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Flashcards in 26: Infertility and ART Deck (33)

Female factor infertility is purely responsible for ?% of all infertility cases. These can be divided into ? factors.

45% to 55%
ovulatory, tubal, uterine, and cervical factors


Female factor infertility may be due to ovulatory factors that interrupt the hypothalamic-pituitary-ovarian axis such as ? The most common causes of ovulatory factor infertility are ?

PCOS, primary ovarian insufficiency, hyperprolactinemia, and thyroid diseases

PCOS and advanced maternal age.


Ovulatory factors are diagnosed by confirming ovulation through ?

menstrual history, ovulation detection kits, midluteal progesterone level, along with endocrine evaluation (TSH, prolactin, FSH, and LH) and assessment of ovarian reserve (Day 3 FSH and estradiol levels, AMH levels, and AFC).


PCOS-related infertility can be treated with ?

weight loss, metformin, and OI with Clomid or letrozole. When refractory to treatment, OI with human gonadotropins can be used along with along with IUI or IVF.


The most common causes of tubal factor infertility are ?
These factors are diagnosed by ? and treated ?

endometriosis, pelvic adhesions, PID and tubal ligation
-diagnosed by history and laparoscopy or laparotomy
-treated surgically to improve fertility rates. Tubal occlusion may be repaired with microsurgical tuboplasty, but most couples opt for IVF.


Female infertility may be due to uterine factors such as ? Uterine factors are diagnosed by ?

uterine synechiae (Asherman's syndrome), polyps, submucosal fibroids, congenital malformations, or endometritis.

diagnosed by pelvic US, HSG, saline sonohysterogram, hysteroscopy, and laparoscopy.


treatment of Uterine infertility factors: Synechiae, fibroids, and polyps can be ? endometritis is treated with ?




Female infertility may also be due to cervical factors such as ? These factors are diagnosed ? and treated how ?

cervical stenosis from surgical or mechanical dilation. also Müllerian duct and Cervicitis or chronic inflammation

diagnosed on PE and treated with surgical or mechanical dilation of the endocervical canal or IUI to bypass the cervix.


Male factor infertility is purely responsible for ?% of all infertility cases.



Male infertility may be idiopathic or due to ?

improper coital practices, sexual dysfunction, endocrine disorders, or abnormalities in spermatogenesis, sperm volume, density, or mobility


Male factor infertility is diagnosed by ? The treatment of male factor infertility depends on the causal agent and includes ?

semen analysis and endocrine evaluation if indicated
-improved coital practices, repair of anatomic defects, ICSI (Intracytoplasmic sperm injection) and the use of donor sperm.


?% of couples find no explanation for infertility after their initial assessment. further assessment and treatment?

search for problems with sperm transport, ability to penetrate and fertilize the egg, and antisperm antibodies. IVF/ICSI can be used to treat these patients.


Couples with unexplained infertility who choose no treatment will conceive up to ?% of the time over 3 to 5 year.

-Most therapies for unexplained infertility have not been shown to have higher success rates than no treatment.


Clomiphene citrate MOA

an antiestrogen that binds to estrogen receptors in the hypothalamus to cause increased FSH and LH production, thereby promoting follicular maturation and ovulation


Letrozole MOA

an aromatase inhibitor that decreases the conversion of androgens into estrogens, thereby lowering estrogen levels and increasing FSH and follicular development. Its use for OI is off-label in the US


Clomiphene citrate is best used for OI in women with ? after specific causes of ? have been ruled out.

chronic anovulation or mild hypothalamic insufficiency
hypothalamic dysfunction


Human menopausal gonadotropins are forms of FSH, or combinations of FSH and LH that directly stimulate ? in patients for whom ? has failed, or those with ?

follicular maturation in patients for whom Clomid has failed, or those with hypothalamic or pituitary failure or unexplained infertility


The primary complications of fertility drugs include ?

ovarian hyperstimulation and multiple gestation pregnancy.


