Infertility

Question 1

How often is no cause found with RPL?

Answer 1

50-70%

Question 2

Risk of pregnancy loss with GS?

Answer 2

12%

Question 3

Risk of pregnancy loss with YS?

Answer 3

8%

Question 4

Risk of loss with FP?

Answer 4

1-7%

Question 5

Risk of loss with FHR?

Answer 5

3-5% if no loss
15-25% if RPL

Question 6

Testing POC and 46 XX? Next steps?

Answer 6

Should do reflex DNA extraction and analysis of maternal blood by
microsatellite analysis can differentiate maternal contamination from fetal source

Question 7

NCCAH and trying to conceive

Answer 7

GC (prednisone 2.5-5 mg qD> hydrocortisone 20 -25 mg/day) recommended as initial
therapy. Metabolized by placental 11BHSD Type 2

If no response, can add OI agent or increase to 7.5 mg/d

Majority not infertile.
Increased SAB risk (25-30%), reduced to 6% w/ tx

Don’t need to tx men unless oligospermia: can do dex 0.25 mg qD or prednisone 5 mg

Question 8

Overnight DEX suppression test

Answer 8

Dex is potent GC and should suppress ACTH/cortisol if no Cushing
**Best first test when Cushing suspected in patient with hirsutism
Give Dex 1 mg PO 11p-12a
Measure cortisol 8 am
if <1.8 ug/dL then negative
Patients must not be taking estrogen or OCPs: increased CBG causes false positive

If initial screening is normal but strong clinical suspicion, repeat 6 mo or sooner if sx worsening

If first test abnormal, perform 2nddifferent test

Question 9

If transsphenoidal surgery for Cushings, post op monitoring:

Answer 9

ree T4/PRL w/in 1-2 weeks post op to evaluate for panhypopituitarism

Question 10

Elevated prolactin: 50-100

Answer 10

oligomenorrhea or amenorrhea

Question 11

Elevated prolactin 20-50 ng/dL

Answer 11

short luteal phase from poor preovulatory follicular
development

Question 12

Elevated prolactin > 100

Answer 12

frank hypogonadism w/ low E2 levels (osteoporosis, GU atrophy)

Question 13

Rule out macroprolactin?

Answer 13

larger forms cleared more slowly, women have normal
mns, pretx serum w/ polyethylene glycol to precipitate macroprolactin to avoid expensive imaging

Question 14

Primary amenorrhea

Answer 14

No mns by 15 w/ secondary sex characteristics
W/in 5 yrs after thelarche if before age 10
No thelarche by age 13

Question 15

Spermatogenesis

Question 16

MEN 1

Question 17

MEN 2

Question 18

Spermiogenesis

Answer 18

process by which haploid round spermatids complete an extraordinary series of events to become streamlined spermatozoa capable of motilit

Question 19

What are males with Kleinfelters at risk for?

Answer 19

osteoporosis, DM, low muscle mass, thromboembolic events, male breast cancer

Question 20

What percentage of men with NOA have abnormal karyotype?

Answer 20

10-15%

Question 21

What percentage of men with oligospermia have abnormal karyotype?

Answer 21

5% versus only 1% with normal sperm count

Question 22

Average testicle volume

Answer 22

15-25 cc

Question 23

Semen fructose testing

Answer 23

The procedure for determining the amount of fructose in semen involves heating semen in a strong acid in the presence of resorcinol. Fructose gives a red color (Selivonoff reaction) and may be read in a photometer. The normal average is 315mg/dL fructose.

Question 24

When to repeat SA if abnormal and suspect due to acute illness

Answer 24

4 weeks

Question 25

2h OGTT how is it done

Answer 25

75mg, draw blood 2x (after 2hrs normal <140mg/dL, impaired
glucose tolerance 140-199, DM >200). prev of impaired glucose tolerance 35%, DM 10%) screen q3-5yrs.

Question 26

How do OCPs decrease androgen symptoms

Answer 26

1. The P component suppress LH secretion and lead to a decrease in ovarian androgen production.
2. The estrogenic component increases the levels of sex hormone–binding globulin (SHBG), which, in turn, results in a decrease in circulating free T levels. The E also potentiates P receptors (P is always the dominant hormone)
3. progestin in the pill can compete for 5a-reductase at the level of the androgen receptor.
4. decreases adrenal androgen production by a mechanism yet unclear, possibly due to a decrease in adrenocorticotropin hormone (ACTH) production.

