Infertility Flashcards
(30 cards)
A 36 yo G1 P0010 LMP 3 weeks ago states she and her husband have been trying to conceive for two years. She is very upset that they have not yet been successful and asks for your help. She states, “I have really good insurance that will pay for everything. I’m afraid my marriage will be over if I can’t get pregnant.”
Your patient has normal periods. Her labs are within normal limits, as is her husband’s semen analysis, but the hysterosalpingogram reveals bilateral tubal occlusion.
She accepts a referral to a reproductive endocrinologist for consultation regarding in vitro fertilization, and thanks you for your help, stating, “I feel like I have some hope now.”
infertility
-85% of heterosexual couples conceive in 1 year
-85% of infertile couples seeking tx will conceive
-Infertility:
-In women <35: after attempting for at least 1 year
-In women >35: 6 months
-In women >40: obtain immediate consultation
-Primary infertility: pt has never conceived
-Secondary infertility: patient conceived before but now cant
etiology
-Female factors: 33%
-1/2 are due to anovulation
-1/2 due to female reproductive tract structural problems (tubal patency, etc.)
-Male factors: 33%
-Both partners: 33%
etiology of infertility: females
-Anovulation
-MC- PCOS
-thyroid ds or hyperprolactinemia
-Tubal obstruction-
-Adhesions from infections, endometriosis, prior surgery
-Uterine etiologies-
-Endometrial polyps, leiomyomata uteri, Asherman’s syndrome, or Müllerian tract anomalies
-Toxic exposure
-Severe wt gain or loss
-AMA
etiology of infertility: male
-Disorders of the hypothalamus, pituitary, adrenals, or testes
-Congenital - Abnormal karyotype
-Acquired- Effect of mumps
-Disorders of post-testicular tract
-Toxic exposure
-Wt gain or loss
-AMA
disparities to care for infertility
-females factors investigated first
-delayed investigation of male factors
-LGBT or single are more likely to be denied infertility care
fecundability
-the ability to conceive
-in AFAB pts -> begins to decline by 32yo with a steeper rate of decline by 37yo
HPI
-how long has infertility been suspected
-have there been previous studies
-menstrual hx
-obstetrical hx
-prior methods of contraception, if any
-sexual dysfunction
-past abdominopelvic surgery
-frequency of intercourse
-use of lubricants, emollients, etc.
-toxic habits, including alcohol, marijuana, tobacco
-environmental or occupational exposure to toxins
-does male partner have any children
-have any other partners of male partner conceived with a diff partner
-any hx of sterilization procedures in either partner
-any hx of inguinal herniorrhaphy -> potential accidental ligation of spermatic artery
female history
-LMP
-Past medical and surgical history -> Thyroid disease, acne, hirsutism, abdominal surgery
-Gynecologic history -> Ovarian cysts, dyspareunia, endometriosis, leiomyomata uteri, PID, STIs
-Complications of pregnancy and delivery, if any
-History of cervical disease
-Medications
-Allergies
-Toxic habits
-Family history of birth defects or early menopause
-Review of systems
-History of cervical cancer screening
physical exam of female partner
-Wt, vital signs
-Thyroid exam
-Tanner stage
-Breasts
-obesity, hirsutism or virilization
-Pelvic exam: lower genital tract lesions or anomalies, or tenderness, enlargement or masses of uterus or adnexa
ancillary testing of female partner
-Ovulation documented by regular menstrual cycles
-FSH- ovarian response
-TSH
-May consider:
-Anti-Müllerian hormone - how many remaining follicles there are
-Ovarian volume (via transvaginal u/s)
-Antral follicle count (via transvaginal u/s) - direct visualization of follicles
-Evidence of diminished ovarian reserve:
-low anti-mullerian hormone (<1ng/mL)
-antral follicle count (<5-7)
-follicle-stimulating hormone (FSH) >10 IU/L
male history
-Sexual dysfunction- Erectile dysfunction, ejaculatory dysfunction
-History of STIs
-Prior fertility
-Childhood illnesses
-Past medical and surgical history
-Medications, including illicit prescriptions, e.g., anabolic steroids, testosterone
-Allergies
physical exam of male partner
-Careful eval of 2ndary sex characteristics: penis, scrotum, pubic and axillary hair, facial and body hair, etc.
-Penis- Hypospadias
-Scrotum:
-Hydrocele or varicocele
-Testicular size
-Cryptorchidism
-Absence of vasa deferentia
-Prostate - Nontender, normal size
evaluation of male fertility
-If no abnormalities on hx and PE -> semen analysis
-May be collected:
-via masturbation (preferred)
-via intercourse using a condom
-Cheap
-Accurate
-Noninvasive
-Semen analysis:
-Volume
-Total sperm number
-Sperm concentration
-Sperm agglutination
-Motility
-Morphology
-pH
anovulation- testing
-Etiologies:
-PCOS
-Hyperprolactinemia or pituitary adenoma
-Menopause
-Premature ovarian insufficiency
-Testing:
-Serum progesterone on day 21, though of uncertain sensitivity
female structural anomalies etiologies
-Adhesions:
-PID
-Endometriotic implants
-Postop adhesions
-Leiomyomata uteri
-Müllerian tract anomalies:
-Bicornuate uterus
-Uterus didelphys
-double vagina
-Vaginal agenesis
-Asherman’s syndrome
ancillary testing of female partner if initial labs are within normal limits
-R/o tubal obstruction or structural abnormalities:
-Hysterosalpingography (tubal obstruction, Asherman’s syndrome, submucous myomas, Müllerian tract anomalies)
-Transvaginal US (endometriomas, leiomyomata uteri, PCOS)
-Sonohysterography (endometrial polyps, Asherman’s syndrome, submucous myomas)
-Hysteroscopy (dx and tx of endometrial polyps, Asherman’s syndrome, and submucous myomas)
-Laparoscopy: gold standard (dx and tx of endometriosis, adhesions)
female structural anomalies: hysterosalpingography
-Hysterosalpingography:
-Catheter inserted in cervix
-Radio-opaque dye injected
-Patency: spillage of dye from distal tubes should be seen
-Potential problems:
-Painful
-Expensive
secondary structural anomaly: asherman’s syndrome (uterine synechiae)
secondary structural anomaly: submucous myoma
hirsutism vs virilization
-hirsutism- hairy, can be genetic
-virilization- will have hirsutism but also has deeper voice, enlarged cliterous
management of infertility
-FOLIC ACID- All pts capable of pregnancy and SA who want to become pregnant -> folic acid 400 mcg PO daily
-Lifestyle:
-healthy wt
-healthy diet
-reduce stress
-exercise
-avoid smoking, alc, drugs (weed too)
-sex every 2-3 days
ovulatory dysfunction management
-Used for pts with:
-PCOS
-Diminished ovarian reserve
-At times, other endocrine disorders (pituitary, thyroid, etc.)
-Clomiphene citrate 50 mg PO daily x 5 days beginning on cycle day 3-5
-Antiestrogen that induces increase in FSH release by blocking estrogen
-increase FSH -> increase follicles
-Perform u/s first to exclude normal follicular and endometrial development
-Obtain neg pregnancy test before beginning clomiphene
-successful in 25-50%
-aromatase inhibitors used for ovulation induction (letrozole)
structural anomalies of the uterus and tubes tx
-Generally require surgery
-Müllerian tract anomalies
-Asherman’s syndrome
-Leiomyomata uteri, especially submucous myomas
-Hydrosalpinx
-Endometriosis
-May also bypass the upper tract by using IVF or use of a surrogate
