Lecture 5: Infertility (enochs) + some Flashcards
Define infertility
- Inability to conceive after 1y of unprotected intercourse of reasonable frequency in women < 35y
- Inability after 6m for women > 35y
Primary = no prior para. Secondary = multips
What conditions tend to result in infertility?
- Oligo/amenorrhea
- Uterine/tubal/peritoneal disease
- Stage 3/4 endometriosis
- Known/suspected male infertility (varicocele)
What is the MCC of infertility?
Ovulator issues
Male is 2nd highest, so evaluate both partners!
what about gynecologic history can affect fertility
- duration of infertility and any previous evaluation/treatment
- menstruation details (frequency/changes/ovulatory signs)
- prior contraceptive use
- hx of ovarian cysts, endometriosis, leiomyomas, STDs, PID
- hx of abnormal pap smears
What is conization?
Cone biopsy of cervix, which can affect cervical anatomy and decrease mucus quality
what about obstetric history is important in regards to assessing infertility
- prior pregnancies
- past pregnancy complications
what coital history is important when assessing infertility
- frequency
- timing (5 days prior to ovulation increases conception)
- dyspareunia
- lubricants (avoid oil based, used water based)
what medical history is important when assessing infertility
- chemo
- radiation
- androgen excess = PCOS
- thyroid disease
- hyperprolactinemia
- medications
- BMI
What typically can cause recurrent pregnancy loss?
- Monosomy X for spontaneous miscarriage
- APS
- Uterine abnormalities
What is the MCC of premature ovarian failure < 40y?
Turners
What is mittelschmerz?
Midcycle pelvic pain associated with ovulation
What are moliminal symptoms?
Breast tenderness, acne, food cravings, mood changes
How does basal body temperature change with ovulation?
Basal temp increase by 0.4-0.8F is strongly predictive of ovulation
(increased temp suggests POSTovulatory state)
How do ovulation predictor kits work?
Measuring urinary LH, since LH surge precipitates ovulation
WHy is FSH good to check ovarian reserve?
- The less eggs you have, the less inhibin you secrete.
- The less inhibin, the more FSH
- FSH > 10 IU/L is associated with diminished ovarian reserve
what serum progesterone level is indicative of current ovulation
> 3
what are common etiologies of ovulatory dysfunction
hypothyrodism
hyperprolactinemia
diminished ovarian resevre (older w/o good eggs)
PCOS
if hyperprolactinemia is found in a patient with suspected ovulatory dysfunction, what is the next step of diagnostics? what is the teatment?
- get head MRI just in case of mico/macroadenoma
- tx w dopamine agonists (bromocriptine or cabergoline) or surgery
What does increased antimullerian hormone mean for follicle count?
More follicles
what is the treatment for women who have diminished ovarian reserve
ovulation induction
IUI/IVF
egg donor
What is the initial treatment for anovulatory infertile women?
Clomiphene citrate (clomid)
what is the MOA of clomiphene citrate (clomid)
estrogen antagonist -> results in increase in FSH levels which increase ovarian follicular activity.
given for 5 days starting on cycle day 2-5
What does letrozole do?
Aromatase inhibitor, which inhibits the production of estrogen and increases FSH
What is ovarian hyperstimulation syndrome?
Excessive exgenous gonadotropin therapy resulting in ovarian enlargement
Supportive tx
Describe intrauterine insemination (IUI)
- wash/concentrate sperm
- Insert catheter into endometrial cavity and inject sperm
Describe in vitro fertilization (IVF)
- Direct injection of mature oocytes into endometrial cavity via sonographic evidence.
What is a hyserosalpingogram used to image? (HSG)
Uterine cavity and tubal imaging via radio-opaque dye
What is chromopertubation?
Injection of methylene blue thru cervical canal during laparoscopy to evaluate tubal patency
Tx for tubal occlusion
- Tubal cannulation
- Tubal reconstruction
- Tubal resection followed by IVF
Tx for endometriosis
- Surgical treatment (removal of adhesions and draining endometriomas)
- IVF
- GnRH
Tx for pelvic adhesions
- Surgical removal
- IVF
How do fibroids affect infertility?
- Obstruction of tubes or distortion of uterus
What is Asherman’s syndrome?
- Intrauterine adhesions
- Hx of D&C
Dx and Tx of Asherman’s syndrome
- Dx: HSG or hysteroscopy
- Tx: Hysteroscopic lysis of adhesions
Why is an endometrial biopsy preformed?
Thought to be more informative than just a serum progesterone level.
No longer routine
What does high estrogen do to cervical mucus?
Thin and sticky
what is a postcoital test
- couple has intercourse on day of ovulation
- women present to office few hours later and cervical mucus sample is obtained
- mucus should stretch >5cm, have visible sperm, minimal inflammatory cells, and dry in a fern shape pattern.
- if any of those dont happen, mucus may be inappropriate
How long does it take sperm to mature?
90d, so any detrimental affect 3 months prior could be the culprit for male infertility
Sperm matures best at slightly below body temp
what are the three causes of male infertility
- abnormalities in sperm production
- abnormalities in sperm function
- obstruction of ductal outflow tract
How is semen analysis performed?
- Dont jack off for 2-3 days
- Sterile cup collection
How do you treat antisperm antibodies?
Corticosteroids
You will see agglutination on semen analysis
low semen volume can indicate what
- partial/complete obstruction of vas deferens
- retrograde ejaculation
what is oligospermia and how do you treat it
<20 million sperm / mL
tx: IUI
what is azoospermia and what causes it
- no sperm!
- Congenital abscence of vas deferens (CF)
- Severe infection
- Vasectomy
Tx with donor or epididymal aspiration
What is asthenospermia and causes and tx?
- Decreased sperm motility
- Prolong abstinence
- Antisperm antibodies
- Infection
- Varicocele
- Tx with intracytoplastic sperm injection or IUI
What is teratospermia and Tx?
- Abnormal morphology
- Tx with IVF
What might low FSH & low testosterone suggest in a male? Tx?
- Kallmann syndrome: anosmia + hypogonadotropic hypogonadism
- Idiopathic hypogonadotropic hypogonadism
- Tx with gonadotropins!
What might elevated FSH with low testosterone suggest?
Testicular failure resulting in oligosermia.
What are the genetic causes of poor semen analysis?
- Klinefelter syndrome (XXY)
- Microdeletion of Y chromosome
- CF
