Infertility and Abortion Flashcards by Courtney Birkett

Fertility

Capacity to conceive and produce offspring

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Fecundability

Probability or achieving a pregnancy in one menstrual cycle

More accurate descriptor b/c recognizes varying degrees of infertility

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Infertility

Diminished capacity to conceive despite frequent coitus

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Subfertility

More appropriate description of most infertile couples

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Sterility

Inability to conceive offspring, usually used after sterilization procedure or specific illness, exposure or genetic condition (mumps, chemo, klinefelter)

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Why does fecundability decrease?

As woman ages due to declining quantity and quality of oocytes (first 3 cycles of unprotected intercourse=.25 and decreased over next 9 months of cycles)

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How to define infertility

Inability to conceive after 12 mos of unprotected intercourse for women 35 or younger
Inability to conceive after 6 mos of unprotected intercourse for women 35+

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Primary and secondary infertility

Primary: individuals who have never conceived (higher 40-44 YO)
Secondary: infertility after prior fertility

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Causes of infertility

Male factor
Female factor (37%)
Combned
Unknown

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Categories of male factor infertility

Endocrine and systemic disorders
Primary testicular defects in spermatogenesis
Sperm transport disorders
Idiopathic male infertility

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Clinical semen findings in male factor infertility

Low sperm conc
Absent sperm
Motility issues
Morphology issues

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How to obtain semen analysis

Masturbation sample at office or lab
2-7 days of sexual abstinence
2 samples taken 1-2 wks apart

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Serum analysis WHO criteria

Vol: 1.5 ml
Sperm conc: 15 mil spermatozoa/mL
Total sperm number: 39 mil spermatazoa per ejaculate
Morphology: 4% normal forms, strict Tygerbergmethod
Vitality: 58% live
Progressive motility: 32%
Total (progressive and nonprogressive motility)- 40%

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Most common congenital abnormality causing primary hypogonadism

Klinefelters (47 XXY)

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Main contributing factors of female factor infertility

Ova
Patent oviduct
Anatomic abnormalities of uterua

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What to consider with ova

Quantity and quality: age and surgeries/injury to ovary

Ovulation: discharge of ova or ovules from ovary

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Complications of ovulation

Polycystic ovarian syndrome
Thyroid dysfunction (hyper and hypo)
Hyperprolactinemia

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Presentation of polycystic ovarian syndrome

Cutaneous signs of hyperandrogenism
Oligomenorrhea or amenorrhea
Obesity and insulin resistance

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Causes of oligomenorrhea and amenorrhea in PCOS

Lack of progesterone (no corpus luteum) causing unopposed estrogen exposure–hyperplastic growth
Irregular sloughing of endometrium–oligomenorrhea

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High prolactin states

Breastfeeding
Breast stimulation/intercourse
Extreme exercise
Meds (risperidone)
If persistently elevated look for pituitary adenoma on MRI

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Tx of PCOS

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Diet and exercise
Provera cycling
Metformin
Clomiphene

Tx of thyroid def

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PTU or levothyroxine

Tx of prolactinemia

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Bromocriptine (Safe in pregnancy but stop when get + pregnancy test)

What is clomiphine?

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SERM

Serious short term complication of ovarian hyperstimulation (lead to thromboembolic events)

Tubal factors leading to infertility

Occluded oviducts (proximal or distal, from untreated STDs or PID, mucous or anatomic abnormalities) Injury/surgery to oviduct r/o with hysterosalpingogram

Limitations of HSG

Not covered by insurances Maybe painful Evaluates for tubal patency not function

Txs for tubal factors

Surgical tubal repair | IVF

Surgical tubal repair

Rarely performed High failure rates Increased risk of ectopic pregnancy

2 most important questions for fertility HPI

Regular menstrual cycles?? (21-35 days and varying 2-7 days in length) How often are they having intercourse??- recommend every other day around ovulation

Other pertinent history questions for fertility

Dysmenorrhea? History of irregular menses? Signs of regular ovulation?

Signs of regular ovulation

Evaluate cervical mucous (spinnbarkeit or egg white) Breast tenderness resolves with menses onset Mittelschmerz (pain with ovulation) Swelling or bloating that subsides with menses Day 21 progesterone lab draw

Important HPI for female

Age, medical history, meds, social history review, surgical history

Important HPI for male

Medical history (mumps) Meds Social history (anabolic steroids, EtOH, chemo, psychotropic meds, chemicals) Surgical history (vasectomy, hernia repair, orchiectomy) Developmental history

Combo HPI

Primary vs secondary infertility (successful, abortions and miscarriages too) How long trying Contraceptives previously?

When to start fertility tx if know there is specific cause for infertility?

No need to wait 6-12 mos so refer early

Reasons for elective abortion

Unplanned pregnancy Fetal anomalies Maternal health

Meds for elective abortion

Misoprostol or mifepristone May have risk of retained products of infection (prophylactic abx) FDA approved to 70 days gestation

Surgical way for elective abortion

Depending on gestational age: Suction D&C Dilation and evacuation Stimulation of labor

Definition of spontaneous abortion

Miscarriage Pregnancy loss which occurs prior to 20 wks gestation Most common complication of pregnancy

Work up for spontaneous abortion

CBC Rh type HCG quantitative Pelvic and transvaginal u/s

Important things to remember for spontaneous abortion

Most common cause is abnormal karyotype (>50%) Usually in first trimester (<8 wks) Genetic studies rarely performed for isolated SAB Rh neg women need rhogram injection

Complete spontaneous abortion

Complete passage of products of conception

Incomplete spontaneous abortion

Retention of part/all products of conception

Threatened spontaneous abortion

Closed cervical os- bleeding with + urine pregnancy test

Inevitable spontaneous abortion

Open cervical os (presents with bleeding)

Missed abortion

Absent heartbeat without bleeding, cervix is closed

Septic spontaneous abortion

Any above abortion with infected POC (products of conception) or endometrial lining

Recurrent abortion

Three or more consecutive losses prior to 20 wks (SABs) "Habitual aborter" Risk increases with each subsequent SAB Refer to reproductive endocrinology

Causes of recurrent abortion

``` Abnormal karyotype Uterine malformations Antiphospholipid antibody (Antiphospholipid syndrome)-lupus common co-presentation Chronic uncontrolled med conditions Insufficient progesterone levels ```

Work up for recurrent abortion

``` History (age, chronic disease) Karyotype of both parents Karyotype of aborted embryo Luteal phase progesterone Antiphospholipid Ab Lupus work up Uterine cavity eval ```

First thing to always check with fertility and pregnancy!!!

BMI

Infertility and Abortion Flashcards

(51 cards)