Female Infertility 4

Question 1

What are some treatment options for male factor infertility?

Answer 1

• Donor inesmination
• In-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI)
• Intrauterine insemination (IUI) for modest abnormalities

Question 2

What are some treatments for female anatomic causes of infertility?

Answer 2

• Uterus - surgery or gestational carrier
• Fallopian tubes - surgery (rare) or IVF

Question 3

What are the treatments for anovulation?

Answer 3

• Treat any underlying endocrinopathy
• Ovulation induction with clomiphene citrate or injectable gonadotropins

Question 4

What is the mechanism and efficacy of clomiphene citrate?

Answer 4

• Mechanism:
  
  • selective estrogen receptor modulator (SERM)
  • competes with endogenous estrogen for estrogen receptors
  • binds for extended interval of time
  • depletes receptor concentrations by interfering with receptor recycling
  • at hypothalamus, estrogen receptor is depleted, leading to reduced negative estrogen feedback
• Efficacy:
  
  • start with 50 mg for 5 days, up to 200 mg
  • will successfully induce ovulation in 70-80% of properly selected women
  • overall cycle fecundability is up to 22% with clomiphene (starting from ~15%)
  • cumulative pregnancy rate of 70-75% expected over 6-9 cycles

Question 5

What are the pros and cons of gonadotropin treatment for infertility?

Answer 5

• Pros
  
  • highly effective
    
    • ex. purified urinary FSH
    • ex. recombinant FSH, LH, hCG
• Cons
  
  • very costly
  • associated with risk of multiple pregnancy and ovarian hyperstimulation syndrome

Question 6

What is the treatment for decreased ovarian reserve, cervical factor, or sexual dysfunction?

Answer 6

• Decreased ovarian reserve
  
  • no good therapy
  • consider oocyte donation
• Cervical factor or sexual dysfunction
  
  • intrauterine insemination

Question 7

What is the treatment approach for unexplained infertility?

Answer 7

• Initial treatment is empiric
  
  • without treatment fecundability is 2-4%
• Common treatments:
  
  • controlled ovarian hyperstimulation (COH) with either CC or gonadotropins
  • done in conjunction with intrauterine insemination (IUI)
  • cycle fecundability reaches ~10%
• IVF in 25-50% of people

Question 8

What is the treatment for endometriosis?

Answer 8

• Laparoscopic assessment and treatment
• Adjunctive medical therapies

Question 9

What are some key features of IVF?

Answer 9

• Oocytes obtained from ovarian follicles by US aspiration
  
  • prepared and combined with sperm
• Non-stimulated cycles used to reduce costs
  
  • Pregnancy rates are ~10%
• Most patients undergoing IVF receive gonadotropins to increase the number of oocytes available for retrieval
• Patient selection:
  
  • IVF-ET most successful for infertile couples when female partner has an adequate follicle pool
  • Antral follicle count (2-10mm in diameter) is a good predictor of ovarian reserve
    
    • < 10 total AF have diminished ovarian reserve
  • AMH is reduced with increasing age and used as a marker