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Infertility Flashcards

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1
Q

Even without treatment, what percent of women will conceive during the second year of attempting?

A

50%

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2
Q

What is the definition of infertility?

A
  • Inability to conceive after 1 year of unprotected intercourse of reasonable frequency in women <35
  • Inability to conceive after 6 months of unprotected intercourse of reasonable frequency in women >35 yo
  • > 40 yo more immediate evaluation and treatment
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3
Q

What conditions known to cause infertility would warrant more immediate evaluation of infertility?

A
  • Oligomenorrhea or amenorrhea
  • Known or suspected uterine, tubal, or peritoneal disease
  • Stage 3 or 4 endometriosis
  • Known or suspected male infertility
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4
Q

What is considered primary infertility? Secondary?

A

Primary: no prior pregnancies
Secondary: following at least one prior conception

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5
Q

What are the most common causes of infertility?

A
  1. Ovulatory
  2. Male
  3. Tubal/uterine
  4. Other
  5. Unexplained

BOTH PARTNERS NEED to be evaluated

If you can’t figure out problem, start on treatment for ovulatory issue

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6
Q

What questions will be asked when assessing infertility?

A
  • Frequency, duration, changes, hot flashes, dysmenorrhea during menstruation
  • Signs of ovulation: cervical mucus changes, ovulation tests, basal body temperatures
  • Prior contraeptive use
  • History of ovarian cysts, endometriosis, leiomyomas, STDs, PID
  • History of abnormal pap smears; conization: can decrease cervical mucus quality and cervical anatomy
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7
Q

What does a prior pregnancy confirm?

A

Ovulation and patent fallopian tube

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8
Q

What pregnancy complications can be helpful in diagnosing infertility?

A
  • Miscarriage
  • Preterm delivery
  • Retained placenta
  • Postpartum D&C
  • Chorioamnionitis
  • Fetal anomalies
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9
Q

What are questions to ask about coital history?

A
  • Frequency
  • Timing: chance of conception increased 5 days preceding ovulation, should have daily intercourse during this period
  • Dyspareunia
  • Lubricants: avoid oil based lubricants, water based preferred
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10
Q

What medical history can impact fertility?

A
  • Chemotherapy
  • Radiation
  • Androgen excess –> PCOS
  • Thyroid disease
  • Hyperprolactinemia
  • Medications
  • BMI: moderate weight reduction in overweight women can normalize menstrual cycles and increase chance of pregnancy
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11
Q

What social history can impact fertility?

A
  • Lifestyle
  • Environmental factors: eating habits, toxins
  • Smoking: lowers fertility in men and women
  • Alcohol
  • Caffeine
  • Illicit drugs
  • Ethnicity: important for pre-conceptional testing
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12
Q

What are key components of infertility 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, mobility
  • Adnexal masses or tenderness
  • Cul-de-sac masses, tenderness, or nodularity
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13
Q

What are common causes of female infertility?

A
  • Ovulatory disorders
  • Endometriosis
  • Pelvic adhesions
  • Tubal blockage or other tubal problems
  • Uterine or cervical factors
  • Unexplained
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14
Q

Genetic testing has a low incidence of abnormalities in female infertility. When should you consider testing?

A
  • History of recurrent pregnancy loss –> 3 or more consecutive loss at <20 weeks gestation or with fetal weight <500 g
  • Premature ovarian failure (<40 yo)
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15
Q

What can cause recurrent pregnancy loss?

A
  • Parental chromosomal abnormalities (aneuploidy, more common in sporadic miscarriages)
  • Antiphospholipid syndrome
  • Uterine abnormalities
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16
Q

What is the most common cause of premature ovarian failure (<40 yo) and a sign of this?

A
  • Turners,menopause occuring at younger age
  • Average normal age of menopause is 51 yo
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17
Q

What can ovulation be affected by?

A

Abnormalities in hypothalamus, pituitary, or ovaries

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18
Q

What are common etiologies of ovulatory dysfunction?

A
  • Hypothyroidism
  • Hyperprolactinemia
  • Diminished ovarian reserve- someone who is older w/o good eggs
  • PCOS
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19
Q

What type of relationship is present between female age and fertility?

