OI and IUI

Question 1

WHO Classification of Ovulatory Disorders

Answer 1

I: Hypo-hypo (5-10%)
II: Normo-normo (75-85%)
III: Hyper-hypo (10-20%)
IV: Hyper PRL (5-10%)

Question 2

Reqts

Answer 2

evidence of ovulation in the IUI cycle
at least 1 patent tube
>5-10M sperm motile (CPG)
no active infection

Question 3

moa clomiphene

Answer 3

a selective estrogen receptor modulator that
binds to estrogen receptors for an extended period of time, this messes with receptor recycling and causes a feedback to your hypothalamus to stimulate GnRH and gonadotropin production because there is a perceived low level of estrogen –> this drives follicular development

in ovulatory women: inc pulse frequency
in anovulatory women: inc pulse amplitude

Question 4

side effects clomiphene

Answer 4

dec cervical mucus quality
dec endometrial growth

Question 5

% fecundability
expectant v cc v gonadotropins v ivf

Answer 5

2-4%
5-10%
7-10%
25-45%

Question 6

T or F:

in anovulatory women, OI + IUI is not superior to OI + timed coitus if normal semen parameters

Answer 6

T

Question 7

T or F:

in ovulatory women, OI + IUI is not superior to OI + timed coitus if normal semen parameters

Answer 7

F

add IUI to inc number of sperm

Question 8

cycle fecundability for OI with CC in ANOVULATORY women

Answer 8

15-22%

Question 9

side effects CC

Answer 9

hot flashes
VMS
headache
breast tenderness
pelvic pressure
n/v
visual disturbances (scotomata, light sensitivity, double vision)
afterimages (palinopsia)
photophobia

Question 10

risks of CC

Answer 10

multiple pregnancy (7-10%)

no causal relationshop:
breast CA (high doses and multiple cycles)
endomCA (baka kasi yung anovulatory nature nung patient yung cause)

Question 11

adjuvant

Answer 11

Glucocorticoids on D5-14

Prednison 5mg OD x 10 days
or
Dexa 0.5-2.0 mg OD x 10 days

Metformin

Question 12

HCG trigger

(CC)

Answer 12

if not properly timed administration, results to atresia

given if lead follicle is 20 mm in diameter

ovulation 34-36hours after, IUI done at 36th hour

(as opposed to using LH kit, which detects the surge so 14-26 hours is ovulation –> next day ka mag IUI… usually 4-6pm ka nagtetest diba)

Question 13

gonadotropins indications

Answer 13

1. hypo-hypo (must contain both FSH and LH)

2.oral OI agents resistant (theoretically beneficial if FSH only so u dont augment LH)

3. unexplained infertility

Question 13

letrozole MOA

Answer 13

competitive nonsteroidal inhibitor of aromatase

block estrogen production in the periphery and brain –> stimulate gonadotropin secretion to stimulate follicular development

results to lower E2 and higher P4 during luteral phase = higher LBR

inc ovulation, PR, CPR for clomiphene resistant

no adverse endometrial effect

Question 13

side effects letrozole

Answer 13

fatigue
dizziness

Question 14

laparoscopic ovarian drilling

Answer 14

for anovulatory infertile women resistant to oral ovulation drugs

side effects:
adhesions
potential to decrease ovarian reserve

MOA: focal destruction of ovarian stroma will decrease intraovarian and systemic androgen concentrations

Question 14

protocols

Answer 14

step up
low slow
step down
sequential

Question 15

step up

Answer 15

75IU x 4-7 days between 5-8pm –> UTZ + serum E2 in the AM –> adjust –> if e2 inc, do utz q1-2 days, if 16-18mm lead follicle, trigger –> 36hrs after

Question 16

low slow

Answer 16

37.5-75 IU

Question 17

step down

Answer 17

150-225 IU (best if u know threshold)

Question 18

e2 levels best for trigger

Answer 18

500-1500pg/ml

200-400/follicle

Question 19

sequential

Answer 19

CC 50-150mg x 5 days then gonadotropins

Question 20

EM must be

Answer 20

greater than or = 7mm on trigger day

Question 21

risks of Gn tx

Answer 21

multiple pregnancy
PTB, LBW, GDM, PES
spontaneous miscarriage (25% v 15% in gen population)

Question 22

cancel cycle if (Gn)

Answer 22

E 900-1400pg/ml
UTZ 4-6 > 10-14mm
3 >/=15

Question 22

GnRH pulse tx indications and dose

Answer 22

hypo-hypo anovulatory women
2.5-5.0ug/pulse q60-90mins

pcos
pre-treat with GnRHa x 6-8weeks (to kill that high LH)

Question 23

indications for IUI (CPG)

Answer 23

mild male factor infertility
unexplained infertility
abnormal cervical mucus
minimal and mild endometriosis
sexual dysfunction

Question 24

CI to IUI

Answer 24

infection
stenosis/atresia
OAT
bilateral tubal obstruction
severe PEM (rASRM III/IV)
dense pelvic adhesions
DOR

Question 25

complications of IUI

Answer 25

pelvic infection
uterine cramping
multifetal pregnancy
OHSS

Question 26

oligo/asthenozoospermia preferred semen preparation technique

Answer 26

density gradient centrifugation because higher percentage of total motile sperm

Question 27

aromatase inhibtors for EU-HYPO

Answer 27

testolactone 500-1000mg BID
anastrazole 1mg OD

Question 28

MOA for glucocorticoids in IUI

Answer 28

androgen suppression
direct effect on developing oocytes
indirect effects on intrafollicular growth factors and cytokines