Infertility/PCOS Flashcards
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
What is fecundability?
Ability to conceive within a given month/cycle
What is the prevalence of infertility?
10-15% of reproductive aged couples
What are the general etiologies of infertility?
1/3 male
1/3 female
1/3 idiopathic
What is the most common female factor that causes infertility?
Ovulatory dysfunction
What is the best amount of sex to have in order to achieve? Why?
Every other day, to allow for sperm to accumulate
What history bits should be obtained when evaluating infertility?
- Menstrual cycle characteristics
- Timing of intercourse in cycle
- Length of infertility
What specific ob/gyn history should be obtained when evaluating infertility? (4)
- STIs
- Previous pregnancies
- Pap results
- Past contraception
How do ruptured appys caused infertility?
Scarring causing tubal damage
What is the LEEP procedure, and what is its effect on fertility?
Excision of the ectocervix in the case of abnormal pap smears
What is Asherman syndrome?
Scar band in the uterus 2/2 repeated D and Cs
What is the effect of hyperthyroidism on menstruation?
Lighter periods
How do varicosities in the testes lead to infertility?
Increased heat
What is the normal amount of semen?
1.5 mL
What is the usual concentration of sperm in seme?
15 million /mL
What is the normal motility of sperm?
32%
True or false: you only need 4% sperm with the correct morphology to be fertile
True
What sort of labs, generally, are useful for evaluating for infertility?
- UA/ STI screen
- CBC
- Hormonal levels
When should FSH be drawn for evaluation of infertility?
Day 3 of ovulatory cycle
What is the homework assignment for patient who are experiencing infertility?
Basal body temperature
When should progesterone levels be obtained?
Day 21 of menstrual cycle
What is the thinking behind the progesterone challenge?
Give 10 days of progesterone, then withdraw to assess for HPA axis and normal vaginal bleeding
What lab test is useful is there is an abnormal LH:FSH ratio? Why?
Fasting glucose to look for insulin resistance
How do you confirm tubal patency?
HSG or sonohysterogram
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
