Tx: Infertility

Question 1

Attempted pregnancy < 12 months

Answer 1

• Timed intercourse with urinary ovulation predictor kit
• Change lifestyle:
  
  • ideal BMI
  • stop smoking
  • limit caffeine and alcohol

Question 2

Infertility > 12 months - PO agents (7)

Answer 2

1. Clomiphene citrate = selective estrogen receptor modulator
2. Letrozole = aromatase inhibitor
   
   • off label use for anovulatory infertility
3. Anastrozole = aromatase inhibitor
4. Bromocriptine = dopamine agonist
   
   • for hyperprolactinemic anovulation
5. Metformin
   
   • use in women with glucose intolerance and anovulation
6. Tamoxifen
   
   • induce ovulation in PCOS
7. ASA/Heparin
   
   • antiphospholipid syndrome

Question 3

Clomiphene citrate infertility dosing

Answer 3

1. 50mg QD x 5 days beginning on 5th day of menses. If evidence of ovulation, repeat each cycle until conception occurs.
2. If no ovulation then increase to 100mg QD x 5 days after 5th day of menses.
3. Then try 150mg QD x 5 days = max dose.
4. If failed after 2-3 cycles consider alt tx

Question 4

Infertility >12m vaginal agents

Answer 4

1. Vaginal progesterone - promote growth for implantation and support early stage of pregnancy
   
   • 100mg vaginal insert QD
   • 200mg or 600mg vaginal suppository
   • Gel
   • Continue until 8-10 weeks gestation

Question 5

Recurrent pregnancy loss vaginal progesterone dosing

Answer 5

1. 200mg suppository PV TID beginning 3 days after LH surge. Continue until 10 weeks gestation.
2. 90mg progesterone gel PV QD
3. Micronized progesterone 100mg PO BID to TID

Controversial efficacy

Question 6

Infertility > 12m injectables

Answer 6

1. FSH - induce follicular development - assisted contraception/IVF
2. hCG - substitute for midcycle LH surge - triggers ovulation
3. GnRH agonist: Leuprolide, Buserelin, nafarelin, triptorelin

Question 7

Fertilization treatments

Answer 7

1. Intravaginal insemination (IVI)
2. Intrauterine insemination (IUI)
3. In vitro fertilization (IVF)
   4.