Infertility, Miscarriage, and Abortion Flashcards
Infertility definition
inability to conceive after 1 yr unprotected sex
if a woman is >35 yo, then 6 months of the same
primary vs secondary infertility
primary = never conceived a child secondary = prior conception, subsequent inability to conceive again
male causes of infertility
endocrine
anatomic
sexual dysfunction
female causes of infertility
ovulatory (PCOS)
cervical
tubal/uterine/peritoneal (PID)
PID, PCOS, endometriosis, uterine fibrosis, idiopathic
non pharm infertility management
protein, fruits, veggies (men can take zinc) exercise to a normal BMI smoking cessation D/C meds that cause infertility
meds that impair infertility via hyperprolactinemia
phenothiazines haloperidol opiates H2 antags SSRis Verapamil estrogen metoclopramide
meds that impair fertility via impaired spermatogenesis
alcohol, caffeine, marijuana, nicotine allopurinol anabolic steroids codeine spironolactone sulfasalazine
assisted reproductive technologies
in vitro fertilization (IVF) intrauterine insemination (IUI)
what increase in basal body temp indicates ovulation
when do you take basal body temp?
0.4-0.6 deg F increase means ovulation has occurred
day 1 of cycle, qd
what do ovulation predictor kits detect
when do you start
LH surge
start 3-4d prior to expected ovulation, have intercourse 24-48 h after color change detected
which infertility medication is a SERM
Clomiphene citrate
Clomiphene MOA dosing AE OHSS common? CI
Selective estrogen receptor modulator; –| (-)fb on HPO axis so body thinks estrogen is low, GnRH inc, LH + FSH inc. resulting in ovulation
50-100mg po qd x5d (start on day 3,4 or 5 of cycle)
OHSS uncommon
AE: ovary enlargement, hot flashes/flushes (bc estrogen “decreased”)
CI: thyroid and adrenal dysfunction
which infertility med is an aromatase inhibitor
Letrozole
what does a patient need in order to respond to clomiphene
sufficient FSH and estradiol to respond
Letrozole MOA dosing AE OHSS common? CI
inhibits aromatase which converts androgens to estrogens, decreases estrogen, GnRH increases, LH and FSH increase
2.5-7.5mg po qd x5d (start on day 3,4 or 5 of cycle)
up to 5 tx cycles
AE: flushing, edema, HA, dizziness, fatigue, night sweats, Nausea, weight gain
OHSS rare
Gonadotropin (FSH)/Follitropin alpha (Gonal-f), Follitropin beta (Follistim AQ)
dosing and admin
AE
OHSS?
individualize dose based on response to therapy, use lowest effective
dose can range from 37-450IU SQ or IM qd
AE: ovarian cysts!, HA, abdominal pain, nausea, inj site rxn, URI
!higher risk of OHSS and multiple births!
32% have multiple gestations
Gonadotropin releasing hormone antagonists meds
Cetrorelix, Ganirelix
GnRH antags (Cetrorelix, Ganirelix)
dose
AE
OHSS?
0.25mg SQ in abdomen
AE: HA, OHSS. abdominal pain, nausea, pelvic pain, vaginal hemorrhage, inj site rxn
Higher risk of OHSS and multiple births
(recombinant) human chorionic gonadotropin/hCG;r-hCG
when to give?
admin route?
AE (OHSS?)
give after GnRH ag or antag
IM or SQ dep on if recombinant or not
risk of OHSS
human menopausal gonadotropin meds
Menotropin/hMG(Menopur)
human menopausal gonadotropin Menotropin/hMG(Menopur)
dosing
AE
CI
75-450 IO sq qd
AE: multiple gestations (35%), HA, OHSS, abd pain, vomiting, diarrhea, ectopic pregnancy,
Ci in primary ovarian failure (high FSH)
Human growth hormone med
Somatropin
somatropin
moa
AE
monitiring
human growth hormone
periph edema, HA, abd pain, arthralgia, inj site rxn, nausea
monitor: fluid status, BG, HbA1c, lipid profile, BP, thyroid fxn, BMI
estrogen use in infertility
reset cycle going into IVF or IUI
Progesterone for infertility
dosage forms
BBW
intravaginal get, insert
IM injection
compounded suppositories
capsules
example of fertilization protocol
four steps, four meds
- mid luteal (21d-28d) - GnRH ag
- menstruation day 2-13 - GnRH ag + gonadotropin
- day 14 - hCG
- day 15 and on - progesterone
GnRH ag med? MOA? duration? AE
Leuprolide (Lupron Depot)
stimulated GnRH and inc (-) fb, shuts it off so it becomes an antag
duration <12 mo
AE: inj site rxn
what should GnRH ags/antags be combined with
gonadotropin
Fertility treatment complications (4 major ones)
multiple births, Ovarian Hyperstimulation Syndrome (OHSS), psychiatric disorders, insurance complications
what is OHSS
ovary enlargement, capillary permeability inc and protein rich fluid escapes into intravascular space
Patient has abdominal distention/discomfort, mild N/V, dyspnea, diarrhea
which stage of OHSS
mild
patient has abdominal distention/discomfort, mild N/V, dyspnea, diarrhea and ascites on ultrasound
which stage of OHSS