A

Inverse relationship

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20
Q

Why does infertility increase as age increases?

A
  • Loss of viable oocytes
  • Risk of genetic abnormalities and mitochondrial deletions in remaining oocytes increases with age –> increased rate of miscarriage
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21
Q

How is ovulatory dysfunction diagnosed?

A
  • Menstrual history: cyclic menses (25-35 days with duration of 3-7 days), Mittleschmerz, Moliminal symptoms (breast tenderness, acne, food cravings, mood changes) good
  • Labs: TSH, FT4, Prolactin
  • Weight: anorexia and bulimia can affect GnRH; obesity can indicate PCOS
  • Basal body temperature: postovulatory rise by .4-.8 F; but insensitive in many women
  • Sonography
  • Ovulation predictor kits
  • Serum progesterone
  • Serum FSH
  • Serum estradiol
  • AMH
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22
Q

How can sonography be used to predict ovulatory dysfunction?

A
  • Serial exams demonstrate maturation of antral follicle and collapse during ovulation
  • Count less than 5-7 can indicate diminished ovarian reserve
  • Benefits: useful in diagnosis of PCOS
  • limitations: time consuming, expensive
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23
Q

How can ovulation predictor kits be used to diagnose ovulatory dysfunction?

A
  • Test concentration of urinary LH
  • Should begin testing 2-3 days before predicted LH surge and continue daily
  • Test with first morning void
  • Ovulation will occur day following urinary LH peak
  • Benefits: some studies shown to have sensitivity of 100%
  • Limitations: expensive
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24
Q

How is serum progesterone used to diagnose ovulatory dysfunction?

