infertility Flashcards
(79 cards)
1
Q
definition of infertility
A
- Inability to conceive after 1 year of unprotected intercourse of reasonable frequency in women < 35yo
- Inability to conceive after 6 mo of unprotected intercourse of reasonable frequency in women > 35yo
- > 40yo – more immediate evaluation and treatment is warranted
2
Q
If a woman has a condition known to cause infertility then more immediate evaluation may be warranted:
A
- Oligomenorrhea or amenorrhea
- Known or suspected uterine, tubal or peritoneal disease
- Stage 3 or 4 endometriosis
- Known or suspected male infertility
3
Q
types of infertility
A
- Primary - No prior pregnancies
- Secondary - Following at least one prior conception
4
Q
Pregnancy involves complex sequence of events:
A
- Ovulation
- Ovum pickup in fallopian tube
- Fertilization
- Transport of fertilized ovum into the uterus
- Implantation
- Receptive uterine cavity
5
Q
etiology of infertility
A
- Male 25%
- Ovulatory 27%
- Tubal/uterine 22%
- Other 9%
- Unexplained 17% - If you cant figure out the problem you will start them on the treatment for an ovulatory issue
Both partners need to be evaluated!
6
Q
obtaining gynecologic hx for infertility
A
- Find out what has been done before
- Menstruation
- Frequency, duration, changes, hot flashes, dysmenorrhea
- Signs of ovulation: Cervical mucus changes, Ovulation tests, Basal body temps - Prior contraceptive use
- H/o ovarian cysts, endometriosis, leiomyomas, STDs, PID
- H/o abnormal pap smears
- Conization – can decrease cervical mucus quality and alter cervical anatomy - Prior pregnancy - Indicates ovulation and patent fallopian tube
- Pregnancy complications
7
Q
components of coital history
A
- Frequency
- Timing
- Chance of conception increased 5 days preceding ovulation
- Should have daily intercourse during this period to maximize chances - Dyspareunia
- Lubricants
- Avoid oil based lubricants that can harm sperm
- Water based lubricants are preferred
8
Q
medical hx components that could affect infertility
A
- Chemotherapy
- Radiation
- Androgen excess = PCOS
- Thyroid disease
- Hyperprolactinemia
- Medications
- BMI: Modest wt reduction in overweight women can normalize menstrual cycles and increase chance of pregnancy
9
Q
social hx components that affect infertility
A
- Lifestyle
- Environmental factors
- Eating habits
- Toxins - Smoking
- Lowers fertility in men and women
- Prevalence of infertility and time to conception longer in women who smoke - Alcohol
- Caffeine
- Illicit drugs
- Ethnicity
- Important for consideration of pre-conceptional testing
10
Q
Key Components of Physical Exam
A
- Weight, BMI
- Thyroid enlargement and presence of nodules or tenderness
- Breast secretions
- Signs of androgen excess
- Tanner staging of breasts, pubic and axillary hair
- Vaginal or cervical abnormalities
- Uterine size, shape, position and mobility
- Adnexal masses or tenderness
- Cul-de-sac masses, tenderness or nodularity
11
Q
6 MCCs of female infertility
A
- Ovulatory disorders
- Endometriosis
- Pelvic adhesions
- Tubal blockage or other tubal problems
- Uterine or cervical factors
- Unexplained
12
Q
when should genetic testing be considered for infertility
A
- History of recurrent pregnancy loss
- 3 or more consecutive losses at ≤ 20 wks gestation or with a fetal wt < 500g
- Premature ovarian failure (<40yo)
13
Q
causes of h/o recurrent pregnancy loss
A
-
Parental chromosomal abnormalities
- MC in sporadic miscarriages
— 50% of spontaneous miscarriages are due to aneuploidy - MC is Monosomy X - Antiphospholipid syndrome
- Uterine abnormalities
14
Q
MCC premature ovarian failure
A
Turners
- Menopause occurring at a younger age
- Average age of menopause is 51yo
15
Q
Ovulation can be affected by abnormalities in the ___, ____, or ____
A
hypothalamus, pituitary or ovaries
16
Q
common causes of ovulatory dysfunction
A
- Hypothyroidism
- Hyperprolactinemia
- Diminished ovarian reserve- someone who is older w/o good eggs
- PCOS
17
Q
relationship with age and ovulatory fysfunction
A
Clear inverse relationship between female age and infertility
- Linked to loss of viable oocytes
- Risk of genetic abnormalities and mitochondrial deletions in remaining oocytes substantially increases with age - Causes increased rate of miscarriage
18
Q
excellent predictor of regular ovulation when evaluating ovulatory dysfunction
A
menstrual hx
19
Q
what is Mittelschmerz
A
midcycle pelvic pain associated with ovulation
20
Q
what are Moliminal symptoms
A
breast tenderness, acne, food cravings, mood changes
during ovulation
21
Q
diagnostics for ovulation dysfunction
A
- Labs - TSH, FT4, Prolactin, progesterone, FSH, AMH
-
Weight - Anorexia and bulimia can cause hypothalamic changes
- Affects GnRH
- Obesity may indicate PCOS -
Basal Body Temperature
- Women check morning oral temperature and graphically charts - sonography
- ovulation predictor kits
22
Q
how does basal body temp help indicate ovulation or staging?
