Flashcards in CM- Infertility Deck (26):
What is a normal conception rate?
monthly conception rate [fecundability] is approximately 25%
[1/4 couples will conceive within a month of trying].
85% will conceive in a year
93% in 2 years
95% in 3 years
What is primary infertility?
1. Inability of a couple to conceive after 1 year of sexual intercourse
2. inability of a couple where the woman is over 35 to conceive within 6 months of trying
What is secondary infertility?
The female partner has conceived at least once before [even if it was a stillbirth or miscarriage] but now hasn't been able to get pregnant in one year of trying
How does infertility change with increasing female age?
The peak age of fertility is 25 and then significant decline starts at 35.
20-30 = 1/10 women have infertility
30-40 = 1/6 women have infertility
40+ = 1/4 women have infertility
What are the most common causes of infertility by diagnosis?
1. male factor 40%
2. anovulation 30%
3. tubal factor 15%
4. pelvic factor [adhesions, endometriosis] 15%
5. uterine factor
6. cervical factor
A woman presents to you complaining of infertility. When asked about her menses, she says she bleeds irregularly, about every 15 to 40 days.
Her basal body temperature charts are monophasic. What is the likely cause of the infertility?
What factors are used to assess ovarian function?
What 4 things point toward normal ovulation?
What 3 factors suggest anovulation/oligo-ovulation?
1. normal menses, reg cycle
2. Mittelschmerz =cramping at day 14
3. Biphasic basal body temp charts are indicative of a progesterone increase after ovulation
4. prior pregnancy indicates the woman ovulated at one time
Possible disruption to normal ovulation:
2. prior exposure to chemo or radiation
3. PCOS, hypogonadotrophic hypogonadism, POF [hyper, hypo]
What is the MOST reliable indicator of ovarian function?
Regular menstrual cycle
What are the lab tests that can evaluate ovarian function?
1. Basal body temperature - if ovulating, it should be biphasic [increased temp with progesterone, but at that point you have missed ovulation]
2. Sonogram - size/shape of uterus and ovaries, leiomyomas, antral follicle count
3. Mid luteal phase progesterone [often used]
4. LH ovulation kits- measure LH surge in urine so you can time intercourse for when you are ovulating
5. Endometrial biopsy [not common]
6. TSH - rule out hypothyroidism, hyperthyroidism
7. prolactin - rule out hyperprolactinemia
8. Testosterone/DHEAS to see if elevated androgens [PCOS]
9. Ovarian reserve testing - FSH and estradiol at day 3 of the cycle if patient is older and you are worried about reserve.
A woman presents with a history of a prior gonorrhea infection. She has normal menses and regular cycles, but she is having trouble getting pregnant. What is the likely cause?
Fallopian tube dysfunction/pelvic factor
-history of pelvic infection
- pelvic pain [endometriosis]
- prior pelvic surgery [ovarian cysts, endometriosis, C-section, tuboplasty, appendix, bowel]
- family history of endometriosis
What are the 4 major factors that contribute to tubal dysfunction/pelvic factor causes of infertility?
1. Prior pelvic infections [gonorrhea, chylamydia, PID, endometritis]
2. pelvic pain [ endometriosis, dysmenorrhea]
3. prior pelvic surgery
-gynecological = ovarian cysts, tuboplasty, endometriosis, C-section
4. Family Hx of endometriosis [1 fam member =7x as likely to get tubal dysfunction]
A woman has a 4 year old girl. She and her husband have been trying to have a boy but she is having trouble getting pregnant. She is 29 and has been trying for a year.
When asked, she says her menses are regular. She has never had an STD or pelvic pain. On delivery of her first child, she had a C-section. What does this make you suspicious for as the cause of the infertility?
Pelvic surgery like C-section are an indication for tubal/pelvic factor of infertility
What tests can you do to check tubal/pelvic factors?
1. Hysterosalpingogram [HSG] - inject dye in the uterus and it goes retrograde through the tubes. If the tubes are intact, there will be "spillage of dye" on both sides
2. Laparoscopy & chromotubation [GOLD STANDARD] - can look for dilated tubes and Fitzhugh curtis adhesions that could be distrupting tubular function
What 5 things would make you suspicious that the cause of infertility was uterine?
