal damage, cervical)
- coital timing
- unexplained
what are the proportions of cause for male / female / both?
1/3 female
1/3 male
1/3 both
surgical history for infertility should include what factors?
- appendix (important)
- D&C
- LEEP (excision of ectocervix for abnormal pap smears)
- laparoscopy for endometriosis
how does LEEP relate to infertility?
causes cervical stenosis (os is scarred)
what % of viable sperm are necessary for a normal sperm count?
4%
what is the normal volume of semen?
1.5 mL
what is the normal % of swimming sperm for semen analysis?
32% motility
a finding of hirsutism in females should indicate which lab tests?
DHEA-S
testosterone
high fasting insulin : glucose ratio indicates?
when would you check for this in the context of infertility?
insulin resistance
if LH : FSH is abnormal
if there are no recent menses, what test could you do? what does it show?
progesterone challenge test
proves HPG axis is intact
anovulation and androgen excess - what should you consider? what could be measured?
late onset congenital adrenal hyperplasia
check 17-OH progesterone levels
what is lacking in luteal phase defect?
progesterone
what are the medications for PCOS?
clomiphene
letrozole
what are the medications for unknown anovulation?
clomiphene (BMI under 30)
letrozole (BMI over 30)
if you are successful in treating infertility, what should you do next?
- check quantitative BHCG
- check (maybe) serum progesterone
- repeat quantitative BHCG in 48 hours
- possibly start progesterone suppositories until labs return
what is the most common cause of infertility?
polycystic ovarian syndrome
what are some diagnostic criteria for PCOS?
- hyperandrogenism
- ovulatory dysfunction
- polycystic ovaries on US
need 2/3 for diagnosis
what conditions are associated with PCOS?
- obesity
- T2DM
- OSA
- dyslipidemia
- infertility
- thyroiditis
- mood disorders
what is the clinical presentation for PCOS?
- menstrual irregularities
- acne
- hirsutism
- androgenic alopecia (temporal balding)
- obesity
what is characteristic for PCOS on US?
“string of pearls” appearance or increased ovarian volume
what is the biochemical presentation for PCOS?
what lab tests should be ordered?
- hyperandrogenism
- LH : FSH over 2
- hyperinsulinemia
- dyslipidemia
thyroid, prolactin, 17-OH progesterone, cortisol (maybe)
what is the role of insulin in PCOS?
- increases ovarian androgen production
- inhibits hepatic production of SHBG
- increased free androgens
- alters follicular development
what are the treatment goals for PCOS?
- lessen symptoms of hyperandrogenism
- manage metabolic comorbidities
- prevent chronic anovulation which can lead to endometrial hyperplasia and carcinoma
- contraception, or ovulation induction if fertility desired
what are the first line treatment strategies for PCOS?
- lifestyle changes: diet, exercise
- oral contraceptive pills
what is the second line treatment strategy for PCOS? what else is required for this?
- spironolactone
- must use form of contraception
what is the role of metformin in PCOS?
- decreases serum free testosterone
- increases HDL
- weight loss
- restores ovulation in 50% PCOS patients
it is NO LONGER recommended as first line or additive treatment (unless also diabetic) except in women with glucose intolerance
in a PCOS patient with infertility and without menses, what test should be done? what is done / what are the results?
provera challenge test
10d of progesterone - should have a withdrawal bleed 7d later
if there is no spontaneous ovulation following a provera challenge test, what should be done?
on day 3-5 start
- clomiphene citrate (anti-estrogen) OR
- letrozole (aromatase inhibitor)
(based on BMI)
what should be done following a provera challenge test and clomiphene / letrozole?
check serum progesterone on day 21
- ovulation = no dose change
- no ovulation = dose increase
what are the lifelong implications of PCOS?
- CVD
- T2DM
- endometrial cancer