Question 27

Glucose/insulin ratio

Answer 27

lower values depicting higher degrees of insulin resistance. A G/I ratio of less than 4.5 has been shown to be sensitive (95 percent) and specific (84 percent) for insulin resistance in a group of women with PCOS, when compared to a control group.

Question 28

Labs in anorexia

Answer 28

Decreased FSH, LH, E2, IGF1
Increased cortisol, rT3
Same: prolactin, TSH, T4

Question 29

Ideal body weight

Answer 29

Females: IBW (kg) = 45.5 kg + 2.3 kg for each inch over 5 feet.

Question 30

CCCT

Answer 30

Clomiphene Citrate Challenge test: baseline FSH/E2 then 100 mg x 100 and repeat FSH/E2 on CD 10

Patients are notified of test results by their coordinator or physician:

A level from 10-12.5 mIU/mL predicts resistance to fertility medications and a diminished prognosis.
At 12.5-15 mIU/mL, the prognosis is poor but pregnancies do occur with aggressive treatment.
Levels greater than 15 mIU/mL indicate that infertility treatment with the patient’s own eggs is not likely to succeed and that egg donation should be offered.

Question 31

Side effects of dopamine agonists

Answer 31

nausea, postural hypotension, mental fogginess

Question 32

Congenital lipoid adrenal hyperplasia

Answer 32

most fatal form of CAH, as it disrupts adrenal and gonadal steroidogenesis. Most cases of lipoid CAH are caused by recessive mutations in the gene encoding steroidogenic acute regulatory protein (StAR). Affected patients typically present with signs of severe adrenal failure in early infancy and 46,XY genetic males are phenotypic females due to disrupted testicular androgen secretion.

Question 33

Anorexia

Answer 33

Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
Intense fear of gaining weight or becoming fat, even though underweight.
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
Even if all the DSM-5 criteria for anorexia are not met, a serious eating disorder can still be present. Atypical anorexia includes those individuals who meet the criteria for anorexia but who are not underweight despite significant weight loss. Research studies have not found a difference in the medical and psychological impacts of anorexia and atypical anorexia.

Question 34

Fragile X

Answer 34

X linked disorder caused by expansion of a repeated trinucleotide segment of DNA, cytosine–guanine–guanine that leads to altered transcription of the fragile X gene FMR1. The large number of repeats in a full mutation allele causes the FMR1 gene to become methylated and inactivated.
The number of cytosine–guanine–guanine repeats varies among individuals and has been classified into four groups depending on the repeat size: 1) unaffected (5–44 repeats), 2) intermediate (45–54 repeats), 3) premutation (55–200 repeats), and 4) full mutation (greater than 200 repeats)

Question 35

Fragile X in men

Answer 35

Most common inherited form of intellectual disability, autism, ADHD

Most affected males have significant intellectual disability.
Long, narrow face and prominent ears, enlarged testicles (macroorchidism), joint and skin laxity, hypotonia, mitral valve prolapse, delay in speech, and delay in gross and fine motor skills. The abnormal facial features are subtle in infancy and become more noticeable with age, making phenotypic diagnosis difficult, especially in the newborn.
Affected females may have a milder phenotype, and it is sometimes hard to establish the diagnosis based on clinical findings alone.

Question 36

Clomid MOA

Answer 36

CC causes depletion of hypothalamic estrogen receptors leading to increased GnRH secretion, thereby increasing pituitary gonadotropin release and ovarian activity [2]. Though high ovulation rate (60–90%) make it an attractive therapy, the pregnancy rate of 10 to 20% [3] is disappointing. Sub-optimal pregnancy rates with CC have been attributed to its peripheral anti-estrogenic effects, mainly on the endometrium and the cervical mucus [4] or its interference with the functioning of the corpus luteum

Question 37

Risk for ovarian infertility

Answer 37

6 Gy

Question 38

Lynch syndrome

Answer 38

60% endometrial cancer risk
24% ovarian cancer risk

Question 39

What percentage of cancer survivors have premature menopause?

Answer 39

10%