Medical Treatment of Infertility

Question 1

what is considered infertiltiy

Answer 1

Failure to conceive after 1yr of regular, unprotected intercourse

Question 2

female causes of infertiltiy

Answer 2

ovarian dysfunction (aging, PCOS, premature ovarian failure, etc), tubal or pelvic factors, endometrial/ cervical

Question 3

male causes of infertility

Answer 3

sperm motility, numbers, or morphology, antibodies, blockages/ obstruction

Question 4

how to decresae prolactin

Answer 4

bromocriptine

Question 5

what lifestyle mods can women make to try to conceive

Answer 5

Weight (BMI >19, <30)
Smoking cessation
<2 drinks/wk, avoid is best if trying to conceive
↓ caffeine intake
Avoid rec drugs like marijuana (🛆LH sec in both M and F)

Question 6

what lifestyle mods can men make to try to conceive

Answer 6

Smoking cessation
<4 drinks/wk
Reduce heat: avoid hot tubs, restrictive clothing (ex- wear boxer shorts, etc)
Avoid rec drugs (ex- anabolic steroids)
Avoid drugs that affect male fertility/ ED
Avoid work contaminants- pesticides, herbicides

Question 7

what lifestyle mods can the couple make together to try to conceive

Answer 7

Timing of intercourse: fertile window = intercourse on multiple days q2d
Use of ovulation tests, vaginal mucus discharge
Counseling to decrease emotional stress + cycles of hope and despair

Question 8

what is the second intervention for infertility

Answer 8

Ovarian stimulation with oral agents- timed intercourse

Question 9

Ovarian stimulation with oral agents- timed intercourse includes agents such as

Answer 9

antiestrogens like clomiphene citrate
reversible aromatase inhibitors like letrozole

Question 10

why are antiestrogens used in infertility

Answer 10

negative feedback blocked = increase in GnRH, FSH, LH = stimulation of ovulation

Question 11

MOA of letrozole

Answer 11

: aromatase inhibitor, blocks conversion of androgens to estrogen

Question 12

what is the benefit of letrozole

Answer 12

no antiestrogen eff on cervix or uterus

Question 13

letrozole dosing

Answer 13

start 2.5mg daily F5D on days 3-7 of cycle, can ↑ up to 7.5mg for subseq cycles

Question 14

letrozole SEs

Answer 14

lack of energy, dizziness, HA, bone pain (10%), hot flashes (18%)

Question 15

response to letrozole is lowered with

Answer 15

age, high/ low BMI, >6 cycles (most preg will occur in 3 cycles)
Not eff for women with limited ovarian reserve (women must have normal process)

Question 16

what is the third tx for infertility

Answer 16

Ovarian stimulation with oral agents- IUI

Question 17

what is IUI

Answer 17

Intrauterine insemination (IUI): sperm sample (with damaged removed) is placed in uterus through vagina using catheter

Question 18

Ovarian stimulation with oral or injectable agents AND IUI is ____ effective than with timed intercourse

Answer 18

more

Question 19

IUI may not work if

Answer 19

severe male factors or women with blocked/ damaged fallopian tubes

Question 20

what is the 4th intervention for infertility

Answer 20

Ovarian stimulation with injectable agents (gonadotropins) + IUI

Question 21

what injectable agents can be used to stimulate follicular development

Answer 21

gonadotropins

Question 22

gonadotropins role and goal in interfility

Answer 22

Role: stimulate ovarian follicular development → goal: produce more than one mature follicle

Question 23

what should be monitored with gonadotrophins stimulating follicular development

Answer 23

follicle size via transvaginal ultrasound + E levels

Question 24

what 2 gonadotrophins are used to induce ovulation

Answer 24

rFSH- recombinant FSH (follitropin alpha or beta)
OR
hMG- human menopausal gonadotropin
Collected from urine of postmenopausal women, contains FSH an LH

Question 25

gonadotrophin SEs

Answer 25

pain and allergic rxns from proteins (w/ hMG only)

Question 26

what gonadotrophin is used to trigger ovulation

Answer 26

HCG: used for triggering ovulation- surrogate for LH surge

Question 27

follicular rupture is expected _____ later after HCG dose

Answer 27

36-40hrs

Question 28

after HCG injection, Follicular rupture 36-40hrs later, then ____ over next ___ days to coincide with ovulation or IUI

Answer 28

timed intercourse 2 days

Question 29

waht is the 5th treatment for infertiltiy

Answer 29

IVF

Question 30

IVF indications

Answer 30

Tubal (pathology, endometriosis), infertility >3yrs or women >36yrs old, male infertility, remains anovulatory after ovulation cycles

Question 31

IVF effectiveness is uncertain after ___ cycles

Answer 31

3

Question 32

steps for IVF

Answer 32

1. Pituitary downreg/ suppression of women’s hormone production 2. Gonadotropin for ovulation induction (and stimulation of more than one ovarian follicle) 3. hCG hormone for final maturation of follicle and release of oocyte 4. Oocyte retrieved from female 34-36hrs after hCG 5. Oocyte cultured in incubator and exposed to sperm from male partner 6. Fertilized ovum are incubated for 2-3 days 7. If successful, will be placed into uterus

Question 33

what is used in IVF for pituitary downregulation and hormone downregultaion?

Answer 33

GnRH agonists (most common) or antagonists

Question 34

what is the long nd short protocol for GnRH agonists

Answer 34

Long protocol: started in luteal phase of prev cycle (day 21) to avoid flare Short protocol or microflare dosing: started shortly after menstruation, small micro doses

Question 35

T or F: GnRH agonist depots should be used for suppression of women’s hormone production in IVF

Answer 35

F- use IN or SQ

Question 36

what is required right after retrievl if GnRH agonists are used

Answer 36

luteal phase support

Question 37

pros of using GnRH antagonist protocol in IVF

Answer 37

fewer injections and lower doses, shorter, no flare effect, no luteal support required

Question 38

cons of using GnRH antagonist protocol in IVF

Answer 38

expensive

Question 39

why is P supplementation required in IVF with GnRH agonists

Answer 39

to maintain uterine lining + support early preg

Question 40

why may E supplementation be required in IVF

Answer 40

to maintain adequate endometrial lining to support implantation May be used with GnRH agonist protocols

Question 41

E supplementation n IVF is usually used with ______ protocols

Answer 41

GnRH agonist

Question 42

what is ICSI

Answer 42

Intracytoplasmic sperm injection (ICSI): single healthy sperm inj directly into oocyte to fertilize Can overcome severe male factors for infertility or low sperm count

Question 43

what is the 6th step for infertility tx

Answer 43

IVF + ICSI