A
- Oral temperatures 97-98°F during follicular phase
- Postovulatory rise in progesterone levels increase basal temperature by 0.4-0.8°F
- This rise in temperature is strongly predictive of ovulation
23
Q
pros and cons of basal body temp for diagnostic testing
A
- Benefits: Inexpensive, easy
- Limitations: Insensitive in many women
24
Q
how does sonography work for diagnostic testing?
A
- Serial exams can demonstrate maturation of an antral follicle and its collapse during ovulation
- Count less than 5-7 can indicate diminished ovarian reserve
25
pros and cons of sonography
Benefits: Useful in diagnosis of PCOS
Limitations: Time consuming, Expensive
26
how do Ovulation Predictor Kits work?
* Tests concentration of urinary LH
* Woman should begin testing 2-3 days before predicted LH surge and continue daily
* Test with concentrated first morning void
* Ovulation will occur the day following the urinary LH peak
27
pros and cons of ovulation predictor kits
* Benefits: in some studies shown to have sensitivity of 100%
* Limitations: Expensive
28
In classic 28 day cycle, check serum ____ on day 21
Can also be checked 7 days following ovulation
progesterone
29
serum progesterone levels during ovulation cycle
1. Follicular phase < 2ng/mL
1. Indicative of Ovulation >3 ng/mL
- Progesterone is being produced by the corpus luteum
30
pros and cons of serum progesterone levels as diagnostics
* Benefits: Easy to do
* Limitations: Progesterone secreted in pulses and a single measurement may not be indicative of overall production
30
Sensitive predictor of ovarian reserve
serum FSH
Typically performed on cycle day #3
31
With decreasing ovarian reserve (how many eggs), less ____ is secreted
**inhibin**
Inhibin inhibits FSH
Results in increased FSH (>10IU/L associated with diminished ovarian reserve)
32
serum FSH >10 mIU/mL indicates ?
significant loss of ovarian reserve
33
* Measure with serum FSH
* Due to increase FSH with decreasing ovarian reserves there will be a increasing estradiol level
* >80 pg/mL is abnormal
Serum Estradiol
34
* Expressed by granulosa cells of small preantral follicles
* Possible role in recruitment of the dominant follicle
* Levels correlate with ovarian primordial follicle number
* < 1ng/mL associated with diminished ovarian reserve
Antimullerian Hormone (AMH)
35
increase Antimullerian Hormone (AMH)
= more ?
follicles
36
tx ovulatory dysfunction
1. If something is abnormal, FIX IT!
1. _Hyperprolactinemia_
- Fasting during testing?
- If no identified cause, check head MRI - r/o micro/macroadenoma
- Tx: Dopamine agonists - **Bromocriptine or Cabergoline; Surgery**
1. _Hypothyroidism_
- CC oligomenorrhea and amenorrhea
--- Even subclinical hypothyroidism can cause problem
- Tx: **Levothyroxine**
1. _Diminished Ovarian reserve_
- **Ovulation Induction**
- **IUI/IVF**
- **Egg Donor**
37
3 ovulation induction options
1. **Clomiphene Citrate** (Clomid)
1. Aromatase Inhibitors - **Letrozole**
1. **Gonadotropins**
38
* Initial tx for most anovulatory infertile women
* Estrogen antagonist - results in increase in FSH levels which increase ovarian follicular activity
* Oral medication
* Given for 5 days starting on cycle day 2-5
which induction option
Clomiphene Citrate (Clomid)
39
* Inhibits the production of estrogens, so it increases FSH
* Oral medication
* Given on cycle day 3-7
which induction option
Aromatase Inhibitors - Letrozole
40
* Urinary or recombinant FSH and LH
* Variety of preparations
* Typically intramuscular or subcutaneous injections
* Expensive!
