Infertility + Associated Conditions Flashcards
Infertility is defined as…
The inability to conceive after 1 year of unprotected intercourse
Primary = no child, secondary = previously successful in conceiving
Infertility should be investigated when…
Pregnancy is not achieved after 12 months of unprotected intercourse: woman is under 35 y.o.
An earlier investigation of infertility (within 6 months) may be appropriate in some women, in cases…
Age 35+
Menstrual abnormality
Previous abdominal/pelvic/urogenital surgery
Hx of pelvic disease, STI’s
Abnormal genital exam
Risk factors for infertility vary because…
It depends on the reason causing infertility - potentially modifiable or not
Female factors of infertility are primarily based on these 3…
Increasing age
Ovulatory dysfunction
Anatomical factors
Some factors that contribute to infertility with aging are…
Increased exposure to development of disease
Ovulation becomes more irregular
Fewer + lower quality eggs remain
Ovulatory dysfunction is when the ovaries ____ and may be caused by factors such as…
Ovaries fail to produce a mature egg on a regular basis
Anovulation
PCOS
Luteal phase defect
Anovulation occurs as a result of disruption of ____
The hypothalamic-pituitary-ovarian (HPO) axis
Anovulation can be due to a variety of causes, such as…
Endocrine disorders
Physical injury to the hypothalamus or pituitary gland
Excessive weight changes
Excessive exercise, stress
Exposure to chemotherapy/radiation
Correction where possible, but not always feasible
Polycystic ovarian syndrome (PCOS) is a syndrome of ovarian dysfunction characterized by…
- Hyperandrogenism
- Ovulatory dysfunction
- Polycystic ovaries
The cause of PCOS is ____, but is thought that…
Unknown - thought that peripheral insulin resistance can lead to hyperinsulinemia + stimulation of excess ovarian androgen production
Is a genetic link
Signs and symptoms of PCOS usually include…
Menstrual irregularities (amenorrhea, oligomenorrhea)
Hyperandrogenism
Overweight/obesity
Infertility
Hyperandrogenism may present as…
Hirsutism - usually body hair in a “male” pattern
Acne
Seborrhea
Alopecia
Associated comorbidities with PCOS include…
Reproductive challenges
Endometrial hyperplasia/cancer
Metabolic issues
OSA
Depression
Goals of treatment for PCOS may be to…
Decrease/get rid of hyperandrogenic features
Manage underlying cardiometabolic abnormalities
Prevent endometrial hyperplasia (as result of chronic anovulation)
Contraception for those not wanting pregnancy, or ovulation induction for pregnancy
The foundation for all PCOS recommendations are…
Lifestyle modifications
1st line therapy for women who are obese/overweight is…
Weight loss through lifestyle modifications - can help improve fertility, hirsutism, and BG/BP/Lipids
For menstrual cycle irregularities, this is 1st line…
CHC’s - oral, patch, ring
CHC’s benefits for PCOS include…
They help regulate menstrual cycle
Protects from endometrial hyperplasia (no progesterone to counteract estrogen with chronic anovulation)
Helps with androgenic symptoms
CHC that is typically started is one with…
Estrogen? Progestin?
