SM_204b: Female Fertility Flashcards
Infertility is ____
Infertility is one year of unprotected intercourse without conception
- Primary: no prior pregnancies
- Secondary: at least one prior conception
- Evaluate women > 35 years after 6 months of attempting conception
Cycle fecundability is when ____
Cycle fecundability is when a single menstrual cycle results in pregnancy
Cycle fecundity is when ____
Cycle fecundity is when a single menstrual cycle results in a life birth
Describe the scope of female infertility
Female infertility
- 15% of all couples require evaluation / treatment and 50% of women over 40
- Decline in US birth and fertility rates
- Fertility peaks at 20-24 and decreases a little until 30-32 and then declines progressively
- Miscarriage rates increase with maternal age
- Aneuploidy rates increase with increasing maternal age
Describe requirements of a successful pregnancy
Successful pregnancy requires
- Oocytes
- Ovulation
- Oocyte transport
- Sperm of adequate number and quality
- Fertilization
- Transport of fertilized ovum into uterus
- Implantation
Describe hypothalamic-pituitary-ovarian-axis
Hypothalamic-pituitary-ovarian-axis
- Hypothalamus releases GnRH
- Anterior pituitary releases FH and LH
- FSH stimulates ovarian follicles to grow and mature and LH stimulates ovulation and corpus luteum formation
Describe menstrual cycle
Menstrual cycle
- Hypothalamus secretes GnRH
- Anterior pituitary secretes FSH
- Ovary secretes estrogen
- Feedback to cause anterior pituitary to secrete LH
- FSH stimulates ovary to release progesterone
Describe differential diagnosis of infertility
Differential diagnosis of infertility
- Anatomic disorders
- Ovulatory dysfunction
- Oocyte factors / decreased ovarian reserve
- Male factors
Anatomic abnormalities of the uterine cavity can be ____ or ____
Anatomic abnormalities of the uterine cavity can be congenital or acquired
- Congenital: mullerian duct abnormalities
- Acquired: fibroids, polyps, Asherman’s syndrome (iatrogenic intrauterine adhesions)
Anatomic abnormalities of the fallopian tubes are usually related to ____ or ____
Anatomic abnormalities of the fallopian tubes are usually related to prior ascending infection or pelvic surgery
Ovulatory dysfunction is most commonly caused by ____ or ____
Ovulatory dysfunction is most commonly caused by polycystic ovary syndrome or hypothalamic amenorrhea
- Less common: hyperprolactinemia, thyroid disease, primary ovarian insufficiency
Describe polycystic ovary syndrome
Polycystic ovary syndrome
- Most common endocrinopathy of women
- Oligo or amenorrhea
- Hyperandrogenemia
- Polycystic ovaries on ultrasound
- Associated with insulin resistance and obesity
Describe hypothalamic amenorrhea
Hypothalamic amenorrhea
- Usually a functional disorder
- Associated with excessive exercise, inadequate nutrition, or stress
- Common pathway is disruption of pulsatile GnRH secretion from hypothalamus
Maximum number of eggs (ovarian reserve) is at _____ and _____ over time
Maximum number of eggs (ovarian reserve) is at birth and decreases over time
Maternal age ____ significantly affect the uterus
Maternal age does NOT significantly affect the uterus
- No adverse impact on endomtrial development or function
- Overall live birth rate per transfer in donor egg IVF cycles 55%: does not vary with recipient age
Male factors contributing to infertility are ____, ____, ____, and ____
Male factors contributing to infertility are hypothalamic-pituitary disorders, primary gonadal disorders, disorders of sperm transport, and idiopathic
- Idiopathic are most common
Unexplained infertility is a diagnosis of ____
Unexplained infertility is a diagnosis of exclusion
- Implies bilateral tubal patency and normal uterine cavity, ovulatory function, and semen quality
- Potential explanations: poor oocyte quality, another specific cause that cannot be identified with existing tests (abnormalities of sperm function, fertilization, implantation, or embryo development)
Describe evaluation of female infertility
Female infertility evaluation
- History and physical
- Assess uterine cavity
- Document tubal patency
- Confirm ovulation
- Assess ovarian reserve
- Semen analysis
Describe taking a female reproductive history
Female reproductive history
- Obstetrical history
- Duration of infertility
- Menstrual cycle length
- Dysmenorrhea
- Moliminal symptoms
- Coital frequency, sexual dysfunction
- Gynecologic history: paps, STI
- Meds, allergies
- Occupation
- Medical history: obesity
- Surgical history
- Social history: tobacco use (ever and current)
- Fam Hx of birth defects, genetic diseases, cancers
- Family reproductive history: # siblings, SAB / stillbirths, sibling reproductive history