A
  • Check progesterone on day 21 in 28 day cycle
  • Can also be checked 7 days following ovulation
  • Serum progesterone: <2 ng/mL
  • > 3 ng/mL indicative of ovulation (progesterone produced by corpus luteum)
  • Benefits: easy to do
  • Limitations: progesterone secreted in pulses and single measurement may not be indicative of overall production
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25
How is serum FSH used to diagnose ovulatory dysfunction?
* Sensitive predictor of ovarian reserve * With decreasing ovarian reserve, less inhibin secreted * Inhibin inhibits FSH resulting in increased FSH * Typically performed on cycle day #3 * >10 mIU/mL indicates significant loss of ovarian reserve
26
How is serum estradiol used to diagnose ovulatory dysfunction?
* Measure with serum FSH * Due to increase FSH with decreasing ovarian reserves, will have increasing estradiol level (overcompensating) * >80 pg/mL is abnormal
27
How is antimullerian hormone used to diagnose ovarian dysfunction?
* Expressed by granulosa cells of small preantral follicles * Possible role in recruitment of dominant follicle * Levels correlate with ovarian primordial follicle number * In PCOS, may be 2-3 fold increase in levels * <1 ng/mL associated with diminished ovarian reserve * INCREASED AMH = MORE FOLLICLES
28
What is treatment for hyperprolactinemia leading to ovarian dysfunction?
* Fasting during testing? * If no identified cause, check head MRI to identify micro/macroadenoma * Treatment with dopamine agonists --> bromocriptine or cabergoline * Surgery
29
What are effects of hypothyroidism on ovulation? What is treatment?
Effects: Oligomenorrhea and amenorrhea, even subclinical can cause problem Treatment: levothyroxine
30
What is treatment for diminished ovarian reserve?
* Ovulation induction * IUI/IVF * Egg donor
31
What is used for ovulation induction?
* Clomiphene citrate * Aromatase inhibitors --> Letrozole * Gonadotropins
32
What is the initial treatment for most anovulatory infertile women?
Ovulation induction with clomiphene citrate
33
What is the mechanism of action of clomiphene citrate?
* Oral medication given for 5 days starting on cycle day 2-5 * Estrogen antagonist that results in increase in FSH which increases ovarian follicular activity
34
What is the mechanism of action of aromatase inhibitors (Letrozole)?
* Oral medication given cycle day 3-7 * Inhibits the production of estrogens, so it increases FSH
35
What is the mechanism of action of gonadotropins?
Urinary or recombinant FSH and LH given intramuscular or SQ Expensive though!
36
What are complications of ovulation induction?
* Multifetal gestation--> increase in obstetrical outcomes * Ovarian hyperstimulation syndrome
37
What is ovarian hyperstimulation syndrome?
Clinical symptom complex associated with ovarian enlargement resulting from exogenous gonadotropin therapy due to increased capillary permeability
38
What are symptoms of ovarian hyperstimulation syndrome?
* Abdominal pain/distension * Ascites * GI problems * Respiratory compromise
39
How is ovarian hyperstimulation syndrome diagnosed and treated?
* Clinical diagnosis and supportive treatment
40
What is intrauterine insemination?
* Sperm washed and concentrated * Long thin catheter threaded through cervical os into endometrial cavity * Sperm injected into endometrial cavity
41
What is in vitro fertilization?
* Mature oocytes from stimulated ovaries are retrieved transvaginally with sonographic guidance * Sperm and ova combined in vitro * Viable embryos transferred transcervially into endometrial cavity using sonographic guidance
42
What are tubal and pelvic factors impacting fertility?
* Dysmenorrhea of chronic pelvic pain may suggest adhesions that prevent normal tube movement, ovum pickup, and transport of fertilized egg into uterus
43
What are etiologies of adhesions causing infertility?
* Pelvic infection: increase in occurance of PID, increasing risk of adhesions and infertility * Endometriosis * Prior pelvic surgery
44
What is diagnostic testing for tubal and pelvic factors impacting fertility?
* Hyserosalpingogram * Chromopertubation
45
What is hyserosalpingogram?
* Injection of radio-opaque medium through the cervical canal to evaluate uterine cavity and tubes * Usually performed on cycle day 5-10
46
What is chromopertubation?
* Injection of methylene blue through cervical canal during laparoscopy to evaluate tubal patency
47
What is treatment for tubal occlusion?
* Tubal cannulation: catheter threaded through tube to create patency * Tubal reconstruction * Tubal resection: proceed with IVF after
48
What is treatment for endometriosis?
* Surgical treatment via removal of adhesions and drainage of endometriomas * IVF * GnRH --> long term treatment may improve later outcomes
49
What is treatment for pelvic adhesions?
* Surgical removal * IVF
50
What is etiology for uterine factors impacting fertility?
* Congenital anomalies: uterine septums, mullerian anomalies * Endometrial polyps * Fibroids * Asherman's syndrome
51
What is the diagnosis and treatment of uterine factors?
* Diagnosis: hysteroscopy * Treatment: hysteroscopic removal
52
How can fibroids cause infertility?
* Can obstruct fallopian tube, distort uterine cavity or fill the uterine cavity * Endometrium overlying is less vascular
53
How are fibroids diagnosed and treated?
* Diagnosis: HSG, ultrasound * Treatment: >5 cm may consider myomectomy or hysteroscopic resection
54
What is asherman's syndrome?
