Infertility II

Question 1

Example of neurologic cause of pelvic pain

Answer 1

Pudendal nerve injury

Question 2

MSK causes of pelvic pain

Answer 2

Fibromyalgia, pelvic flood dysfunction, pubic symphysis pain

Question 3

Definition of endometriosis

Answer 3

Functional endometrial glands and stroma outside of endometrium

Question 4

Frequency of endometriosis among infertile patients

Answer 4

25-50%

Question 5

Frequency of endometriosis with chronic pelvic pain

Answer 5

30-80%

Question 6

Risk factors for endometriosis

Answer 6

AA, low BMI, smoking, Alcohol use

Question 7

Genetics of endometriosis

Answer 7

Genes involved in:
-ectopic cell survival
-attachment/invasion into peritoneal surfaces
-proliferation of ectopic cells
-neovascularization
-inflammatory response
-escape from apoptosis
-cell adhesion molecules
-Matrix metalloprotinases (MMP) peritoneal invasion
-Increased aromatase activity in the ectopic endometrium

Question 8

Immunobiology of endo

Answer 8

Impaired immune response
More immune cells in peritoneal fluid (cytokines, growth factors, prostaglandins)
Altered macrophage activity
Altered NK activity (endo leads to SUPPRESSION of NK cell activity)

Question 9

What percent of patients with endometriosis are asymptomatic?

Answer 9

20-30%

Question 10

Key changes in endometriotic implants

Answer 10

-Aromatase leads to autonomous E2 production
-Progesterone resistance (decrease anti-E2 effect of P4 and amplifies E2 effects)
-Pr-B not expressed
-Pr-A expressed which favors 17 Beta hydroxysteroid dehydrogenase I NOT II (increased production of potent E2)
-Increase VEG-F to increase blood supply

Question 11

Why does endo cause pain

Answer 11

1. Ectopic bleeding
2. Nerve irritation or invasion
3. Activated macrophage production
4. Severity of pain is associated with depth of invasion (eg. > 6 mm)

Question 12

How do progestins help endo pain?

Answer 12

Decidualization of lesions
Atrophy of lesions
Inhibit MMP
Inhibit angiogenesis
Stop bleeding

Question 13

GnRH agonist and endometriosis

Answer 13

Higher affinity for GnRH receptor in hypothalamus
Has longer half life and occupies R for longer time
Prolonged activation leads to down regulation of pituitary/ovarian axis
Hypoestrogenic state

Norethindrone acetate is FDA approved for add back

Question 14

What is threshold hypothesis?

Answer 14

Small amounts of E2 will alleviate hypo E symptoms but not stimulate endometriosis

Question 15

Unique things about aromatase inhibitors?

Answer 15

in premenopausal must use with OCPs which help suppress endometriosis and avoid ovarian stimulation and support bone health

AI alone can worsen bone loss

Question 16

LUNA

Answer 16

laparoscopic uterosacral nerve ablation
Disrupt efferent innervation of uterosacral ligaments
SE: prolapse, ureteral transection
No benefit

Question 17

Management of endometrioma

Answer 17

drain, darin and cauterize wall, remove rate of recurrence with drainage: 80-100%

Question 18

Presacral neurectomy

Answer 18

Interrupts sympathetic nerves in superior hypogastric plexus
decreases midline pain
SE: bleeding, constipation, urinary retention

Question 19

Pain recurrence after HRT + BSO with endo

Answer 19

3-5%
Use continuous E+P rather than E so that P4 can act as an anti-estrogen and decrease recurrence risk

Question 20

How does endo cause infertility?

Answer 20

Distorted anatomy
Impaired transport in tube
Altered peritoneal environment (increased volume, macrophases, PGDs, VEGF)
Poor egg/embryo quality
Impaired implantation (altered CAM/immune cells)
Ovulatory abnormalities: abnormal follicle growth, luteal phase dysfunction
Longer follicular phase, lower E2, multiple or premature LH surge, decreased fluid P4 concentration
Altered immune function (increase IgA and IgG and lymphocytes in endometrium decreased implantation)

Question 21

Surgery for endo and infertility?

Answer 21

Stage I/II: minimal fecundity benefit with NNT=12 for additional pregnancy
Stage III/IV: small improvement in LBR, but loss of ovarian cortex

Question 22

IVF outcomes after endometrioma cystectomy

Answer 22

No improvement in follicular response, MII eggs retrieved or pregnancy rate
Conservative surgery did not lower IVF success
Decision to operate: confidence in diagnosis, loss of cortex, pain, improved access

Question 23

Rate of success after endometrial ablation

Answer 23

heavy bleeding improved: 70%
amenorrhea: 15-50%

Question 24

High viscosity HSC fluid

Answer 24

Hyskon (dextran and glucose), high complication rate

Small volume can expand plasma volume and lead to fluid overload, pulmonary edema
Anaphylaxis
Max deficit: 300-500

Question 25

Low viscosity HSC fluid

Answer 25

Hypotonic
Electrolyte free: sorbitol, mannitol, glycine
Electrolyte rich: NS, LR

Question 26

Max deficit for electrolyte free

Benefit?

Answer 26

1000-1500
can use with monopolar energy devices

Question 27

Max deficit for electrolyte rich

Answer 27

2500

Question 28

Normal sodium level

Answer 28

135-145 meq/L

Question 29

What happens with Na level < 115

Answer 29

Brainstem herniation, respiratory arrest, coma, death

Question 30

How to correct hyponatremia

Answer 30

Hypertonic Saline (1-2 meq/L/hr)
not more than 12 meq in the first 24 hours
avoid rapid correction that can cause central pontine myelinolysis

Question 31

What is central pontine myelinolysis

Answer 31

central demyelinating lesion
initially improves with sodium correction and then neurologic status worsens
mutism, paresis, pseudobulbar palsy, movement and behavioral changes

Question 32

Intracardiac air emboli

Answer 32

cogwheel or mill murmur
Durant’s maneuver (left lateral decubitus and trendelenburg)
want air to stay in the right heart until it can be absorbed or suctioned