Flashcards in Chapter 19 - Module 2 - Infertility Deck (47):
Infertility can be ...
Wanted (tubal ligation) or unwanted (experienced by about 15% of couples in the U.S. and is a profound and extremely difficult challenge, a major life crisis).
Infertility is the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.
Classification is primary (a couple who has never been pregnant) or secondary (the inability to become pregnant, or to carry a pregnancy to term, following the birth of one or more biological children).
Secondary infertility rates > primary infertility rates
Infertility and age
For women over 35, infertility evaluation and treatment is considered after six months of attempting pregnancy, instead of one year, because:
- remaining time for successful pregnancy is limited
- fecundity declines gradually beginning at age 32 and more rapidly after 37
- incidence of conditions impairing fertility (e.g. fibroids, endometriosis) increases
- higher risk of pregnancy loss
Sperm production relies on ...
Sperm production relies on a functioning hypothalamic-pituitary-testicular axis that has many similarities to the hypothalamic-pituitary-ovarian axis in women.
The pituitary produces follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in response to the secretion of gonadotropin-releasing hormone (GnRH) by the hypothalamus.
FSH and LH, in males
FSH and LH in males initiate testicular production of era a d testosterone which are necessary for spermatogenesis. Takes about 72 days.
Female infertility etiologies
- majority: d/t ovulatory dysfunction and tubal and pelvic problems
- combined or interactional causes
Infertility, rates d/t gender
55% d/t female factors
35% d/t male factors
10% no known cause, "unexplained infertility"
Ovulatory dysfunction may involve either a total lack of ovulation or the occurrence of irregular ovulation. Anovulation usually evidenced by irregular menstrual bleeding patterns or amenorrhea.
Causes of ovulatory dysfunction
Numerous causes are possible, can result from any interruption of the hypothalamic-pituitary-ovarian (HPO) axis
- hyperandrogenic disorders
- physiologic anovulation at either end of the reproductive spectrum
- pituitary tumors
- thyroid disorders
- eating disorders
- low or high BMI
- shortened Luteal Phase, less than 13 days elapse between the midcycle LH surge and the onset of menses.
Tubal problems as a cause of infertility ...
Usually related to blockages within the tubes. Can be anatomical, but more likely as a result of the progression of STIs to pelvic inflammatory disorder (PID).
Tubal problems can be d/t previous ectopic pregnancy or tubal surgery.
Other pelvic problems to consider in infertility ...
- Asherman syndrome
- other uterine factors
Endometriosis is a condition in which menstrual tissue grows outside of the uterus rather than being sloughed off with each menstrual period. May or may not cause pain. Amount of pain is unrelated to extent of disease process.
Asherman syndrome results from intrauterine adhesions that obstruct or obliterate the uterine cavity. Asherman syndrome is usually caused by over zealous postpartum curettage, but can also occur after cesarean birth, myomectomy, or other uterine surgery.
Hypomenorrhea, amenorrhea, or dysmenorrhea may be present.
Other potential uterine causes of infertility ...
Other uterine causes of infertility include fibroids, endometrial polyps, and chronic endometritis. The effects of these factors on fertility are unknown, and these are not a common cause of infertility.
Male etiologies of infertility
Male factors may be d/t anatomical or structural problems, abnormalities in sperm production, and sexual, hormonal, and genetic conditions.
Structural causes of male infertility ...
A structural cause of male infertility is undescended testes (cryptorchidism). Normally descended by age 2, if not, internal body temperatures, higher than external, may damage sperm.
Hypospadias may make it difficult to deposit semen in the woman's vagina.
Untreated or recurrent STIs in the male may result in scarring and blockage of the reproductive tract.
Hypospadias is a congenital anomaly that results in the urethral outlet being located on the shaft of the penis rather than at the end.
Mumps and male infertility ...
Mumps contracted in males, particularly after adolescence, may result in orchitis or testicular inflammation, usually unilateral, so rarely sterility results.
Other causes of male infertility ...
Infection, in particular of the prostate, decreased blood flow to the testes such as with testicular torsion, environmental factors, erectile dysfunction, hormonal problems such as decreased testosterone production, genetic problems such as Klinefelter's syndrome. Often idiopathic.
Combined or interactional causes of infertility include the inability of sperm to survive in the woman's cervical mucus d/t antisperm antibodies. Antisperm antibodies can be present in either the male or female.
Other combined causes include simultaneous female and male causes of infertility that combined increase the risk for infertility.
Diagnosing infertility ...
Infertility diagnosis isn't made until a couple has attempted pregnancy for at least 12 months.
Earlier assessment is warranted for:
- women over the age of 35
- women with a history of oligo/amenorrhea
- women with suspected or known uterine/tubal disease or endometriosis
- women with a sub-fertile partner
Assessment of infertility ...
Evaluation begins with a thorough history and physical exam of both partners. Initial assessment of the male can be done by clinicians providing gynecologic care (relevant history and semen analysis) prior to referring the male to another clinician if necessary.
Interview separately and as a couple
Diagnostic testing for infertility ...
Most useful and cost-effective if done sequentially in a logical order.
Obtain an accurate and detailed history form woman and her partner. This includes general medical, family, social, emotional, occupational, recreational, and lifestyle histories.
Identify the duration of infertility and any previous evaluation or treatment.
Detailed gynecologic history, with particular attention to the menstrual and pregnancy (him and her) histories as well as any previous surgeries or procedures.
Frequency of coitus, any sexual difficulties, and history of STIs in either partner.
Him and her
Have either had a baby with a previous partner?