IVF and ICSI may be used to bypass the normal mechanisms of ? with deliveries in about ?% of cases.

gamete transport and fertilization


Infertility is defined as the failure of a couple to conceive after ? of unprotected sexual intercourse. If the female partner is 35 year of age or older, evaluation should be initiated after ? of unprotected intercourse

12 months

6 months


fecundity rate in a normal couple who has had unprotected intercourse

20% to 25% for the first 3 months, followed by 15% during the next 9 months
80% to 90% of couples are able to spontaneously conceive within 12 months


Average Conception Rates for All Couples

20% Conceive within 1 month
60% Conceive within 6 months
75% Conceive within 9 months
80% Conceive within 12 months
90% Conceive within 18 months


WHO classifications

WHO group 1: hypogonadotropic hypogonadal anovulation (hypothalamic amenorrhea)
WHO group 2: normogonadotropic normoestrogenic anovulation (polycystic ovarian syndrome [PCOS])
WHO group 3: hypergonadotropic hypoestrogenic anovulation (premature ovarian failure, advanced maternal age)
WHO group 4: hyperprolactinemic anovulation


Causes of Ovulatory Factor Infertility

-Central: Pituitary insufficiency (trauma, tumor, congenital), Hypothalamic insufficiency, Hyperprolactinemia (drug, tumor, empty sella), Luteal phase defects
-Peripheral defects: Gonadal dysgenesis, POF, Ovarian tumor, Ovarian resistance
-Metabolic disease:
PCOS (chronic hyperandrogenemic an ovulation), Thyroid disease, Liver disease, Obesity, Androgen excess (adrenal, neoplastic)


2/3 criteria to diagnose PCOS are ?

menstrual irregularity due to oligo-ovulation or anovulation, clinical or biochemical evidence of hyperandrogenism (hirsutism, acne, male pattern balding, or elevated serum androgen concentrations)
-also exclusion of other causes of hyperandrogenism and menstrual irregularity.


2/3 criteria to diagnose PCOS are ?

menstrual irregularity due to oligo-ovulation or anovulation, clinical or biochemical evidence of hyperandrogenism (hirsutism, acne, male pattern balding, or elevated serum androgen concentrations)
-also exclusion of other causes of hyperandrogenism and menstrual irregularity.


clomiphene citrate challenge test (CCCT)
largely replaced by ?

used to assess for decreased ovarian reserve
-100 mg of clomiphene citrate (Clomid) on days 5-9 of the menstrual cycle.
(FSH) level is measured on days 3 and 10. Even small elevations in FSH levels correlate with decreased fecundity
-replaced by the use of basal FSH/estradiol testing, the antral follicle count (AFC), and the anti-Mullërian hormone (AMH) assay.


Day 3 FSH level is based on the notion that ?

women with good ovarian reserve will make enough ovarian hormone early in the menstrual cycle to provide inhibition of FSH
-less than 10 mIU/mL is indicative of adequate ovarian reserve; 10 to 15 mIU/mL of borderline, and greater than 20 mIU/mL is indicative of poor ovarian reserve


Metformin (Glucophage) in PCOS

insulin sensitizer results in inhibition of gluconeogenesis and increased peripheral glucose uptake. PCOS patients using metformin experience a decrease in fasting insulin levels and testosterone levels; helps promote the reestablishment of spontaneous ovulation


Drugs That Decrease Semen Quality and Quantity

Cimetidine, Metoclopramide, Anabolic steroids, Sulfasalazine, Chemotherapeutic agents, Marijuana, Spironolactone, Beta blockers, Alcohol abuse, Antidepressants, Nitrofurans, Heroin/cocaine abuse


Semen Analysis Normal Parameters

Volume greater than 2.0 mL
pH 7.2–7.8
Concentration greater than 20 million/mL
Morphology greater than 30% normal forms
Motility more than 50% with forward progression
WBC more than 1 million/mL


endocrine evaluation in case of abnormal semen analysis

TFTs, prolactin, LH, and FSH (to assess for parenchymal damage to testes and hypogonadism).


Preimplantation genetic diagnosis (PGD)

evaluation of the embryo for genetic abnormalities prior to transfer during an IVF cycle.
i.e. sickle cell anemia, Tay-Sachs disease, cystic fibrosis, Down syndrome, hemophilia A, and fragile X syndrome