1. length and amount of menses [fibroids]
2. history of D&C
3. recurrent miscarriages
4. IUD use [maybe secondary infection]
5. prior pregnancy history
What are the 5 tests that you would want to do to evaluate uterine function?
4. pelvic US
5. late luteal phase endometrial biopsy versus serum progesterone [gold standard for luteal phase defects]
What are the 3 major cervical factors that contribute to infertility?
What are functional tests you can do?
1. Mid-cycle, pre-ovulatory mucus quality [should be clear, thin and strechy due to influence of estrogen]
2. Hx of previous pap smears, LEEP, cryotherapy, laser or cold-knife cone
3. Prior infections
Evaluate cervix with:
1. postcoital test [ovulate, bang, look at mucus]
2. pap smear
3. culture for gonorrhea, chlamydia, ureaplasma and mycoplasma
What are some factors that can lead to poor sperm function and male factor infertility?
1. illness within 70-90 days
2. viral orchitis** most common cause
3. urogenital surgery
4. irradiation, chemo
5. hernia repair
6. testicular torsion
7. hot tubs
8. smoking, marijuana, alcohol
9. anabolic steroids
What tests are done to confirm male/sperm function?
1. serum analysis [GOLD STANDARD]
-2 to 5 ml,
-over 20 million sperm/ml
- WHO >30% normal morphology [Strict >6-14%]
- less than 1 million WBCs
2. semen culture if WBCs on analysis
3. Endocine testing [LH, FSH, testosterone, prolactin]
-azoospermia = no sperm at all
- mild oligospermia = 5 to 15 million/ml
- severe oligospermia = <5million /ml
- Y chromosome microdeletions
What 5 tests are done as a "basic initial workup" for infertility?
1. semen analysis
2. ovulation assessment - BBT, ovulation predictor kit, mid-luteal progesterone
3. TSH, PRL
5. in females >35, FSH, estradiol on cycle day 3
When should the following tests be performed?
1. semen analysis
2. hysterosalpingogram, hysteroscopy, hysterosonogram
3. Mid luteal phase progesterone
4. urinary ovulation kit
5. endometrial biopsy
6. lab work [serum stuff]
1. 2-3 days of abstinence then analyze sperm w/in 1hr of ejaculation
2. after menstruation but before ovulation [day 6-10]
3. mid luteal phase
4. It measures an LH surge so take the shortest menstrual cycle, subtract 18 and that is when you should start peeing on the stick and looking for a + LH surge
5. 10-12 days after ovulation [determined by BBT or urine LH kit]
6. day 3 of cycle for best FSH/E2
What are treatment options for ovulatory dysfunction causes of infertility?
1. Clomiphene [estrogen antagonist so there is no neg feedback on HP axis--> FSH/LH surge]
2. Gonadotropin injections - use this one with hypo, hypo. It increases FSH. Use with sonogram and Intrauterine insemination
What are the treatment options for tubal/pelvic causes of infertility if :
1. it is a uterine filling defect [submucousal fibroid, polyp, adhesion]
2. uterine malfunction [bicornate, septate]
3. tubal occlusion [proximal]
4. tubal occlusion [distal]
5. if there are signs/symptoms of endometriosis or adhesions
1. hysteroscopy to diagnose/treat
2. treat and counsel
4. laparoscopy or IVF
5. laparoscopy, maybe IVF
What is the treatment for uterine factor infertility due to:
1. uterine filling defect [submucosal fibroid, polyp, adhesion]
2. uterine malfunction [bicornate, septate]
3. Large >4cm uterine fibroid
1. hysteroscopy to diagnose and treat
2. treat and counsel accordingly
How are cervical factors of infertility treated?
1. treat positive cervical cultures
2. treat abnormal pap smears prior to infertilty treatment
3. if there was an abnormal postcoital test, consider IUI [intrauterine insemination]
If a semen analysis is abnormal, what do you do?
What are treatment options to improve chances of fertility?
If the test is abnormal, repeat the test and refer him to a urologist.
1. IUI in conjunction with giving the female gonadotropins
2. IVF/ICSI [inject single sperm into single egg]
3. consider sperm donor if azoospermia