Intrauterine adhesions that occur most often with a history of having a D&C
55
How is asherman's syndrome diagnosed and treated?
* Diagnosed: HSG or hysteroscopy * Treatment: hysteroscopic lysis of adhesions
56
How are uterine factors influencing fertility diagnosed?
* Endometrial biopsy
57
How are endometrial biopsies used for infertility?
Throught to provide more information about adequate progesterone levels for endometrial preparation prior to implantation Benefits: can evaluate luteal phase Limitations: intraobserver bias and interobserver variability, painful No longer considered routine part of infertility evaluation!
58
How do cervical glands influence fertility?
Mid-cycle high estrogen levels cause mucous to become thin and stretchy and create reservoir for sperm
59
What is the cause of cervical abnormalities leading to infertility?
* History of LEEP or cone surgery * Cryosurgery * Cervical infection
60
How are cervical factors influencing fertility diagnosed?
* Postcoital test
61
What is a 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
62
What are indications of appropriate mucus on postcoital test?
* Mucus should stretch >5 cm * Should visualize at least 4 motile sperm on microscopy * Minimal inflammatory cells on microscopy * Dried mucus forms ferning pattern
63
What is treatment for cervical factors influencing fertility?
IUI
64
What are causes of male infertility?
* Pubertal development: hypospadias, cryptorchidism * Sexual function difficulties: erectile dysfunction (may indicate decreased testosterone) and ejaculatory dysfunction * STDs - epididymitis, prostatis * Mumps: can lead to testicular inflammation and damage to spermatogenic stem cells * Testicular trauma * Testicular torsion * Varicocele: dilated veins of pampiniform plexus of the spermatic cords that drain the testes
65
What are factors that influence spermatogenesis?
Any detrimental effect in last 3 months can cause issue (takes 90 days to mature sperm) * Occurs best at temperature slightly below body temperature: illness with high fevers or chronic hot tub use can impair sperm quality
66
What are causes of male infertility?
* Abnormalities of sperm production * Abnormalities of sperm function * Obstruction of ductal outflow tract
67
What are components of semen analysis?
* Male should refrain from ejaculation for 2-3 days * Specimen collected in sterile cup * Volume, count, motility, morphology, WBCs, and round cells analyzed * If round cells are high may not have enough mature sperm * Can also evaluate for antisperm antibodies
68
What are antisperm antibodies?
* Present in 4-8% of infertile men * Antibodies block fertilization
69
What should you do if sperm agglutination is present on analysis?
Test for antisperm antibodies
70
How is antisperm antibodies treated?
Corticosteroids
71
What can low semen volume indicate?
* Inappropriate collection or short abstinence interval * Partial or complete obstruction of vas deferens due to infection, tumor, or prior surgery or trauma * Retrograde ejaculation due to failed closure of bladder neck during ejaculation causing seminal fluid to flow backward
72
If retrograde ejaculation is occuring, what will you see?
Sperm in urine on UA
73
What is oligospermia and how is it treated?
* <20 million sperm/mL * Treatment: IUI
74
What is azospermia?
No sperm, occurs in 1% of men
75
What are causes of azoospermia?
* Congenital absence of vas deferens * Severe infection * Vasectomy
76
What is treatment for azoospermia?
* Sperm donor * Epididymal aspiration or testicular biopsy with sperm aspiration
77
What is asthenospermia?
Decreased sperm motility
78
What are causes of asthenospermia?
* Prolonged abstinence * Antisperm antibodies * Infection * Varicocele
79
What is treatment for asthenospermia?
Intracytoplasmic sperm injection
80
What is teratospermia and how is it treated?
* Abnormal sperm morphology treated with IVF
81
Abnormal semen analysis is indication for what?
Referral to infertility specialist
82
When are antisperm antibodies prevalent and how are they treated?
* Vasectomy * Testicular torsion * Testicular biopsy * Situations where the blood-testis barrier is breached * Treated with corticosteroids
83
What hormones can be evaluated for infertility in men?
* Prolactin, TSH * FSH, testosterone
84
What could cause low FSH, low testosterone and how is it treated?
* Kallmann syndrome: anosmia associated with hypogonadotropic hypogonadism * Idiopathic hypogonadotropic hypogonadism * Treatment: gonadotropins
85
What could cause elevated FSH, low testosterone?
* Testicular failure --> oligospermia * Replacement testosterone will decrease gonadotropin stimulation of remaining testicular function so should not be used until fertility treatment completed (testosterone can actually make man never make sperm)
86
If men have poor semen analysis results, what is indicated?
Karyotype
87
What are causes of abnormal semen characteristics?
* Klinefelter syndrome (47 XXY) * Microdeletion of Y chromosome * Cystic fibrosis
88
What are characteristics of men with Klinefelter syndrome?
* Tall, undervirilized men * Gynecomastia
89
What can microdeletion of Y chromosome cause?
Unviable sperm
90
How does cystic fibrosis impact male fertility?
* Congenital absence of the vas deference causing obstructive azoospermia * Mutations in CFTR gene
91
How is infertility due to cystic fibrosis treated?
Epididymal aspiration to obtain sperm for IVF

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