- ROS: symptoms of thyroid dysfunction, hyperprolactinemia, pelvic / abdo,minal pain, dyspareunia, dyschezia, hirsutism, weight gain / loss
Describe physical exam for female infertility
Female infertility physical exam
- Height, weight, BMI, blood pressure
- Thyroid (enlargement, nodules, tenderness)
- Hirsutism
- Breast mass / galactorrhea
- Pelvic tenderness / mass
- RV nodularity
Assessment of uterine cavity involves ____, ____, ____, and ____
Assessment of uterine cavity involves hysteroscopy, transvaginal ultrasound, HSG, and sonohysterogram
Assessment of tubal patency involves ____ or ____
Assessment of tubal patency involves hysterosalpinogram or saline infused sonohistogram
- Hysterosalpinogram: oil or water based dye injected through cervix and pictures of uterus and fallopian tubes are taken under fluoroscopy
- Saline infused sonohistogram: ability to demonstrate tubal patency as high as 80% but inferior to hysterosalpinogram when evaluated for tubal factor infertility
- Historical gold standard: laparoscopy with chromoperturbation
Describe assessment of ovulation
Assessment of ovulation
- History consistent with ovulation: regular cycles and moliminal symptoms before menses
- Basal body temperatures charting
- Serum progesterone on day 21 of a 28 day cycle
- Home ovulation predictor kits
Various methods acceptable
Ovarian reserve is ____
Ovarian reserve is quantity of good quality oocytes
- Decrease in fertility in order women is related to decreasing quantity of good quality oocytes
- Most common tests performed: day 3 FSH (FSH > 10-15 on day 2 or 3 is abnormal), anti-mullerian hormone, antral follicle count
Anti-mullerian hormone is from ____
Anti-mullerian hormone is from granulosa cells of the preantral and small antral follicles
- # of small antral follicles correlates with size of residual follicular pool
- Anti-mullerian hormone levels decrease as menopause approaches
Antral follicle count is an ___ measure of ovarian reserve
Antral follicle count is an indirect measure of ovarian reserve
- Transvaginal ultrasound measurement of follicles measuring 2-10 mm in both ovaries
Describe evaluation of male factors contributing to infertility
Male factors contributing to infertility evaluation
- Previous paternity
- Trauma, surgeries, infections, toxins
- Seuxal function
- Habits: tobacco, marijuana, wet heat, underwear
- Fam Hx: genetic disorders, birth defects, infertility
- Semen analysis: seminal volume > 1.5 mL, sperm concentration > 15 million/mL, motility > 40%, morphology >4% using strict criteria
Describe treatment for anatomical problems contributing to female infertility
Anatomical problems contributing to female infertility treatment
- Uterus: surgery, gestational carrier
- Fallopian tubes: surgery, IVF
Treatment for ovulatory dysfunction involves ____ or ____
Treatment of ovulatory dysfunction involves treating the underlying endocrinopathy and inducing ovulation with medications
- Ovulation induced with medications: clomiphene citrate, letrozole, injectable gonadotropins
Clomiphene citrate is a ____ used to treat ____
Clomiphene citrate is a selective estrogen receptor modulator used to treat ovulatory dysfunction
Letrozole is a ____ used to treat ____
Letrozole is an oral non-steroidal aromatase inhibitor used to treat ovulatory dysfunction
- First line for PCOS
- Slightly higher pregnancy rates than clomiphene
Injectable gonadotropins are ____ effective
Injectable gonadotropins are highly effective
- Purified urinary FSH, LH
- Recombinant FSH, LH, hCG
- Costly
- Increased risk of multiple pregnancy and ovarian hyperstimulation syndrome
There is ____ therapy for decreased ovarian reserve or age related infertility
There is no good therapy for decreased ovarian reserve or age related infertility
- Consider oocyte donation
Treatment of male factors contributing to infertility is ____, ____, or ____
Treatment of male factors contributing to infertility is
- Intrauterine insemination for modest abnormalities
- IVF with intracytoplasmic sperm injection
- Donor insemination
Describe treatment for unexplained female infertility
Unexplained female infertility treatment
- Approximate cycle fecundability 2-4% without treatment
- Evidence-based treatments: clomiphene + intrauterine insemination, IVF
Success of IVF depends on ____
Success of IVF depends on patient selection
- Age is very predictive of success
- IVF more successful if female partner has adequate ovarian reserve (even in setting of male factor)
- Antral follicle count (antral follicles 2-10 mm) are a good predictor of response
- Anti-mullerian hormone reduced with increasing age and is another useful marker of ovarian reserve