Low dose of estrogen
Progestin with low androgenicity
If a patient has CI to CHC or does not want CHC, we could try these 2nd line agents…
Progestin-only therapy (Does not help with androgenic sx’s)
Metformin
Metformin in PCOS has been shown to help with…
Improving glucose tolerance
Reduced androgen production in ovaries
May help restore ovulatory cycles
1st line medication to help with hirsutism for PCOS is…
CHC - suppresses androgen (similar to helping with menstrual irregularities)
2nd line options with hirsutism for PCOS is…
Antiandrogen - spironolactone, finasteride
Does require contraception
Medications that can be used to help with acne for PCOS include…
1st line: CHC’s - low androgen progestins
Topical acne medications
Consider spironolactone (antiandrogen)
Metabolic abnormalities associated with PCOS are treated…
Similar to the normal population
Including obesity, insulin resistance, dyslipidemia, OSA, depression/anxiety
The 1st thing we should do to aid with fertility is…
Lifestyle modification + optimization of health
Helps to restore ovulatory cycles as well as insulin resistance, CV risk, hirsutism
Ovulation induction can be used to aid fertility - medications that can help with this include…
Letrozole
Clomiphene citrate
Metformin
If these don’t work… gonadotropins or IVF will be considered
Letrozole MOA to help with anovulation is…
Aromatase suppression also decreases estrogen. Hypothalamus + pituitary gland increases FSH output, stimulating ovarian follicles to develop + mature, so ovulation can occur
On average, letrozole will be tried for ____ cycles before pregnancy occurs
3
Recall that letrozole AE’s include…
Hypoestrogenic AE’s - hot flashes, night sweats
Nausea, fatigue
Multiple births are more likely
Letrozole and clomiphene are CI…
In pregnancy - do not want to be messing with estrogen hormone levels
Letrozole is dosed…
For 5 days, usually on days 3-7 or 5-9 of the menstrual cycle
Clomiphene is another drug used to induce ovulation. Its MOA is…
SERM - blocks estradiol receptors in hypothalamus, increasing FSH release = growth of ovarian follicles, and ovulation
Clomiphene is dosed…
For 5 days, starting on day 5 of menstrual cycle (after spontaneous or progestin-induced menstruation)
OR at anytime if amenorrheic and no recent bleeding has occurred
Similar to letrozole, clomiphene AE’s include…
Hot flashes/night sweats (low estrogen)
Multiple gestations
Abdominal pain
Vision disturbances
With letrozole and clomiphene, ovulation is expected ____ after the last dose
5-10 days
Success with ovarian stimulation often declines with…
Age - IVF may be required
Replenishment of ejaculate volume requires ____. The egg can survive for up to ____ after ovulation. Sperm can survive up to ____ in the female reproductive tract.
24-48 hours. 24 hours after ovulation. 5 days
Metformin MOA for aiding fertility is not very well known, however it is usually used as an add-on to…
Clomiphene
Luteal phase defect is caused by…
Insufficient progesterone levels - does not allow for preparation of endometrium for implantation, resulting in failure to implant
This is the primary drug used for luteal phase support:
Progesterone
Protocols for administration may depend on protocol for ovarian stimulation. Also recognize that optimal timing and dose is not entirely known
Most common anatomical factor contributing to infertility is…
Blocked fallopian tubes - often relevant with endometriosis and pelvic inflammatory disease
Many cases of male factor infertility are unknown. For other, infertility may be due to…
- Obstructive/physical/genetic factors (trauma, surgery, STI)
- Sexual intercourse factors (low libido, ED)
- Endocrine factors (obesity, hypothalamic/pituitary dysfunction
- Sperm factors
Treatment options for male factor infertility may include…
Correcting modifiable risk factors
Surgical repair
Hormone therapy
Sperm cryopreservation
Assisted reproductive technologies
Basal body temperature charting works because…
Progesterone is thermogenic - with ovulation, corpus luteam releases progesterone causing increase in temperature. Measure temp to find most fertile period
Counselling tips on basal body temperature charting include…
Taking 1st measurement on 1st day of menstrual period
Take upon awakening, before activity or getting out of bed
Record information for 1-3 cycles to identify pattern
CHART DAILY - indicate changes (intercourse, illness, changes in sleeping pattern)
Ovulation prediction kits work by…
Detecting LH surge that precedes ovulation, by measuring its concentration in the urine
We should provide the following information with ovulation prediction kits…
Chart menstrual cycle ahead of time so that ovulation may be predicted (most fertile period is 14 days before next menses)
Begin testing 2-4 days before anticipated ovulation at the same time of day (usually AM)