which induction option
Gonadotropins
41
Complications of ovulation induction
1. Multifetal gestation
1. Ovarian hyperstimulation syndrome
42
* Clinical symptom complex associated with ovarian enlargement resulting from exogenous gonadotropin therapy
* Due to increased capillary permeability
Ovarian hyperstimulation syndrome
43
s/s and tx for Ovarian hyperstimulation syndrome
* Sx - Abdominal pain/distension, ascites, GI problems, respiratory compromise
* Clinical diagnosis
* Treatment - Supportive!
44
what is Intrauterine Insemination (IUI)
1. Sperm is washed and concentrated
1. Long, thin catheter threaded through the cervical os into the endometrial cavity
1. Sperm injected into endometrial cavity
45
what is In Vitro Fertilization (IVF)
1. Mature oocytes from stmulated ovaries are retrieved transvaginally with sonographic guidance
1. Sperm and ova are combined in vitro
1. Viable embryos are transferred transcervically into the endometrial cavity using sonographic guidance
46
tubal and pelvic factors of infertility
1. **Dysmenorrhea** of chronic pelvic pain may suggest
1. **Adhesions** prevent normal tube movement, ovum pickup and transport of fertilized egg into the uterus
47
causes of tubal and pelvic infertility factors
1. Pelvic infection - Increase in the occurrence of PID, increases the risk of adhesions and infertility
1. Endometriosis
1. Prior pelvic surgery
48
diagnostic testing for tubal and pelvic infertility factors
1. **Hyserosalpingogram (HSG)**
$327-1085
- Injection of a **radio-opaque medium** thru cervical canal to evaluate the uterine **cavity and tube**s
- Usually perform on cycle day 5-10
2. **Chromopertubation**
- Injection of **methylene blue** thru cervical canal during **laparoscopy** to evaluate **tubal patency**
49
tx tubal and pelvic factors
1. _Tubal Occlusion_
- **Tubal cannulation** - Catheter threaded through the tube to create patency
- **Tubal Reconstruction**
- **Tubal Resection** - Proceed with **IVF** afterward
2. _Endometriosis_
- **Surgery** - Removal of adhesions; Drainage of endometriomas
- **IVF**
- **GnRH** = long term tx may improve later outcomes
3. _Pelvic adhesions_
- **Surgical removal**
- **IVF**
50
causes of uterine factors
1. Congenital anomalies – uterine septums, mullerian anomalies
2. Endometrial polyps
3. Fibroids
4. Asherman’s syndrome
51
dx and tx for endometrial polyps
* Diagnosis - hysteroscopy
* Treatment – hysteroscopic removal
52
what are fibroids?
dx and tx?
* Can obstruct a fallopian tube, distort the uterine cavity or fill the uterine cavity
* Endometrium overlying is less vascular
* Diagnosis – HSG, ultrasound
* Treatment - >5cm may consider myomectomy or hysteroscopic resection
53
what is Asherman’s syndrome
dx and tx?
* Intrauterine adhesions
* Occurs most often with a history of having a D&C
* dx – HSG or hysteroscopy
* tx – hysteroscopic lysis of adhesions
54
diagnostic testing for uterine infertility factors
Endometrial bx
* Adequate progesterone levels are required for endometrial preparation prior to implantation
* Thought to provide more info then serum progesterone alone
* Thought to have little predictive value and no longer considered routine part of infertility evaluation
55
pros and cons of endometrial bx
* Benefits: can evaluate luteal phase
* Limitations: Intraobserver bias and interobserver variability, Painful!
