Lecture 7- Infertility Flashcards
What is fecundability and fecundity?
- chances of becoming pregnant off of that one cycle.
- probability of pregnancy resulting in live birth from one menstrual cycle
- both decrease over time
What are examples of elective infertility?
Tubal ligation
Vasectomy
What is the definition of infertility?
Failure to achieve IUP > 12 months
What are some causes of unexpected infertility?
Wars, diagnosis of cancer, chemo
When will you bring down the infertility to less than 6 months?
> 35 y/o
history of oligo/amenorrhea
unknown uterine/pelvic factors
hx prior infertility
How many couples experience difficultly with conception?
15% of couples
What’s primary infertility?
Never fathered a child/ never been pregnant
What is secondary infertility in a female?
Has been pregnant before but now can’t get pregnant
What are three etiologies of female infertility?
Presence of ovulation cycles
HPG dysfunction and ovulatory dysfunction
Anatomic dysfunction
What are two different types of HPG dysfunction and ovulatory dysfunction?
Oligo-ovulation (not ovulating every cycle)
Amenorrhea
What are some things that can cause oligo-ovulation problems?
HPG dysfunction: thyroid
Pituitary: hyperprolactinemia
PCOS
What are some causes of Amenorrhea?
Pregnancy
Hyperandrogenism
stress related hypothalamic dysfunction
Premature ovarian failure
What does basal body temperature allow you to determine?
Time of ovulation; biphasic curve (due to rise with progesterone levels after LH surge)
When is LH present in the urine?
1 day before ovulation
What is the normal range for serum progesterone?
6-25
What progesterone levels are considered low?
3-5 ng/mL
Elevated prolactin- what should you look at if she isn’t pregnant?
Pituitary- look for prolactin secreting tumor
What hormone stimulates prolactin?
Thyroid releasing hormone
What shuts down prolactin secretion?
Dopamine
What are some things in the uterus that can lead to infertility?
Fibroids, leiomyoma, anomalous structure, polyps
What are some things in the fallopain tubes/ peritoneum that can cause infertility?
Obstruction/ adhesions PID Appendicitis Endometriosis Priory surgery
With anatomic dysfunction what imaging diagnostics would be helpful?
TVUS (trans vaginal US)
What is cryptochidism?
Undescended testicle
WHat is hypospadias?
Urethral opening is lower down than normal
How many semen samples do you need for a proper analysis?
2 or 3 over 2 week period
How many days before giving a semen sample should males be abstient?
2-3 days
How much is normal volume of ejaculate volume?
1.5 mL
How many million sperm should you have per mL?
15 million
What percentage of the sperm should be mobile?
> 40%
In primary hypogonadism what lab levels are abnormal in males?
Low testosterone
or elevated FSH, LH
In males if there is low testosterone what should be checked?
Prolactin
What day of the cycle do you want to draw FSH and estradiol?
cycle day 3
What day do you want to draw serum progesterone?
Day 20, 21
When do you start clomiphene citrate?
Cycle days 3-5 (follicular phase)
When will ovulation occur after first dose of clomiphene citrate?
5-12 days after last dose
What are some side effects of clomiphene citrate?
hot flashes, HA, nausea, 10% risk of multi-gestation pregnancy
What type of drug is clomiphene citrate?
SERM, competes with estrogen
how long is daily progesterone supplement given?
From oocyte retrieval through first 10 weeks
What is a female with Male pattern distribution related to excess terminal hair? (coarse hair)
Hirsuitism
What is Masculinization of a female d/t increased testosterone?
Virlization
What are some ways that virilization manifests?
Clitoral hypertrophy Hirsuitism Deepening voice Remodeled muscle mass breast atrophy male pattern baldness
What are common ddx for virilization?
PCOS
CAH
idiopathic (diagnosis of exclusion)
What is treatment for hyperandrogenic disorders?
Supress or block action at receptor site
What is the carrier protein that binds to testosterone?
SHBG (sex hormone binding globulin)
Where is SHBG produced?
In the liver
What stimulates SHBG production?
Estrogen
Where are there testosterone receptors?
Hair follicles
Sebaceous glands
Genital skin
What is constitutional hirsutism
increased of testosterone at target cells, not necessarily the increase in testosterone overall
Individuals with PCOS who have acanthrosis nigricans often have what?
Insulin resistance
In pCOS is estrone or estradiol present at higher levels?
Estrone
What two blood levels are increased or upper limits of normal in PCOS?
Androstenedione and testosterone
In PCOS what will TG levels be at?
150 mg/dL
In PCOS what levels will HDL be at?
<50 mg/dL
In PCOS, fasting blood glucose is greater than what?
> 100 md/dL
On an US from someone with PCOS what will be seen?
1 or 2 ovaries w/ greater than o12 follicles (2-9 mm in diameter) see a lot of immature follicles
In PCOS are there any variation in FSH or LH?
No, so there is no trigger for final development, ovulation of ovums
What medication in PCOS helps decrease insulin resistance?
Metformin
If a person has had sudden symptoms of rapid onset acne, hirsuitism, amenorrhea, virilzation what should you suspect?
Sertoli-Leydig tumor
The deficiency of _________ is the most common cause of adrenal hyperplasia.
21-hydroxylase deficiency
What accumulates when 21-hydroxylase is deficient?
Progesterone
17 alpha hydroxyprogesterone (17-OH_progesterone)
What happens with the most severe form of 21-hydroxylase deficiency?
Female infant is virilized (ambiguous genitalia) and can suffer from life threatening salt wasting
When 21-hydroxylase deficiency manifests at puberty what may precede thelarche?
Adrenarche
What is treatment for CAH aimed at restoring?
Normal cortisol levels, usually supplement gluccocorticods like prednisone
Can medical therapy for adrenal and ovarian disorders resolve hirsutism?
No, can only supress new hair growth
What is a result of Cushing syndrome?
Adrenal excess as a result of adrenal neoplasm or an ACTH_producing tumor
What is the name for hirustism where there is no explanation for the cause of the disorder?
Constitutional hirsutism
Women with constitutional hirsutism have a greater activity of 5 alpha reductase and therefore more…
Free testosterone
What is the most commonly used androgen blocker for constitutional hirsuitism?
Spironolactone
What is when some drugs with androgen activity are implicated in hirsutism and virilization?
Iatrogenic androgen excess
What is an attenuated androgen used for the suppression of pelvic endometriosis and can lead to iatrogenic androgen excess and hirsutism, acne, deepening of the voice?
Danazol
For semen analysis, rapid progressive motility should be …
> 32%
For semen analysis, normal morphology should be …
> 4%
