Female Infertility 2

Question 1

What are the common disorders in the differential diagnosis for infertility?

Answer 1

• Male factor
• Anatomic disorders of the female reproductive tract
• Anovulation
• Decreased ovarian reserve

Question 2

What are the common male factors that lead to infertility?

Answer 2

• Usually idiopathic (40-50%)
• Primary gonadal disorders (30-40%)
• Disorders of sperm transport (10-20%)
• Hypothalamic-pituitary disorders (1-2%)

Question 3

What are some common anovulatory causes of infertility?

Answer 3

• More common:
  
  • polycystic ovarian syndrome
  • hypothalamic amenorrhea
• Less common:
  
  • hyperprolactinemia
  • thyroid disease
  • premature ovarian failure

Question 4

What are some anatomic abnormalities of the female reproductive tract that can lead to infertility?

Answer 4

• Abnormalities of the uterine cavity
  
  • congenital
    
    • _​_mullerian duct abnormalities
  • acquired
    
    • _​_fibroids, polyps, Asherman’s syndrome
• Abnormalities of the fallopian tubes
  
  • usually related to prior ascending infection or pelvic surgery

Question 5

What effect does age have on infertility?

Answer 5

• No significant effect on the uterus or endometrial development or function
• No effect on the egg itself in terms of live birth per transfer rate
• Decreased ovarian reserve
  
  • 6-7 million oogonia by 16-20 week gestation and 1-2 million at birth
  • 300,000 to 500,000 at puberty, 400-500 at reproductive age
  • By age 40, size of the follicular pool declines to ~25,000
  • At menopause, <1000 follicles remain

Question 6

Polycystic ovary syndrome

Answer 6

• Most common endocrinopathy of women
• Perimenarchal onset
• Hyperandrogenemia
• Insulin resistance
• Frequently associated with obesity

Question 7

Hypothalamic amenorrhea

Answer 7

• Usually a functional disorder:
  
  • Excessive exercise
  • Inadequate nutrition
  • Stress
• Common pathway is disruption of pulsatile GnRH secretion from the hypothalamus

Question 8

What are some less common problems that lead to infertility?

Answer 8

• Cervical abnormalities
• Endometriosis
• Sexual dysfunction

Question 9

What are some cervical abnormalities that can lead to infertility?

Answer 9

• Chronic cervicitis or cervical stenosis
  
  • conization or other treatments for cervical disease
  • impairs sperm-mucus interaction
  • usually identified by speculum examination

Question 10

Endometriosis

Answer 10

• Benign disease, defined by presence of endometrial glands and stroma outside of the uterus
  
  • ectopic tissue usually located in the pelvis but can appear anywhere in the body
• Associated with pelvic pain and infertility
• Possible pathogenic mechanism (no generally accepted theory)
  
  • retrograde menstruation and implantation
  • coelomic metaplasia
  • direct transplantation
  • vascular dissemination

Question 11

How does endometriosis cause infertility?

Answer 11

• 20-40% of infertile women have the disease
  
  • distorted adenexal anatomy
    
    • inhibits or prevents ovum capture after ovulation
  • excess production of:
    
    • prostaglandins
    • metalloproteinases
    • cytokines
    • chemokines
  • results in chronic inflammation
  • impairs ovarian, tubal, or endometrial function
  • disorders of folliculogenesis, fertilization, or implantation

Question 12

How is the diagnosis of unexplained infertility derived?

Answer 12

• Diagnosis of exclusion
  
  • implies the following:
    
    • normal semen quality
    • normal ovulatory function
    • normal uterine cavity
    • bilateral tubal patency
• Incidence from 10-30% among infertile populations
• 2 potential explanations for unexplained infertility
  
  • poor oocyte quality
  • other specific abnormalities that cannot be identified with existing tests:
    
    • sperm function
    • fertilization
    • implantation
    • embryo development