56
what secretes mucus? how is that important for the sperm
* Cervical glands secrete mucus
* Mid-cycle high estrogen levels cause mucous to become thin and stretchy
* Creates reservoir for sperm
57
causes of cervical infertility factors
* History of LEEP or cone surgery
* Cryosurgery
* Cervical infection
58
diagnostic for cervical factors and how to perform
Postcoital test
* Couple has intercourse on day of ovulation
* Women present to office a few hours later and a sample of cervical mucus is obtained
59
indications of appropriate cervical mucus
1. Mucus should stretch >5cm
1. Should visualize at least 4 motile sperm on microscopy
1. Minimal inflammatory cells on microscopy
1. Dried mucus should form a ferning pattern
60
tx cervical infertility factors
IUI
61
male infertility hx factors
1. **Pubertal development**
- Hypospadias
- Cryptorchidism – failure of testes to descend
2. **Sexual function difficulties**
- ED - May indicate decreased testosterone
- Ejaculatory dysfunction
3. **STDs** – epididymitis, prostatis
4. **Mumps** - Can lead to testicular inflammation and damage to spermatogenic stem cells
1. **Testicular trauma**
1. **Testicular torsion**
1. **Varicocele** - Dilated veins of the pampiniform plexus of the spermatic cords that drain the testes
62
Takes how long from stem cell to mature sperm
90 days
* 70 days to produce sperm
* Additional 12-21 days for sperm to travel into the epididymis
* Any detrimental affect in the prior 3 months can be an issue
* Occurs best at temperature slightly below body temperature - Illness with high fevers or chronic hot tube use can impair sperm quality
63
causes of male infertility
* Abnormalities of sperm production
* Abnormalities of sperm function
* Obstruction of ductal outflow tract
64
how to perform semen analysis
1. Male should refrain from ejaculation for 2-3 days
1. Specimen collected in sterile cup
65
semen analysis can also evaluate for ?
tx?
Antisperm antibodies
* Antibodies block fertilization
* Presence of sperm agglutination on analysis should prompt testing for antisperm antibodies
* tx: Corticosteroids
66
semen analysis - semen low volume indication
Low volume – this is for Urology
1. Could be due to inappropriate collection or short abstinence interval
2. Can indicate:
- Partial or complete obstruction of vas deferens - infection, tumor or prior surgery or trauma
- Retrograde ejaculation - failed closure of the bladder neck during ejaculation; Seminal fluid flows backward into bladder
--- Check UA = detect sperm in urine
67
tx for oligospermia
* < 20 million sperm/mL
* tx: IUI
68
causes and tx for azoospermia
no sperm
1. Causes:
* Congenital absence of vas deferens (Cystic Fibrosis)
* Severe infection
* Vasectomy
2. Treatment:
* Sperm donor
* Epididymal aspiration or testicular biopsy with sperm aspiration
69
what is Asthenospermia
causes and tx?
decreased sperm motility
1. Causes
* Prolonged abstinence
* Antisperm antibodies
* Infection
* Varicocele
2. Tx: Intracytoplasmic sperm injection
70
what is Teratospermia?
tx?
* abnormal sperm morphology
* IVF
71
Abnormal semen analysis is indication for ?
referral to infertility specialist!
72
causes of antisperm ab?
* Vasectomy
* Testicular torsion
* Testicular biopsy
* Situations where the blood-testis barrier is breached
73
hormone evalution for infertility
1. Prolactin, TSH
1. FSH, Testosterone
74
Low FSH, Low testosterone is indicative of what?
tx?
| hormone eval
* Kallmann syndrome: Anosmia associated with hypogonadotropic hypogonadism
* Idiopathic hypogonadotropic hypogonadism
* Treatment: Gonadotropins
75
Elevated FSH, Low testosterone is indicative of what? tx?
| hormone eval
**_Testicular failure_**
1. Oligospermia
- Replacement **testosterone will decrease gonadotropin stimulation** of remaining testicular function so **should not be used until fertility tx completed** (testosterone can make man never make sperm)
76
a common cause of abnml semen characteristics
genetic abnormalities
77
Karyotype indicated for men who ?
for men with poor semen analysis results
78
causes of genetic abnormalities that warren genetic testing
1. **Klinefelter syndrome (47 XXY)**
- Characteristics: Tall, undervirilized men; Gynecomastia
2. **Microdeletion of Y chromosome**
- Can result in unviable sperm
3. **Cystic Fibrosis**
- Congenital absence of vas deferens = obstructive azoospermia
- Mutations in CFTR gene
- Tx: Epididymal aspiration to obtain sperm for IVF
