Infertility, Miscarriage, and Abortion Flashcards
what is infertility?
inability to conceive a child after one year of frequent contraceptive free intercourse
if woman is>35, then 6 months of the same
two types of infertility
Primary: never conceived a child
Secondary: prior conception w. subsequent inability to conceive again
causes of infertility
male factor
endocrine, anatomic, sexual dysfunction
causes of infertility
female factors
PCOS
cervical issues
Tubule/uterine/peritoneal issues (PID)
non pharmacologic management of Infertility
- diet
a. men and women: protein, fruits, vegetables
b. men: zinc - exercise
a. weight loss/ gain. best weight is a normal BMI or within 15% of IBW - smoking cessation
- d/c meds that are associated with infertility
- assistive reproductive procedures
medications that impair fertility
cause hyperprolactinemia
phenothiazines haloperidol opiates h2 antagonists SSRI's verapamil estrogen metoclopramide
mediations that impair fertility
impaired spermatogenesis
alcohol, caffeine, marijuana, nicoteine allopurinol anabolic steroids codeine spirinolactone sulfasazaline
Predicting ovulation
- Basal Body temperature
2. Ovulation predictor kits
basal body temperature testing
what is it?
how does it work?
counseling?
use a specific basal body temperature thermometer
progesterone causes an increase in basal body temp
04-0.6 degree rise in body temp->ovulation has occurred
counseling: place at bedside at night.
start at least 5 min and prior to rising for activity
chart temp, illness, intercourse, medications, et.
test daily, start day 1 of cycle
ovulation predictor tests
how does it work?
counseling
detects lh IN URINE FOR THE SURGE PRIOR TO OVULATOIN
counseling: start 3-4 days before expected ovulation
check at same time every day until you see a color change on the test
have intercourse 24-48 hours after color change detected
all kits vary in testing method and accuracy so you must counsel patients
Clomiphene Citrate
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects: Serious:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
%chance of pregnancy:
Pearls:
Clomiphene Citrate
Class: Selective estrogen receptor modulator
Indication: treatment of ovulatory dysfunction in women desiring pregnancy
Mechanism of Action: Blocks estrogen receptors, makes body think it is in a hypoestrogenic state. in turn increases GNRH production.
Effects of mechanism of Action:
increases FSH, LH, therefore stimulating ovulation
Dosing: 50-150 mg oral daily for five days starting on days 3,4,5 of the cycle. max dose 150mg daily for 5 days. not recommended for more than 6 cycles
Adverse Effects: ovary enlargenement, hot flashes, headache, abdominal distention, abdominal distress, bloating. N&V, breast discomfort, abnormal uterine bleeding, visual disturbances
Absolute Contraindications: thyroid and adrenal dysfunction
Pregnancy: –
Warning/ Precautions:
Drug-Drug Interactions (DDIs):
Monitoring Parameters:
pretreatment screening of triglycerides
% chance of pregnancy: 30% chance. 7.98% dance of multiple gestations
Pearls:
- OHSS rare
- 50-150 mg oral daily for five days starting on days 3,4,5 of the cycle. max dose 150mg daily for 5 days. not recommended for more than 6 cycles
Letrozole
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects: Serious:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters: –
%chance of pregnancy:
Pearls:
Class: aromatase inhibitor
Indication: stimulation in anovulatory females with PCOS
Mechanism of Action: converts androgens into estrogens. Hypoestrogen state causes increase in GNRH. also causes thin cervical mucus
Effects of mechanism of Action: increase in GNRH causes increase in FSH, LH thus leading to ovulation
Dosing: 2.5-7.5 mg oral daily for 5 days starting on days 3,4, and 5 of the cycle
up to 5 treatment cycles, with dose increase with subsequent cycles if poor ovulatory response. MDD 7.5 mg for 5 days
Adverse Effects: Serious: flushing, edema, headache, dizziness, fatigue. night sweats, hypercholesterolemia, weight gain, nausea,
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):
Monitoring Parameters: –
%chance of pregnancy:
23% (but higher in women with PCOS and unexplained fertility)
multiple gestations: 13%
Pearls:
1st line in women with PCOS or unexplained infertility.
2.5-7.5 mg oral daily for 5 days starting on days 3,4, and 5 of the cycle
up to 5 treatment cycles, with dose increase with subsequent cycles if poor ovulatory response. MDD 7.5 mg for 5 days
Pearls of clomiphene
Pearls:
- OHSS rare
- 50-150 mg oral daily for five days starting on days 3,4,5 of the cycle. max dose 150mg daily for 5 days. not recommended for more than 6 cycles
Pearls of Letrozole
Pearls:
1st line in women with PCOS or unexplained infertility.
