definition of infertility?
-Age < 35: Failure to conceive after one year of unprotected intercourse
-Age > 35: failure to conceive after 6 m of unprorected intercourse
-the inability to maintain a pregnancy beyond the first trimester ("3 or more" -- I think she means 3 or more losses before the first tri)
What is the difference between primary and secondary infertility?
Primary: no prior pregnancies
Secondary: there have been prior pregnancies
What is fecundability?
What is the average chance?
The probability of conception in a single menstrual cycle.
(average 85% pregnant in a year)
Common causes of female infertility?
-Ovulatory disorders (44%) - specifics on another card
-Pelvic adhesions (13%) - prior surgeries, PID
-Tubal occlusion (14%) - prior PID, GC/CT
What questions will we ask when getting a patient's history?
-Duration of infertility and previous evaluation
-GYN history including thyroid, galactorrhea, hirsutism, pain, dysparunia (painful intercourse), dysmenorrhea, oophorectomy (ovary removal)
List some causes of ovulatory disorders.
Recall Ovulatory disorders cause 44% of female infertility
-Hypothalamic issues- disturb normal pulsatile GnRH (eating disorders, stress, intense exercise)
-Hyperprolactinemia, Lactational amenorrhea - suppress pulsatile GnRH
-Hypothyroidism - interferes w dopamine, adverse affect on GnRH secretion
-Genetic -> early ovarian decline (ie early menopause)
-Extremes of BMI
One way to investigate infertility is to confirm ovulation. How do we do this?
-Basal body temp chart (less common now)
-Ovulation predictor kits (peak of LH 12-24 h before ovulation; measure urinary LH)
-Serum progesterone (luteal phase)
Probably not tested but maybe helpful: WHO classifications of ovulatory disorders has 3 main categories. Examples of each on reverse.
Class 1: Hypogonadotropic hypogonadal anovulation
Class 2: Normogonadotrophic normoestrogenic anovulation
Class 3: Hypergonadotropic hypoestrogenic anovulation
(Hyperprolactinemia = another category)
Class 1: Hypogonadotropic hypogonadal anovulation. Example: excessive exercise, low BMI
Class 2: Normogonadotrophic normoestrogenic anovulation. Example: PCOS
Class 3: Hypergonadotropic hypoestrogenic anovulation. Example: primary gonadal failure
Semen Analysis: what are we looking fo?
Volume 2 cc
Sperm concentration 15million/cc
Motility: 40% forward progression
Morphology: 40% normal by WHO criteria
At what age does female fertility start to decline?
At what age does female fertility start to decline?
Jen's notes say 25-29; Laurie's notes say 20-24. Shit. But from this graph, I'm still going with 25-29.
What are some tests of tubal patency that are done as part of an infertility workup?
Hysterosalpingogram (HSG). Radiologic study for which radio-opaque dye is inhected into cervix, and passes through fallopian tubes (if they are patent). Helpful for seeing contours of uterine cavity as well as tubal patency.
A laparoscopy-hysteroscopy is less common.
Information from the Hutterites (tribe where they married early and did not use contraception): what was avg age of last pregnancy?
What was infertility rate?
Avg age of last preg: 40.9
Infertility rate: 2.4%
Age 40: 33% infertile
Age 45: 87% infertile
What is oocyte aging? when does it occur?
what will accelerate follicular loss?
Oocyte aging: steady decline in oocyte number from mid-gestation to puberty.
Rate of follicular loss acceperates from mid-30s.
Accelerators of follicular loss: smoking, radiation, chemo, autoimmune disease
What is Reduced ovarian reserve?
what is an ovarian reserve test?
Reduced ovarian reserve = "decreased oocytes for age" (her notes). "Diminished ovarian reserve can refer to diminished oocyte quality, quantity, and reproductive potential" (from ppt).
-Hormonal levels (FSH) might reflect residual ovarian function.
-Can do a clomiphene citrate challenge test
-can do an ultrasound antral count for size of ovaries
(Predicts good/fair/poor response to treatment)
How does pregnancy loss relate to maternal age?
Loss increases with maternal age:
maternal age 20-24: loss = 14%
maternal age > 44: loss = 53%
Overview of treatment: what are the options?
How could lifestyle modifications help treat infertility?
-Weight modulation: women of very high or very low BMI are prone to ovulation dysfunction
-For hypothalamic amenorrhea: modify exercise, modify diet, seek counseling
-PCOS: for many women weight loss can restore ovulation
Ovulation induction: how is this done?
-Selective Estrogen Receptor Modulators (SERMS): clomiphene citrate = estrogen antagonist and agonist. increases FSH/LH levels. used for Normogonadotrophic normoestrogenic anovulation (example: PCOS)
-Aromatase inhibitors: for Normogonadotrophic normoestrogenic anovulation (example: PCOS)
-Dopamine agonists: for patients with hyperprolactinemia
What is Assisted Reproductive Technology? When is it done?
In vitro fertilization, intracytoplasmic sperm injection, pre-implantation genetic diagnosis.
Done for tubal/peritoneal disease, sperm disorders, failure of other therapies, advanced reproductive age, genetic issues
What is the process of Assisted Reproductive Technology?
Oocytes retrieved by ultrasound guided needle aspiration of follicular fluid.
Fertilization by insemination and embryo culture, followed by embryo transfer.
Summary for this poorly-taught lecture?
-Female fertility declines with age.
-Testing for causes of infertility includes confirmation of ovulation, tubal patency, semen analysis
-Treatment includes ovulation induction, intrauterine insemination, and Assisted Repro Technology such as IVF
What has the greatest impact on declining fertility with age? what also plays a role?
Increasing oocyte aneuploidy with age (most chromosomally abnormal embryos do not implant, and if they implant they may spontaneously abort)
Also increased likelihood of endometriosis and fibroids with age -> decr fertility.
What is endometriosis? s/s? how can it affect fertility?
-presence of endometrial glands and stroma outside of the uterine endometrial lining.
-s/s: dysmenorrhea, dyspareunia
-production of cytokines and growth factors from endometriosis may impair ovulation, fertilization, implantation.