Infertility/PCOS Flashcards by tcarlso 3

What is the definition for infertility before 35 years of age? After?

Unable to conceive for more than 12 months

- 6 months if women is over 35

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What is fecundability?

Ability to conceive within a given month/cycle

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What is the prevalence of infertility?

10-15% of reproductive aged couples

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What are the general etiologies of infertility?

1/3 male
1/3 female
1/3 idiopathic

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What is the most common female factor that causes infertility?

Ovulatory dysfunction

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What is the best amount of sex to have in order to achieve? Why?

Every other day, to allow for sperm to accumulate

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What history bits should be obtained when evaluating infertility?

Menstrual cycle characteristics
Timing of intercourse in cycle
Length of infertility

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What specific ob/gyn history should be obtained when evaluating infertility? (4)

STIs
Previous pregnancies
Pap results
Past contraception

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How do ruptured appys caused infertility?

Scarring causing tubal damage

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What is the LEEP procedure, and what is its effect on fertility?

Excision of the ectocervix in the case of abnormal pap smears

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What is Asherman syndrome?

Scar band in the uterus 2/2 repeated D and Cs

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What is the effect of hyperthyroidism on menstruation?

Lighter periods

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How do varicosities in the testes lead to infertility?

Increased heat

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What is the normal amount of semen?

1.5 mL

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What is the usual concentration of sperm in seme?

15 million /mL

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What is the normal motility of sperm?

32%

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True or false: you only need 4% sperm with the correct morphology to be fertile

True

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What sort of labs, generally, are useful for evaluating for infertility?

UA/ STI screen
CBC
Hormonal levels

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When should FSH be drawn for evaluation of infertility?

Day 3 of ovulatory cycle

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What is the homework assignment for patient who are experiencing infertility?

Basal body temperature

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When should progesterone levels be obtained?

Day 21 of menstrual cycle

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What is the thinking behind the progesterone challenge?

Give 10 days of progesterone, then withdraw to assess for HPA axis and normal vaginal bleeding

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What lab test is useful is there is an abnormal LH:FSH ratio? Why?

Fasting glucose to look for insulin resistance

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How do you confirm tubal patency?

HSG or sonohysterogram

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What is a hysterosalpingogram?

Injecting dye into the uterus to assess for patency of fallopian tubes

What are hydrosalpinx?

A distally blocked fallopian tube filled with serous or clear fluid

What does the 17 hydroxyprogesterone test assess for?

21 or 11 hydroxylase deficiency

What is the postcoital test?

Couple has sex, then you take a vaginal swab and assess

What is the Spinnbarkeit test? What is the basis for this?

Assessing for the stretch of the cervical mucus Increases stretchiness near ovulation

When should couples be having intercourse to help achieve conception?

day 10-20, every other day

What is the "infertility path"?

The fact that insurance companie do not usually pay for fertility testing, so may be spending a lot with consults

What is clomifene? Use? MOA?

Selective estrogen receptor modulator that induces ovulation to help achieve conception with PCOS

What is the treatment for luteal phase defects?

Exogenous progesterone

What is the treatment for PCOS pts who want to achieve conception?

Clomiphene

What is the use and MOA of letrozole?

Oral nonsteroidal aromatase inhibitor for the treatment of hormonally sensitive breast cancer, or to induce fertility by releasing follicles

What labs should be obtained after conception is achieved in an infertile couple?

Serum hCG and once again in 48 hours

What is the role of progesterone suppositories in fertility?

Add them after pregnancy is attained, to ensure that the pregnancy is maintained

When does cardiac activity become apparent by US?

4.5 weeks ish

What is the hCG level that indicates when TVUS can visualize the pregnancy? Abdominal?

1500 for TVUS | 6500 for abdominal

What is the most common cause of female infertility?

PCOS

What is the prevalence of PCOS?

4-12% of reproductive age women

What is the etiology of PCOS?

Idiopathic

What is the triad that defines PCOS?

- Hyperandrogenism - Ovulatory dysfunction - Polycystic ovaries on US

What are the associated conditions with PCOS? (5)

- Obesity - DM II - OSA - Dyslipidemia - Thyroiditis

What are the conditions that need to be ruled out before diagnosing PCOS? (6)

- Hypothyroidism - Hyperprolactinemia - Androgen-secreting tumor - Adult onset congenital hyperplasia - Cushing's - Pregnancy

What is the usual clinical presentation of PCOS? (5)

- Menstrual irregularities - Acne - Hirsutism - Androgenic alopecia - Obesity

What is the classic US finding of PCOS?

"String of pearls" that circumscribe the ovary

What are the labs that are useful for assessing hyperandrogenism in PCOS?

Free testosterone and/or total

What is the LH:FSH ratio that is indicative of PCOS?

more than 2

Hyper of hypoinsulinemia with PCOS?

hyperinsulinemia

What are the lipid levels like with PCOS?

Dyslipidemia

What are the HPA axis hormones that should be checked with PCOS? (4)

Thyroid Prolactin 17-OH progesterone Cortisol

What is the role of insulin in PCOS? (3)

- Increases ovarian androgen production - Inhibits hepatic production of SHBG - increases free androgens

What are the four major goals of treatment for PCOS (generally)?

- Lessen s/sx of hyperandrogenism - Manage metabolic comorbidities - Prevent chronic anovulation - Contraception

What is the major consequence of untreated anovulation with PCOS?

Endometrial hyperplasia and carcinoma

What are the two major first line therapies for PCOS?

- Lifestyle changes | - Oral contraceptive pills

What is the role of oral contraceptive pills with PCOS?

- Protects against endometrial hyperplasia | - Helps with acne, hirsutism

What are the oral contraceptives that should be used in the treatment of PCOS?

Those with minimal androgenicity

What is the major second line pharmacotherapy for PCOS? MOA?

Spironolactone---aldosterone and androgen antagonist

What is the role of metformin in treating PCOS?

- Restores ovulation in PCOS pts - Decreases testosterone level - Weight loss But ONLY if they have hyperglycemia

When should Clomiphene be started after a failed progesterone challenge? When should f/u be done? What should be done if she is still not ovulating at f/u?

3-5 days later Check serum progesterone on day 21 to assess for ovulation. If not ovulating, then up dose

In whom is Clomiphene / letrozole better for?

Clomiphene for normal weight women Letrozole for overweight

What are the lifelong complications of PCOS? (3)

- CV disease - DM II - Endometrial cancer