Infertility - Exam 1 Flashcards by Johannah Crumpton

Define infertility

Inability to achieve a successfulpregnancy based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors

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When should you start evaluating a women for infertility based on age?

Inability to conceive after 1 year of unprotected intercourse of reasonable frequency in women <35yo

Inability to conceive after 6 months of unprotected intercourse of reasonable frequency in women >35yo

> 40yo – more immediate evaluation and treatment is warranted

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What conditions would cause an infertility work up to be immediate?

Oligomenorrhea or amenorrhea

Known or suspected uterine, tubal or peritoneal disease

Stage 3 or 4 endometriosis

Known or suspected male infertility

LGBTQ+

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What is the MC etiology behind infertility? what is second?

Ovulatory 27%

then male 25%

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What would you want to ask your female pt about when starting a work up for infertility?

menstruation hx

prior contraceptive use

History of ovarian cysts, endometriosis, leiomyomas, STDs, PID

History of abnormal pap smears

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What effect does conization have on the cervix?

can decrease cervical mucus quality and alter cervical anatomy

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What is good pt education regarding coital timing when trying to get pregnant?

Chance of conception increased 5 days preceding ovulation and should have daily intercourse during this period to maximize chances

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What is good pt education regarding lubricants when trying to get pregnant?

Avoid oil based lubricants that can harm sperm

Water based lubricants are preferred

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What 7 things if you see it in a women’s history would make it harder to get pregnant? Which 2 are the most serious?

Chemotherapy**
Radiation**
Androgen excess -> PCOS
Thyroid disease
Hyperprolactinemia
Medications
High BMI

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consider looking at this chart again

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What are common causes of female infertility?

Ovulatory disorders

Endometriosis

Pelvic adhesions

Tubal blockage or other tubal problems

Uterine or cervical factors

Unexplained

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When should you consider genetic testing when looking for a cause of female infertility?

History of recurrent pregnancy loss 3 or more consecutive losses at ≤ 20 weeks gestation or with a fetal weight <500grams

Premature ovarian failure (<40yo) due to menopause at a younger age

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If your female pt is having 3 or more consecutive losses at less than 20 weeks gestation, ______, ______ or ______ could be the cause

Parental chromosomal abnormalities

Antiphospholipid syndrome

Uterine abnormalities

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50% of spontaneous miscarriages are due to aneuploidy: Most common is _____

Monosomy X: Turner’s syndrome

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What is the average age of menopause?

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Ovulation can be affected by abnormalities in the _____, ______ or _____. Clear inverse relationship between _____ and infertility due to _____

hypothalamus

pituitary

ovaries

female age

loss of viable oocytes

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_____ is excellent predictor of regular ovulation. Cyclic menses every ____ days with a duration of _____ indicates ovulation

Menstrual history

25-35

3-7 days

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______ midcycle pelvic pain associated with ovulation
______ breast tenderness, acne, food cravings, mood changes

Mittelschmerz

Moliminal symptoms

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What temp are women during the follicular phase? Postovulatory rise in progesterone levels increase basal temperature by _____ and strongly predicts ______

97-98°F

0.4-0.8°F

ovulation

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What are the benefits and limitations of basal body temping?

Benefits: Inexpensive, easy

Limitations: Insensitive in many women

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Consider looking at this chart again, she really likes it and references it many times

maybe do it?

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What can an US show in terms of infertility diagnostic testing?

Can help evaluate ovarian reserve as well as uterine and adnexal pathology

Serial exams can demonstrate maturation of an antral follicle and its collapse during ovulation

Count less than 5-7 can indicate diminished ovarian reserve

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What do ovulation predictor kits test? What is the pt education? Who are these NOT good for? When will ovulation happen?

urinary LH

Woman should begin testing 2-3 days before predicted LH surge and continue daily

Women with PCOS may have a chronic elevated level of LH so not reliable method

Ovulation will occur the day following the urinary LH peak

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When should you check a serum progesterone for infertility? should be ____ in the follicular phase. Should be ____ in ovulation

check serum progesterone on day 21 or 1 week prior to expected menstruation. Can also be checked 7 days following ovulation

Follicular phase <2ng/mL

Indicative of Ovulation >3 ng/mL

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What is the limitation of checking serum progesterone?

Progesterone secreted in pulses and a single measurement may not be indicative of overall production

____ is a sensitive predictor of ovarian reserve. With _____ ovarian reserve (how many eggs), ____ inhibin is secreted.

Serum FSH decreasing less

______ inhibits FSH. FSH level _____ is associated with diminished ovarian reserve

Inhibin FSH >10IU/L

When should serum FSH be drawn? FSH _____ indicates significant loss of ovarian reserve

Perform cycle day 2-4 with estradiol >10 mIU/mL

______ is measured with serum FSH. Due to increase FSH with decreasing ovarian reserves there will be a _____ estradiol level. ____ is abnormal

serum estradiol increasing >80 pg/mL

______ is expressed by granulosa cells of small preantral follicles. Possible role in recruitment of the ______

Anti-mullerian Hormone (AMH) dominant follicle

Anti-mullerian Hormone (AMH) levels correlate with _______. ______ is ovarian primordial follicle number

ovarian primordial follicle number <1ng/mL

Increased AMH means ______.

more follicles

What is the tx for hyperprolactinemia?

Bromocriptine or Cabergoline also need to check head MRI to look for adenomas may need sx

hypothyroidism commonly cause _____ and ______

oligomenorrhea and amenorrhea tx with levothyroxine

What is the tx for diminished ovarian reserve?

Ovulation Induction IUI/IVF Egg Donor

_____ is the initial tx for most anovulatory infertile women. What is the MOA? What is the pt education with regards to timing?