2.5-7.5 mg oral daily for 5 days starting on days 3,4, and 5 of the cycle
up to 5 treatment cycles, with dose increase with subsequent cycles if poor ovulatory response. MDD 7.5 mg for 5 days
Follitropin alpha (Gonal-f, Gonal-fRFF),Follitropin beta
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects: Serious:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:
Pearls:
Class: Gonadotropin (FSH)
Indication: to stimulate the development of multiple follicles with assisted reproductive technology.
induction of ovulation and pregnancy in alignment-anovulatory infertile patients in whom the cause of infertility is functional and not caused by primary ovarian failure
Mechanism of Action: stimulated ovarian folicular growth in women who do not have primary ovarian failure.
Effects of mechanism of Action: growth and maturation of follicles
Dosing: dose should be individualized based on response to therapy. doses can vary from 37.5-450 IU SQ or IM per day
Adverse Effects: headache, ovarian cysts, abdominal pain, nausea, enlargement of the abdomen, injection site reaction, URTI
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs):–
Monitoring Parameters: –
%chance of pregnancy:
35%
multiple gestations: 32%
Pearls:
1. risk of OHSS and multiple births is higher b/c injectables stimulate the ovary more
2.SQ and im INJECTION(IM in canada)
- follitropin alpha is a pen
- Gonal f vials require reconstitution.
- store in refrigerator,
pearls of follitropin/ Gonal-f
Pearls:
1. risk of OHSS and multiple births (32%) is higher b/c injectables stimulate the ovary more
2.SQ and im INJECTION(IM in canada)
- follitropin alpha is a pen
- Gonal f vials require reconstitution.
- store in refrigerator,
LEUPROLIDE (lupron-Depot)
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects: Serious:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:–
Pearls:–
Class:Gonadotropin releasing hormone agonist
Indication: IVF
Mechanism of Action: initially causes stimulation of pituitary gonadotropins LH and fsh. Continues use causes levels go gonadotropins to fall, ultimately decreasing LSH and FH productions.
Effects of mechanism of Action: reduces interference from pituitary gland with development of eggs when FSH is administered. creates high response to gonadotropins when simultaneously used with leuprolide
Dosing: 0.5- 1 mg SQ injection qd
Adverse Effects: Serious: pain at injection site, vasodilation, emotional lability, mood changes, headache, pain, acne, seborrhea etc.
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:–
Pearls:–
CEtrorelix, Ganireliz
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects: Serious:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:
Pearls:
Class:Gonadotropin releasing hormone antagonists
Indication: controlled ovarian stimulation
Mechanism of Action: competes with naturally occurring GNRH for binding on receptors in the pituitary. delays LH surge, preventing ovulation until the follicles are of adequate size
Effects of mechanism of Action: inhibition of premature LH surges in pts. undergoing controlled ovarian stimulation
Dosing: 0.25 mg SQ
Adverse Effects: Serious: headache, OHSS, abdominal pain, nausea, pelvic pain, vaginal hemorrhage, injection site reaction
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:–
Pearls: higher risk of OHSS and multiple births
HCG (human and recombinant)
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects: Serious:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:–
Pearls:
Class:
Indication: induction of ovulation and pregnancy in the anovulatory, infertile woman
Mechanism of Action: HCG acts as a substitute for LH to stimulate ovulation.
Effects of mechanism of Action: stimulate ovulation
Dosing: 5k-10k units of IM one day after last dose of menotropin
Adverse Effects: Serious: risk of OHSS
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:–
Pearls:trigger injection
Menotropin
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:
Dosing:
Adverse Effects: Serious:
Absolute Contraindications:
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:–
Pearls:
Class: human menopausal gonadotropin
Indication: for multiple follicular development and pregnancy in ovulatory women as part of an assisted reproductive technology cycle
Mechanism of Action: purified combo of LH and FSH. provides ovarian follicular growth and maturation in females who do not have primary ovarian failure
Effects of mechanism of Action: follicular maturation and growth
Dosing: varying protocols
Adverse Effects: Serious: multiple gestations (35%)
headache, OHSS, abdominal pain, vomiting, diarrhea, breast tenderness, ectopic pregnancy etc.
