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Year 2 OBGYN > Infertility and polycystic ovarian syndrome > Flashcards

Infertility and polycystic ovarian syndrome Flashcards

1
Q

definition: infertility

A

inability to conceive despite regular, unprotected intercourse without conception for 12 months (6 months if woman is over 35)

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2
Q

definition: fecundability

A

ability to conceive within a given month / cycle

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3
Q

infertility affects what % of reproductive age couples?

A

10-15%

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4
Q

what are the etiologies of infertility?

A
  • male factor
  • female factors (endometriosis, tubal damage, cervical)
  • coital timing
  • unexplained
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5
Q

what are the proportions of cause for male / female / both?

A

1/3 female
1/3 male
1/3 both

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6
Q

surgical history for infertility should include what factors?

A
  • appendix (important)
  • D&C
  • LEEP (excision of ectocervix for abnormal pap smears)
  • laparoscopy for endometriosis
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7
Q

how does LEEP relate to infertility?

A

causes cervical stenosis (os is scarred)

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8
Q

what % of viable sperm are necessary for a normal sperm count?

A

4%

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9
Q

what is the normal volume of semen?

A

1.5 mL

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10
Q

what is the normal % of swimming sperm for semen analysis?

A

32% motility

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11
Q

a finding of hirsutism in females should indicate which lab tests?

A

DHEA-S

testosterone

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12
Q

high fasting insulin : glucose ratio indicates?

when would you check for this in the context of infertility?

A

insulin resistance

if LH : FSH is abnormal

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13
Q

if there are no recent menses, what test could you do? what does it show?

A

progesterone challenge test

proves HPG axis is intact

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14
Q

anovulation and androgen excess - what should you consider? what could be measured?

A

late onset congenital adrenal hyperplasia

check 17-OH progesterone levels

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15
Q

what is lacking in luteal phase defect?

A

progesterone

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16
Q

what are the medications for PCOS?

A

clomiphene

letrozole

17
Q

what are the medications for unknown anovulation?

A

clomiphene (BMI under 30)

letrozole (BMI over 30)

18
Q

if you are successful in treating infertility, what should you do next?

A
  • check quantitative BHCG
  • check (maybe) serum progesterone
  • repeat quantitative BHCG in 48 hours
  • possibly start progesterone suppositories until labs return
19
Q

what is the most common cause of infertility?

A

polycystic ovarian syndrome

20
Q

what are some diagnostic criteria for PCOS?

A
  • hyperandrogenism
  • ovulatory dysfunction
  • polycystic ovaries on US

need 2/3 for diagnosis

21
Q

what conditions are associated with PCOS?

A
  • obesity
  • T2DM
  • OSA
  • dyslipidemia
  • infertility
  • thyroiditis
  • mood disorders
22
Q

what is the clinical presentation for PCOS?

A
  • menstrual irregularities
  • acne
  • hirsutism
  • androgenic alopecia (temporal balding)
  • obesity
23
Q

what is characteristic for PCOS on US?

A

“string of pearls” appearance or increased ovarian volume

24
Q

what is the biochemical presentation for PCOS?

what lab tests should be ordered?

A
  • hyperandrogenism
  • LH : FSH over 2
  • hyperinsulinemia
  • dyslipidemia

thyroid, prolactin, 17-OH progesterone, cortisol (maybe)

25
Q

what is the role of insulin in PCOS?

A
  • increases ovarian androgen production
  • inhibits hepatic production of SHBG
  • increased free androgens
  • alters follicular development
26
Q

what are the treatment goals for PCOS?

A
  1. lessen symptoms of hyperandrogenism
  2. manage metabolic comorbidities
  3. prevent chronic anovulation which can lead to endometrial hyperplasia and carcinoma
  4. contraception, or ovulation induction if fertility desired
27
Q

what are the first line treatment strategies for PCOS?

A
  • lifestyle changes: diet, exercise

- oral contraceptive pills

28
Q

what is the second line treatment strategy for PCOS? what else is required for this?

A
  • spironolactone

- must use form of contraception

29
Q

what is the role of metformin in PCOS?

A
  • 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

30
Q

in a PCOS patient with infertility and without menses, what test should be done? what is done / what are the results?

A

provera challenge test

10d of progesterone - should have a withdrawal bleed 7d later

31
Q

if there is no spontaneous ovulation following a provera challenge test, what should be done?

A

on day 3-5 start

  • clomiphene citrate (anti-estrogen) OR
  • letrozole (aromatase inhibitor)

(based on BMI)

32
Q

what should be done following a provera challenge test and clomiphene / letrozole?

A

check serum progesterone on day 21

  • ovulation = no dose change
  • no ovulation = dose increase
33
Q

what are the lifelong implications of PCOS?

A
  • CVD
  • T2DM
  • endometrial cancer

Year 2 OBGYN (33 decks)

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