Infertility

Question 1

infertility definition

Answer 1

no pregnancy after 1 year of unprotected well timed intercourse

Question 2

fecundability

Answer 2

probability of pregnancy in a single menstrual cycle

Question 3

fecundity

Answer 3

probability of live birth in a single menstrual cycle

Question 4

fertile window

Answer 4

6-day interval ending on the day of ovulation

Question 5

when is the highest fecundity?

Answer 5

w/i 2 days of ovulation

Question 6

what can maximize the likelihood of conception?

Answer 6

increasing frequency of intercourse beginning soon after cessation of menses and continuing to ovulation

Question 7

home ovulation monitoring is only recommended for who?

Answer 7

• pts w/ regular cycles

- only accurate 50% of the time

Question 8

fecundability (prob. of pregnancy per month for fertile couples planning to conceive) for

• daily intercourse
• alternate days
• once a week

Answer 8

• daily: 37%
• alternate: 33%
• once/week: 15%

Question 9

optimal frequency of intercourse

Answer 9

• every 1-2 days but factor in patient stress

- cycles days 10-20 probably hit the fertile window in most cases

Question 10

lubricants that are ok

Answer 10

• mineral oil
• canola oil (WUT??)
• hydroxyethylcellulose - based lubricants (Pre-seed, ConveivEase)

Question 11

lubricants that are not ok

Answer 11

• olive oil
• salive
• astroglide
• KY

Question 12

how does BMI effect fertility?

Answer 12

• BMI > 35 can double time to pregnancy

- BMI < 19 can quadruple time to pregnancy

Question 13

lifestyle factors that effect fertility

Answer 13

• smoking increases infertility by 60%
• alcohol > 2 drinks/day increases infertility by 60%
• drugs can increase infertility 70%
• toxins at work can increase infertility 40%
• caffeine > 250mg daily can decrease pregnancy rates (controversial)

Question 14

recommended folic acid

Answer 14

400 mcg to reduce NTDs

Question 15

effects of smoking

Answer 15

• OR of infertility is 1.6
• menopause occurs 1-4 yrs earlier
• increases risk of miscarriage
• decreases sperm density, motility and morphology - but no definite decrease in male fertilty

Question 16

what factors make up fertility evaluation?

Answer 16

• H&P
• assessment of ovulation
• ovarian reserve testing
• uterine abnormalities
• tubal patency
• male fertility testing
• optimization of medical conditions and medications

Question 17

H&P for fertility

Answer 17

• duration
• menstrual hx
• pregnancy hx
• gyn hx
• previous method of contraception
• coital frequency and sexual dysfunction
• PSH
• PMH
• meds
• fam and social hx

Question 18

PE for fertility

Answer 18

• vitals
• thyroid
• breasts
• signs of androgen excess
• pelvic exam

Question 19

what accounts for 40% of infertility in women?

Answer 19

-ovulatory dysfunction (MC is PCOS)

Question 20

evaluation of ovulation

Answer 20

• hx: regular periods is a good indication of ovulation

- are they using home-checking methods?

Question 21

lab test for ovulation

Answer 21

• serum progesterone
• get 1 week before expected onset of menses
• if > 3ng/mL presumed ovulation

Question 22

meds that can induce ovulation

Answer 22

• clomiphene citrate (clomid)
• letrozole (femara)
• gonadotropins (follistim, gonal-F)

Question 23

MoA of clomiphene citrate

Answer 23

• selective E receptor modulator
• interrupts the negative feedback b/w estradiol and FSH
• FSH increases, facilitating follicle growth and ovulation

Question 24

MoA of letrozole

Answer 24

• aromatase inhibitor, blocks production of estradiol
• also interrupts the negative feedback b/w estradiol and FSH
• off label

Question 25

tx for pts resistant to meds

Answer 25

- gonadotropins | - ovarian drilling

Question 26

what is ovarian reserve

Answer 26

- reproductive potential as a function of the number and quality of remaining oocytes - gives a sense of how quickly a pt is reproductively aging

Question 27

evaluation of ovarian reserve

Answer 27

- cycle day 3 FSH and estradiol - day 3 antral follicle count by US - serum AMH level

Question 28

when is the only time you can interpret FSH?

Answer 28

if estradiol is low

Question 29

what is the antral follicle count

Answer 29

- sum of antral follicles in both ovaries | - low count is associated w/ poor response to ovarian stimulation

Question 30

serum AMH level

Answer 30

- AMH is produced by granulosa cells of early follicles | - relatively consistent levels during menstrual cycle

Question 31

low AMH (< 1-2 nl/ml) is associated with what?

Answer 31

- poor response - poor embyro quality - poor pregnancy outcomes in IVF

Question 32

tx for low ovarian reserve

Answer 32

- not possible to reserve process - worse response to all types of tx offered - therapy aimed at increasing chance of pregnancy each month - donor oocyte or embry

Question 33

tubal disease

Answer 33

-obstructed fallopian tubes block egg and sperm from ever meeting

Question 34

RFs for tubal disease

Answer 34

- hx of STI (esp. chlamydia) - hx of pelvic surgery - hx of ectopic pregnancy - hx of appendicitis

Question 35

processes to check for tubal patency

Answer 35

- hysterosalpingogram | - laparoscopy w/ chromopertubation

Question 36

tx for tubal obstruction

Answer 36

- rarely gets surgery | - more often use in vitro

Question 37

evaluation to check for uterine abnormalities

Answer 37

- HSG to look at size and shape of uterine cavity, developmental or acquired anomalies - sonohysterography to look for polyps or fibroids - hysteroscopy: definitive for diagnosis and tx of intrauterine pathology

Question 38

male factor is responsible for infertility how often?

Answer 38

about 20% of cases but is a contributor to about 30-40% of cases

Question 39

factors of a semen analysis

Answer 39

- volume - concentration - motility - morphology - total motile count

Question 40

tx for male factor infertility

Answer 40

- referral to urology - hormone testing - if counts are minimally decreased: intrauterine insemination - counts very low: IVF

Question 41

indications to refer

Answer 41

- trying over 12 mos - trying over 6 mos if female > 35 - abnl semen analysis - irregular periods - suspect PCOS or tubal blockage - no success after 3 cycles of clomid