Moderate
Patient has patient has abdominal distention/discomfort, mild N/V, dyspnea, diarrhea and ascites on ultrasound, oliguria/anuria, intractable N/V, hydrothorax
which stage of OHSS
severe
Patient has low BP, pleural effusion, rapid weight gain, severe abdominal pain, venous thrombosis, acute renal failure, respiratory distress, sepsis
which stage of OHSS
Critical
PCOS
patho
inappropriate GnRH stimulation, inc LH and FSH, excessive androgen production, endometrial hyperplasia and cancer, LH and FSH surge when follicle is not ready, no ovulation
Rotterdam Criteria (at least 2 of...) chronic anovulation (amenorrhea) androgen excess polycystic ovaries
1 cause of anovulatory infertility
PCOS
PCOS risk factors
FHx PCOS, DM, insulin resistance, irregular menses or anovulation, CV disease
PCOS s + sx
androgen excess: irregular menses, amenorrhea, hirsutism, acne, alopecia
Metabolic: obesity, insulin resistance, dyslipidemia
Polycystic ovaries: 12+ follicles 2-9cm ea., inc ovarian volume >10mL during ovarian phase
PCOS treatment
non pharm
exercise, diet
hirsutism: bleaching, plucking, shaving, eflornithine (Vaniqa) 13.9% cream
acne: OTC agents
tx metabolic conditions with statins, insulin, sensitizing agents
PCOS pharm tx options
CHC
antiandrogens
insulin sensitizers (metformin)
oral ovulation induction agents (clomiphene, letrozole)
injectable ovulation induction (gonadotropins)
PCOS CHC tx
target
MOA
clinical pearls
targets menstrual cycle irregularity, hirsutism and acne
estrogen suppresses LH secretion, decrease androgen excess, increase circulating sex hormone binding globulin, inc cycle regularity
1st line!
nonandrogenic progestin preferred (Norgestimate, Desogestrel, Drosperinone)
1st line PCOS tx
CHCs (Drosperinone preferred progestin)
**unless fertility is desired
PCOS antiandrogen tx
target
MOA
clinical pearls
targets hirsutism and acne
inhibits ovarian and adrenal steroidogenesis and competes for androgen receptors in hair follicles
can combine w CHC is fertility not desired
Spironolactone most commonly used
PCOS insulin sensitizer (Metformin) tx
targets
recommended to use in addition to what?
targets hirsutism, acne, menstrual irregularities, anovulation, insulin resistance, infertility
use in addition to clomiphene (SERM)
PCOS oral ovulation induction agents
targets
agent?
targets infertility only
letrozole first line if desires infertility improvements
PCOS injectable ovulation induction agents
when to use
target
use when failed oral ovulation induction with letrozole
PCOS tx algorithm order
(lifestyle mod if obese), letrozole for ovulation induction, metformin, refer to infertility expert
endometriosis
dx
patho
dx with laparoscopic surgery (GOLD STANDARD)
patho: retrograde menstruation/lymphatic spread of hormone sensitive endometrial cells and tissues that implant, induce inflammatory response, angiogenesis and adhesions
endometriosis risk factors
obstruction of menstrual flow exposure to diethylstilbestrol in utero short menstrual cycles low birth weight exposure to endocrine disrupting chemicals
endometriosis sx
pelvic pain DYSMENORRHEA, often NSAIDs do not help dyspareunia infertility GI sx
endometriosis tx associated pain
diff than endometriosis fertility tx
surgical (1st line or after pharm failure)
pharmacologic
NSAIDS +/-
hormonal: CHC, progestins = 1st line
GnRH ag, antag = 2nd line
danazol
aromatase inhibitor
what do CHCs do in endometriosis tx
cyclical or continuously used for dysmenorrhea and pelvic pain
what do progestins do in endometriosis tx
what are the option
dysmenorrhea and pelvic pain
norethindrone, medroxyprogesterone acetate, LNG IUD
tx of endometriosis assoc infertility
surgical, artificial insemination, assisted reproductive technology (IVF, IUI)
first, second and third line agents for endometriosis pain tx
NSAIDs +
CHC or POC
GnRH ag (Leuprolide) or GnRH antag (elagolix)
Danazol, aromatase inhibitors
miscarriage risk factors
women who have experienced previous early pregnancy loss
advanced maternal age
miscarriage sx
vaginal bleeding
uterine cramping
managing a miscarriage
what to give for pain?
what to give for medication?
NSAIDs or APAP
Misoprostol 800mcg vaginally, may repeat if needed within 7d
Medications for medical abortion
Mifepristone 200mg on day 1 +
Misoprostol 800 mg buccally or vaginally 24-48h after mifepristone
Methotrexate - use through 49d gestational age
Misoprostol for medical abortion counseling
Take 24-48h post mifepristone
bleeding and cramping will start a couple hours after taking misoprostol
call if bleeding soaks 2 full-size pads per hour for two consecutive hours