Absolute Contraindications: women with primary ovarian failure (HIGH FSH)
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters: –
%chance of pregnancy:–
Pearls:
CI: in women with primary ovarian failure
Somatopin
Class:
Indication:
Mechanism of Action:
Effects of mechanism of Action:–
Dosing:
Adverse Effects: Serious:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:
%chance of pregnancy:–
Pearls:–
Class: Human growth hormone
Indication: IVF
Mechanism of Action: activator of proliferation and differentiation of the ovarian follicles, and administration generally increases ovarian weight and follicular size
Effects of mechanism of Action:–
Dosing: 2.5 mg SQ every other day starting day 6 of menstual cycle until HCG is given
Adverse Effects: Serious:
Absolute Contraindications:–
Pregnancy: –
Warning/ Precautions: –
Drug-Drug Interactions (DDIs): –
Monitoring Parameters:
fluid status
glucose level
hgba1c, LIPID PROFILE, bp, THYROID FUNCTION, bmi
%chance of pregnancy:–
Pearls:–
EStrogen
not a contraceptive form
frequency of adverse events specific to product
perform a transvaginal ultrasound blood test
progesterone
BBW for invasive breast cancer, dementia, and cv DISEASE
example of fertilization protocol
- GNRH agonists (total 1-3 weeks) starting days 21-28
- gnrh AGONISTS+ GONADOTopin
(starting days 2-13) - HCG: day 14
- Progesterone (day 15 and beyond
fertility treatment complications
multiple births
multiple births,
Gonadotropins have highest rate of multiple births.
- clomiphene and letrozole,
- gonadotropins
- VF
Ovarian Hyperstimulation Syndrome
patho
SS:
life threatening
vary enlargement causes increased capillary permeability. protein rich fluids escapes into intravascular space.
SS: bloating, sob, LETHARGY, N/V/D
stages of ohss
mild: GI symptoms, mild dyspnea
moderate: mild feature+ ascites
severe: mild and moderate feature + ascites, hydrothorax, severe dyspnea, oliguria/anuria, intractable NV
critical: low BP, pleural effusion, rapid weight gain 9>24 hours), syncope, severe abdominal pain, VT, anuria/ acute renal failure, pericardial effusion, rapid respiratory distress syndrome
psychiatric disorders with infertility
women have psychiatric disorders related to emotional reactions to infertility. most often anxiety and depression.
insurance complications
one IVF session costs more than 12k
Disorder:PCOS
What is it:
Diagnosis:
Patho:
risk factors:
Signs and Symptoms:
Treatment:
non pharm
pharm:
What is it:
Diagnosis:
- chronic annovulation
- clinical or biochemical signs of androgen excess
- polycystic ovaries in absence of other metabolic disturbances
Patho:
inappropriate gnrh stimulation, excessive lh fsh, follicles do not mature and ovulation does not occur, excessive androgen production, metabolic dysfunctions (insulin resistance and hyperinsulinemia)
risk factors: family history, DM, insulin resistance, irregular menses or annovulation, or CV disease
Signs and Symptoms: androgen excess: irregular menses, amenorrhea, oligomenorrhea, hirsutism, acne,,
Metabolic: obesity, insulin resistance dyslipidemia, metabolic syndrome
polycystic ovaries: 12 or more follicles measuring 2-9 cm in diameter or increased ovarian volume
Clinical Presentation:
Treatment: non pharm 1. exercise 2.diet 3. hirsutism: bleaching, plucking, shaving, electrolysis, eflorinthine (vaniqa cream)
pharm:
pharm:
metabolic agents may be treatedtraditionally
- CHC; targets menstrual irregularity
first line if fertility not desired
nonandrogenic progestin preffered (norgestimate, desogestrel, drospirinone - anti androgens: to target hirsutism and acne. synergistic effect with CHC. spironolactone
- insulin sensitizers: metformin-increased insulin sensitivity and decrease androgen excess. targets androgen excess symptoms as well as infertility. additional to clomiphene to reg menstrual cycles and ovulation to improve infertility
- oral ovulation induction: clomiphene, letrozole: targets infertility in those who desire improvements in firtility
- injectable ovulation induction: used in those who have failed oral therapies for infertility
pharm treatment of PCOS
pharm:
metabolic agents may be treatedtraditionally
- CHC; targets menstrual irregularity
first line if fertility not desired