Clomiphene Citrate (Clomid) Estrogen antagonist  results in increase in FSH levels which increase ovarian follicular activity Given for 5 days starting on cycle day 2-5

_______ is also a first line medication to induce ovulation. What is the MOA? What is the pt education with regards to timing?

Letrozole Inhibits the production of estrogens, so it increases FSH Given on cycle day 3-7

What is the drug class of Clomiphene Citrate? Letrozole?

Clomiphene Citrate (Clomid) : Estrogen antagonist Letrozole: Aromatase Inhibitors

______ are urinary or recombinant FSH and LH. What is the route?

Gonadotropins typically intramuscular or subcutaneous injections Expensive!

______ is a clinical symptom complex associated with ovarian enlargement resulting from exogenous gonadotropin therapy. What is it due to? What are some symptoms?

Ovarian hyperstimulation syndrome increased capillary permeability Abdominal pain/distension, ascites, GI problems, respiratory compromise

What is IUI?

Intrauterine Insemination (IUI) Sperm is washed and concentrated Long, thin catheter threaded through the cervical os into the endometrial cavity Sperm injected into endometrial cavity

How does IVF work?

Mature oocytes from stimulated ovaries are retrieved transvaginally with sonographic guidance Sperm and ova are combined in vitro Viable embryos are transferred transcervically into the endometrial cavity using sonographic guidance

What are 4 tubal/pelvic factors that may affect fertility?

Adhesions prevent normal tube movement, ovum pickup and transport of fertilized egg into the uterus pelvic infections/PID endometriosis prior pelvic sx

What are 2 diagnostic testing option if concerned about a pelvic/tubal cause of infertility? What are the differences between the 2?

Hyserosalpingogram (HSG): Injection of a radio-opaque medium thru the cervical canal to evaluate the uterine cavity and tubes. Usually on cycle day 5-10 Chromopertubation: Injection of methylene blue thru cervical canal during laparoscopy to evaluate tubal patency

What is the name for this condition?

hydrosalpinx

If a pt had tubal resection, need to proceed with _____ after

Proceed with IVF afterward

If a pt has endometriosis, what would you recommend with regards to pregnancy?

Surgical treatment: Removal of adhesions Drainage of endometriomas IVF GnRH for long term tx, may improve later outcomes

How do you dx uterine fibroids? What is the tx?

HSG, ultrasound 5cm may consider myomectomy or hysteroscopic resection

What is Asherman's syndrome? Occurs most often with a history of having a ______. How do you dx? What is the tx?

Intrauterine adhesions D&C HSG or hysteroscopy hysteroscopic lysis of adhesions

_____ are used to measure the progesterone levels and is thought to provide more information than serum progesterone alone. Is it routinely done?

endometrial bx NOT routinely done

_____ glands secrete mucus. Mid-cycle high estrogen levels cause mucous to become ______

Cervical thin and stretchy

What are the 3 causes of cervical factors that cause infertility?

History of LEEP or cone surgery Cryosurgery Cervical infection

What virus can lead to testicular inflammation and damage to spermatogenic stem cells?

mumps

**Takes ____ from stem cell to mature sperm. ______ to produce sperm. How long does it take for the sperm to travel into the epididymis?

**90 days- any detrimental effect in the prior 3 months can be an issue 70 days 12-21 days

For semen analysis men should refrain from ejaculation for _______. What are considered normal reference values? Volume: Count: Motility: Morphology: WBCs: Round cells:

Volume > 1.5mL Count >20 million/mL Motility >50% Morphology >14% WBCs <1million/mL - infection Round cells <5 million/mL – not enough mature sperm

semen analysis can also evaluate for _____. Presence of sperm agglutination on analysis should prompt testing for ______. What is the tx?

Anti-sperm antibodies anti-sperm antibodies tx: corticosteroids

If semen volume is too low, what should you do next?

send to Urology

What is retrograde ejaculation? What is it due to?

Due to failed closure of the bladder neck during ejaculation Seminal fluid flows backward into bladder Check UA -> detect sperm in urine

If sperm count is below _____ should recommend _____

<20 million sperm/mL IUI

What are 3 causes of azoospermia?

Congenital absence of vas deferens (Cystic Fibrosis) Severe infection Vasectomy

_______ is decreased sperm motility. What are 4 causes? What is the tx?

Asthenospermia Prolonged abstinence Antisperm antibodies Infection Varicocele Intracytoplasmic sperm injection

______ is abnormal sperm morphology. What is the tx?

Teratospermia IVF

What is the tx for anti-sperm antibodies?

Corticosteroids

Low FSH, Low testosterone is ______ syndrome. What is it associated with? What is the tx?

Kallmann syndrome Anosmia associated with hypogonadotropic hypogonadism Gonadotropins

Elevated FSH, Low testosterone is _______. What happens to the sperm? What is the tx? **What is important to remember about the tx?

Testicular failure Oligospermia Testosterone testosterone will decrease gonadotropin and can make the male NEVER make sperm

_____ is indicated for men with poor semen analysis results because it can cause abnormal semen characteristics

Karyotype

What is Klinefelter syndrome? What are the characteristics?

(47 XXY) Tall, undervirilized (low hormones) men Gynecomastia

Why can CF cause infertility? What is the tx?

Congenital absence of the vas deferens causing obstructive azoospermia Mutations in CFTR gene Epididymal aspiration to obtain sperm for IVF

What happens if the Y chromosome is “broken” and only makes antimullerian hormone.

there will NOT be any testosterone present so the Wolffian ducts will not develop results with NO distinguishable female or male structures

If the Y chromosome is “broken” and only makes testosterone?

so there is NO antimullerian hormone present to get rid of the female ducts so female structures will develop. Testosterone will encourage the growth of the Wolffian ducts result is BOTH female and male structures will be present= INTERSEX disorder