LECTURE 53 - infertility Flashcards
What age & PMH indicates that a pt should be evaluated for infertility?
- women over 35 YO (evaluate early!!)
- Hx of oligomenorrhea/amenorrhea
- Uterine/tubal disease or endometriosis
- Partner known to be subfertile
When should a women < 35 YO trying to conceive be evaluated for infertility?
If unable to become pregnant after 12 MONTHS of frequent, unprotected intercourse
When should a women 35-40 YO trying to conceive be evaluated for infertility?
If unable to become pregnant after 6 MONTHS of frequent, unprotected intercourse
When should a women > 40 YO trying to conceive be evaluated for infertility?
If unable to become pregnant after LESS THAN 6 MONTHS of frequent, unprotected intercourse
List the 4 main factors that contribute to infertility
- cervical factors (10%)
- uterine factors (< 10%)
- tubal & peritoneal factors (40%)
- ovulatory factors (40%)
Describe how cervical factors contributes to infertility
Cervical mucus not receptive to sperm
Describe how uterine factors contributes to infertility
Anatomic factors:
Mass
Non-anatomic factors:
Subclinical inflammation
Chronic endometriosis
Describe how tubal & peritoneal factors contributes to infertility
- Blocked fallopian tube(s)
- Interference with normal movement of the fallopian tube(s)
- Barrier between fallopian tube and the ovary
- Alteration of the pelvic environment
Describe how ovulatory factors contributes to infertility
Hypothalamic pituitary failure:
Abnormal response to, or a decreased production of GnRH
Dysfunction of hypothalamic-pituitary ovarian axis
Ovarian failure:
Primary ovarian insufficiency or diminished ovarian reserve
List appropriate non-pharmacologic treatment for a couple experiencing infertility
- weight adjustment
gain if hypothalamic anovulation & BMI < 20
lose if high BMI, insulin resistance - Avoid smoking, alcohol, caffeine & illicit drugs
- Reduce stress
- “Expectant management”
Define “expectant management”
Regular menstruation periods present → confirm evidence of ovulation
List resources / strategies for expectant management
- Urine ovulation predictor kits
- Timed intercourse
- Change in cervical mucus
- Basal body temperature monitoring
- Vaginal monitoring
- Mid-luteal phase progesterone level
- FSH level (day 3 of cycle)
List potential complications of pharmacological infertility treatments
Ovarian hyperstimulation syndrome (OHSS)
Risk of cancers (endometrial)
Multiple births (gonadotropin ,IVF)
List types of pharmacological treatments available for infertility treatment
- Controlled ovarian hyperstimulation
- Gonadotropins w/ or w/o IUI
- Assisted reproductive techniques
Describe controlled ovarian hyperstimulation as a treatment option for infertility
Aromatase inhibitor (letrozole - Femara)
w/ or w/o IUI
- 2.5 - 10 mg PO x 5 days, start of day 3 of menses
- Avoid use with CYP2A6 substrate
- Monitor use with tamoxifen & methadone (CYP2C19)
Describe gonadotropins w/ or w/o IUI as a treatment option for infertility
Combination of FSH & LH or either alone
increases FSH
IM or SUBQ injections
requires careful monitoring
Human Chorionic Gonadotropin (hCG)
used to trigger ovulation
injection at the end of ovulation - timing is ver important
2 products → recombinant hCG & urinary hCG
IM or SUBQ injections
List the types of assisted reproductive techniques available to treat infertility
Intrauterine insemination (IUI)
In vitro fertilization (IVF)
Intravaginal culture
Intracytoplasmic sperm injection (ICSI)
(done in conjunction with IVF)