nonandrogenic progestin preffered (norgestimate, desogestrel, drospirinone - anti androgens: to target hirsutism and acne. synergistic effect with CHC. spironolactone
- insulin sensitizers: metformin-increased insulin sensitivity and decrease androgen excess. targets androgen excess symptoms as well as infertility. additional to clomiphene to reg menstrual cycles and ovulation to improve infertility
- oral ovulation induction: clomiphene, letrozole: targets infertility in those who desire improvements in firtility
- injectable ovulation induction: used in those who have failed oral therapies for infertility
timeline for infertility in pcos
- recommend lifestyle modification (if obese)
- if not pregnant after that (or wasn’t obese to begin with), add clomiphene or letrizole
- if not pregnant, add metformin,
- if not pregnant after that, refer to infertility expert
Disorder:endometriosis
What is it:
Diagnosis:
Patho:
risk factors:
Signs and Symptoms:
Treatment:
non pharm
pharm:
Disorder: endometriosis
What is it: endometrial like tissue outside of the uterus
Diagnosis: based on hx and pelvic exam findings
Patho: peritoneal disease results from retrodage menstruation or lymphatic spread of steroid hormone sensitive endometrial cells and tissues
risk factors:
obstruction of menstrual flow
exposure to diethylstilbestrol in utero
prolonged exposure to endogenous estrogen due to monarch, late menopauseobesity
short menstrual cycles
low birth weight
exposure to endocrine disrupting chemicals
Signs and Symptoms:
pelvic pain 4 D'S: dysmenorrhea dyspareunia (painful sex) dysuria dyschezia (painful bowel movements
Treatment:
non pharm
surgical
pharm:
nsaids for dysmenorrhea
CHC (most common)FOR DYSMENNORHEA AND Pelvic pain
progestins for dysmenorrhea and pelvic pain (norethindrone, DPMA, levonorgestrel IUD
gnrh AGOnists for up to 6 mo. due to risk of boneless
gnrh antagonist
pharm treatment of endometriosis associated pain
pharm:
1. nsaids for dysmenorrhea.
can add
2.CHC (most common)FOR DYSMENNORHEA AND Pelvic pain
OR
progestins for dysmenorrhea and pelvic pain (norethindrone, DPMA, levonorgestrel IUD
- gnrh AGOnists for up to 6 mo. due to risk of boneless
OR
gnrh antagonist
(cannot use this and CHC at ssame time. must have pt use non hormonal contraceptives)
- Danazol, aromatase inhibitors
treatment of endometriosis associated infertility
- surgical
- artificial insemination
- assisted reproductive surgery
DisorderMiscarriage
What is it:
Diagnosis:
Patho:–
risk factors:
Signs and Symptoms:
Treatment:
non pharm
pharm:
Disorder:PCOS
What is it: early pregnancy loss within the first <13 weeks of gestation
Diagnosis: ultrasound
Patho:–
risk factors: women who have experienced previous early pregnancy loss.
advanced maternal age
Signs and Symptoms:
vaginal bleeding
uterine cramping
Treatment:
non pharm
pharm:
1, expectant management:
2. med management:
misopristol 800 mg vaginally. may repeat if needed within 7 days
ae: moderate to heavy bleeding and cramping
call md if soaking 2 maxi pads / hour for 2 hours
3.surgical evacuation
Misoprostol (miscarriage)
moa
route
counseling
mimics prostalgandins: bonds to smooth muscle myometrium and causes uterine contractions.
route: vaginally
Medications for medical abortion
Mifepristone
misoprostol
methotrexate
mifepristone
moa
route
ae
contraception
blocks progesterone, causing, decimal necrosis, rhythmic uterine contraction, cervical ripening
route: buccal or vaginally
ae: bleeding, pain,N/V/D, dizziness, headache, chills, weakness, (can use nsaids for pain)
contraception: all methods can be provided immediately after uncomplication medication abortion
DMPA and etonogestrel injection can be given say of mifepristone
CHC can be started on day of misoprostol
abortion counseling sheet
- instructions
mifepristone: taken at home - misoprostol would be taken 24-48 hours after mifepristone was taken. place 2 pills inside each check for 30 min, then swish with water and swallow anything remainin
expect: bleeding cramping within a couple hours after misoprostol, may have some bleeding b4 with the mifeprisone
may experience N/V/D fever and chills
OTCs: no extra NSAIDS, orc’s FOR DIARRHEA
went to call provider: bleeding that soaks 2 full size pads per hour for 2 cones hours
confirm pt has provider phone number.