Have they had a baby together?
Her: vaginal or cesarean birth, ask about nipple discharge, hirsutism, pelvic pain, dyspareunia, symptoms of thyroid disorders.
Physical exam, female
A complete physical, including pelvic, needs to be completed for the woman. In particular, note:
- acne, hirsutism, or alopecia that could indicate a hyperandrogenic disorder
- thyroid abnormalities, such as enlargement, nodule, or tenderness
The pelvic exam focuses on: identifying any abnormalities of the internal genitalia, such as enlargement, tenderness, and masses as well as evidence of gynecologic infections or STIs.
Diagnostic testing, if infection is suspected.
If infection is suspected, microscopic examination of vaginal secretions and chlamydia and gonorrhea testing should be performed.
Physical exam, male
The male also gets a complete physical exam, with attention to the reproductive organs to r/o structural problems.
Diagnostic testing and procedures
Basic and simple diagnostic procedures to be done with an initial infertility evaluation include:
- ovulation detection, by basal body temperature or by OTC urine tests that detect LH, but this can be costly in the long run.
- semen analysis, needs to be done early in infertility evaluation
Other, more specific tests that may be warranted: lab testing, hysterosalpingogram, transvaginal US, hysteroscopy, laparoscopy, postcoital testing, endometrial biopsy, sperm penetration assay.
Basal body temperature
BBT thermometer is calibrated in tenths.
Take temperature before rising from bed but definitely before eating or drinking.
Temperatures consistently lower than 98 during the follicular phase and consistently higher than 98 during the luteal phase.
Record for at least three months.
Oral, axillary, or rectal but be consistent.
Masturbation with ejaculation into a sterile container or ejaculation into a specail collection condom.
Defined period of abstinence of 2-3 days prior to collection.
No more than one hour should elapse between collection and microscopic examination.
Keep sample at room or body temperature.
Complete evaluation involves two semen samples, at least.
TSH, prolactin levels
If amenorrheic or s/sx of hyperandrogenic disorder: FSH, LH, and testosterone measurements.
Hysterosalpingogram (HSG) is ...
A hysterosalpingogram (HSG) is a procedure in which a water-soluble or oil-soluble contrast is injected through the woman's cervix into her uterus. During the HSG, the transport of the contrast is observed by radiologic imaging. Perform 2-5 days post end of menstruation. Normal result: Contrast travels through the uterus and into Fallopian tubes indicating that the fallopian tubes are patent or whether a structural abnormality is present in the uterus or tubes.
Transvaginal Ultrasound and Hysteroscopy
Transvaginal ultrasound can help identify uterine factor associated with infertility, such as fibroids and endometrial polyps.
Hysteroscopy can be used for definitive diagnosis and treatment of intrauterine conditions causing infertility.
The outside surfaces of the uterus, tubes, and ovaries can be observed via a laparoscope, which is inserted into the abdomen trough the umbilicus. The pelvic organs are examined for any abnormalities, including structural alterations, endometriosis, or pelvic adhesions.
Prevention of infertility
Seek early treatment if STIs are suspected.
Certain contraceptive methods protect future fertility by decreased the risk of PID, etopic pregnancies, and endometriosis.
Cause dependent, if cause known.
Patient Education about period of fertility, health promotion, smoking cessation, maintenance of a healthy weight, regular exercise, reduce caffeine and alcohol consumption.
If evidence of anovulation or infrequent ovulation, medication to induce ovulation can be given.
Clomiphene citrate (Clomid, Serophene)
Clomiphene citrate (Clomid, Serophene)
Clomiphene citrate is taken orally once a day for five consecutive days, starting on the 3rd to 5th day after menses begins. Initial dose is usually 50 mg. Ovulation usually happens 14 days after the first dose. Can increase dose in increments of 50 mg if ovulation does not occur at the lower dose. At higher doses, consider other approaches/
Clomiphene citrate works by binding estrogen receptors in the pituitary gland, thereby blocking those receptors from detecting circulating estrogen. As a result the hypothalamus increases its secretion of GnRH, which stimulates the pituitary to secrete FSH and LH. These stimulate and initiate an ovulatory menstrual cycle.
Clomiphene citrate and polycystic ovary syndrome
Combine insulin sensitizing agents, such as metformin, with clomiphene citrate as those with PCOS may not respond to either medication by itself.
Clomiphene citrate, SE and monitoring
Hot flashes, HA, ovarian enlargement, multiple gestation, and, less frequently, nausea and visual disturbances.
Monitoring: ovulation detection via BBT charting, urine LH testing, or serum progesterone levels.
Treatment limit: six ovulatory cycles
Short Luteal Phase treatment
There is an association between hyperprolactinemia and short luteal phase. In the absences of this identifiable cause, treatment of short luteal phase can be ambiguous.
In vitro fertilization
In vitro fertilization is the most widely used assisted reproductive technology procedure. Ovaries are hyperstimulated with medication and several mature ova are surgically retrieved, placed in a laboratory dish, and then mixed with sperm. After fertilization, one or more embryos are transferred directly into the woman's uterus for implantation.
GIFT - gamete intrafallopian transfer
Fertilizaiton occurs in vivo. Sperm and egg are placed directly into the fallopian tube for fertilization.
ZIFT - zygote intrafallopian transfer
in vitro fertilization with resulting zygotes placed in the fallopian tube laparoscopically the day after fertilization.
Intracytoplasmic sperm injection (ICSI)
A single sperm is injected directly into an egg. Used with the man has a low sperm count or for other causes of male infertility. Used in conjunction with IVF or ZIFT.