Infertility and polycystic ovarian syndrome

Question 1

definition: infertility

Answer 1

inability to conceive despite regular, unprotected intercourse without conception for 12 months (6 months if woman is over 35)

Question 2

definition: fecundability

Answer 2

ability to conceive within a given month / cycle

Question 3

infertility affects what % of reproductive age couples?

Answer 3

10-15%

Question 4

what are the etiologies of infertility?

Answer 4

• male factor
• female factors (endometriosis, tubal damage, cervical)
• coital timing
• unexplained

Question 5

what are the proportions of cause for male / female / both?

Answer 5

1/3 female
1/3 male
1/3 both

Question 6

surgical history for infertility should include what factors?

Answer 6

• appendix (important)
• D&C
• LEEP (excision of ectocervix for abnormal pap smears)
• laparoscopy for endometriosis

Question 7

how does LEEP relate to infertility?

Answer 7

causes cervical stenosis (os is scarred)

Question 8

what % of viable sperm are necessary for a normal sperm count?

Answer 8

4%

Question 9

what is the normal volume of semen?

Answer 9

1.5 mL

Question 10

what is the normal % of swimming sperm for semen analysis?

Answer 10

32% motility

Question 11

a finding of hirsutism in females should indicate which lab tests?

Answer 11

DHEA-S

testosterone

Question 12

high fasting insulin : glucose ratio indicates?

when would you check for this in the context of infertility?

Answer 12

insulin resistance

if LH : FSH is abnormal

Question 13

if there are no recent menses, what test could you do? what does it show?

Answer 13

progesterone challenge test

proves HPG axis is intact

Question 14

anovulation and androgen excess - what should you consider? what could be measured?

Answer 14

late onset congenital adrenal hyperplasia

check 17-OH progesterone levels

Question 15

what is lacking in luteal phase defect?

Answer 15

progesterone

Question 16

what are the medications for PCOS?

Answer 16

clomiphene

letrozole

Question 17

what are the medications for unknown anovulation?

Answer 17

clomiphene (BMI under 30)

letrozole (BMI over 30)

Question 18

if you are successful in treating infertility, what should you do next?

Answer 18

• check quantitative BHCG
• check (maybe) serum progesterone
• repeat quantitative BHCG in 48 hours
• possibly start progesterone suppositories until labs return

Question 19

what is the most common cause of infertility?

Answer 19

polycystic ovarian syndrome

Question 20

what are some diagnostic criteria for PCOS?

Answer 20

• hyperandrogenism
• ovulatory dysfunction
• polycystic ovaries on US

need 2/3 for diagnosis

Question 21

what conditions are associated with PCOS?

Answer 21

• obesity
• T2DM
• OSA
• dyslipidemia
• infertility
• thyroiditis
• mood disorders

Question 22

what is the clinical presentation for PCOS?

Answer 22

• menstrual irregularities
• acne
• hirsutism
• androgenic alopecia (temporal balding)
• obesity

Question 23

what is characteristic for PCOS on US?

Answer 23

“string of pearls” appearance or increased ovarian volume

Question 24

what is the biochemical presentation for PCOS?

what lab tests should be ordered?

Answer 24

• hyperandrogenism
• LH : FSH over 2
• hyperinsulinemia
• dyslipidemia

thyroid, prolactin, 17-OH progesterone, cortisol (maybe)

Question 25

what is the role of insulin in PCOS?

Answer 25

- increases ovarian androgen production - inhibits hepatic production of SHBG - increased free androgens - alters follicular development

Question 26

what are the treatment goals for PCOS?

Answer 26

1. lessen symptoms of hyperandrogenism 2. manage metabolic comorbidities 3. prevent chronic anovulation which can lead to endometrial hyperplasia and carcinoma 4. contraception, or ovulation induction if fertility desired

Question 27

what are the first line treatment strategies for PCOS?

Answer 27

- lifestyle changes: diet, exercise | - oral contraceptive pills

Question 28

what is the second line treatment strategy for PCOS? what else is required for this?

Answer 28

- spironolactone | - must use form of contraception

Question 29

what is the role of metformin in PCOS?

Answer 29

- decreases serum free testosterone - increases HDL - weight loss - restores ovulation in 50% PCOS patients it is NO LONGER recommended as first line or additive treatment (unless also diabetic) except in women with glucose intolerance

Question 30

in a PCOS patient with infertility and without menses, what test should be done? what is done / what are the results?

Answer 30

provera challenge test 10d of progesterone - should have a withdrawal bleed 7d later

Question 31

if there is no spontaneous ovulation following a provera challenge test, what should be done?

Answer 31

on day 3-5 start - clomiphene citrate (anti-estrogen) OR - letrozole (aromatase inhibitor) (based on BMI)

Question 32

what should be done following a provera challenge test and clomiphene / letrozole?

Answer 32

check serum progesterone on day 21 - ovulation = no dose change - no ovulation = dose increase

Question 33

what are the lifelong implications of PCOS?

Answer 33

- CVD - T2DM - endometrial cancer