Workup for Fertility

Question 1

What is the 
1. FSH
2. LH
3. Estradiol
4. Lining
like in PCOS?

Answer 1

1. low/normal
2. high
3. low/normal
4. thick

Question 2

What is the 
1. FSH
2. LH
3. Estradiol
4. Lining
like in Hypothalamic amenorrhea?

Answer 2

1. low
2. low
3. low
4. thin

Question 3

What is the 
1. FSH
2. LH
3. Estradiol
4. Lining
like in premature ovarian insufficiency?

Answer 3

1. high
2. high
3. very low
4. thin

Question 4

3 main diagnoses, and 2 others, that could be causes anovulation

Answer 4

Main: PCOS, hypothalamic amenorrhea, premature ovarian insufficiency
Others: hyperprolactinemia, thyroid problems

Question 5

Infertility definition

Answer 5

1 year of frequent and unprotected coitus without conception
Suggests decreased capacity to conceive and reproduce
Not irreversible

Question 6

Primary infertility

Answer 6

Couple who has never achieved a pregnancy

Question 7

Secondary infertility

Answer 7

At least one previous conception has taken place

Question 8

Why do pregnancy rates decrease as women age?

Answer 8

Decrease in the egg quality

More likely to get aneuploidy

Question 9

How long do sperm live in the female repro tract for? How long can the egg live?

Answer 9

Sperm: 3-5 days
Egg: 24 hours

Question 10

4 important goals of invaluation

Answer 10

Identify the cause(s) of the infertility
Provide a basis for potentially successful treatment options
Provide a realistic prognosis
Offer emotional support

Question 11

Tests for fertility

1. Male
2. Female

Answer 11

1. Semen analysis

2. Hysterosalpingogram, ovarian reserve testing, evidence of ovulation, pelvic ultrasound, thyroid, prolactin tests

Question 12

How do you assess ovarian reserve (2 ways)

Answer 12

Day 3 FSH and estradiol

Anti-mullerian hormone assay

Question 13

How does measuring the Day 3 FSH and estradiol tell you about the ovarian reserve?

Answer 13

On Day 3 the estradiol should be low (no feedback on the pituitary, so just a bit FSH)
Looking at how hard FSH has to work to get the dominant follicle
High FSH = trying really hard to get dominant follicle
Low FSH (under 10) = lots of eggs so easy to make dominant follicle
Want to see FSH under 10!

Question 14

How does the anti-mullerian hormone assay (AMH) tell you about the ovarian reserve?

Answer 14

AMH is a hormone made by the follicles at varying stages of development (not the dominant follicle)
So if there is high AMH there is a high ovarian reserve

Question 15

Gold standard to confirm ovulation

Answer 15

Luteal phase progesterone (should be high)

Question 16

What are some ways to confirm ovulation?

Answer 16

Luteal phase progesterone
Cervical mucus changes
LH surge detection (can use LH sticks - ovulation will happen the next day)
Basal body temp charts (mediated by progesterone)
Just having a regular cycle!

Question 17

Hysterosalpingogram

Answer 17

Go to test to evaluate tubes and uterus
Ultrasound is an alternative
Its not always accessible
Speculum, clamp, insert dye and then use X-ray to look

Question 18

4 times that intrauterine insemination is indicated?

Answer 18

Donor insemination
Mild-moderate male factor
Sexual dysfunction
Unexplained infertility

Question 19

When is IVF appropriate?

Answer 19

Tubal blockage
Severe male factor
Age (or low ovarian reserve)
Unexplained
Fertility preservation
Recurrent miscarriage or genetic disease carriers

Question 20

Basic steps of IVF

Answer 20

Ovarian stimulation (inject FSH)
Egg retrieval 
Fertilization
Culture
Embryo transfer (into uterus, just like IUI)
Freeze extra embryos

Question 21

3 things we look at to determine embryo quality

Answer 21

Expansion (maturity) of blastocyst
Quality of inner cell mass
Quality of trophectoderm

Question 22

How much does IVF cost?

Answer 22

Approximately $12,000

With genetic testing up to $18000

Question 23

Make sure to investigate early in patients over what age?

Answer 23

35