Infertility + Associated Conditions

Question 1

Infertility is defined as…

Answer 1

The inability to conceive after 1 year of unprotected intercourse

Primary = no child, secondary = previously successful in conceiving

Question 2

Infertility should be investigated when…

Answer 2

Pregnancy is not achieved after 12 months of unprotected intercourse: woman is under 35 y.o.

Question 3

An earlier investigation of infertility (within 6 months) may be appropriate in some women, in cases…

Answer 3

Age 35+
Menstrual abnormality
Previous abdominal/pelvic/urogenital surgery
Hx of pelvic disease, STI’s
Abnormal genital exam

Question 4

Risk factors for infertility vary because…

Answer 4

It depends on the reason causing infertility - potentially modifiable or not

Question 5

Female factors of infertility are primarily based on these 3…

Answer 5

Increasing age
Ovulatory dysfunction
Anatomical factors

Question 6

Some factors that contribute to infertility with aging are…

Answer 6

Increased exposure to development of disease
Ovulation becomes more irregular
Fewer + lower quality eggs remain

Question 7

Ovulatory dysfunction is when the ovaries ____ and may be caused by factors such as…

Answer 7

Ovaries fail to produce a mature egg on a regular basis

Anovulation
PCOS
Luteal phase defect

Question 8

Anovulation occurs as a result of disruption of ____

Answer 8

The hypothalamic-pituitary-ovarian (HPO) axis

Question 9

Anovulation can be due to a variety of causes, such as…

Answer 9

Endocrine disorders
Physical injury to the hypothalamus or pituitary gland
Excessive weight changes
Excessive exercise, stress
Exposure to chemotherapy/radiation

Correction where possible, but not always feasible

Question 10

Polycystic ovarian syndrome (PCOS) is a syndrome of ovarian dysfunction characterized by…

Answer 10

1. Hyperandrogenism
2. Ovulatory dysfunction
3. Polycystic ovaries

Question 11

The cause of PCOS is ____, but is thought that…

Answer 11

Unknown - thought that peripheral insulin resistance can lead to hyperinsulinemia + stimulation of excess ovarian androgen production

Is a genetic link

Question 12

Signs and symptoms of PCOS usually include…

Answer 12

Menstrual irregularities (amenorrhea, oligomenorrhea)
Hyperandrogenism
Overweight/obesity
Infertility

Question 13

Hyperandrogenism may present as…

Answer 13

Hirsutism - usually body hair in a “male” pattern
Acne
Seborrhea
Alopecia

Question 14

Associated comorbidities with PCOS include…

Answer 14

Reproductive challenges
Endometrial hyperplasia/cancer
Metabolic issues
OSA
Depression

Question 15

Goals of treatment for PCOS may be to…

Answer 15

Decrease/get rid of hyperandrogenic features
Manage underlying cardiometabolic abnormalities
Prevent endometrial hyperplasia (as result of chronic anovulation)
Contraception for those not wanting pregnancy, or ovulation induction for pregnancy

Question 16

The foundation for all PCOS recommendations are…

Answer 16

Lifestyle modifications

Question 17

1st line therapy for women who are obese/overweight is…

Answer 17

Weight loss through lifestyle modifications - can help improve fertility, hirsutism, and BG/BP/Lipids

Question 18

For menstrual cycle irregularities, this is 1st line…

Answer 18

CHC’s - oral, patch, ring

Question 19

CHC’s benefits for PCOS include…

Answer 19

They help regulate menstrual cycle
Protects from endometrial hyperplasia (no progesterone to counteract estrogen with chronic anovulation)
Helps with androgenic symptoms

Question 20

CHC that is typically started is one with…

Estrogen? Progestin?

Answer 20

Low dose of estrogen
Progestin with low androgenicity

Question 21

If a patient has CI to CHC or does not want CHC, we could try these 2nd line agents…

Answer 21

Progestin-only therapy (Does not help with androgenic sx’s)

Metformin

Question 22

Metformin in PCOS has been shown to help with…

Answer 22

Improving glucose tolerance
Reduced androgen production in ovaries
May help restore ovulatory cycles

Question 23

1st line medication to help with hirsutism for PCOS is…

Answer 23

CHC - suppresses androgen (similar to helping with menstrual irregularities)

Question 24

2nd line options with hirsutism for PCOS is…

Answer 24

Antiandrogen - spironolactone, finasteride

Does require contraception

Question 25

Medications that can be used to help with acne for PCOS include...

Answer 25

1st line: CHC's - low androgen progestins Topical acne medications Consider spironolactone (antiandrogen)

Question 26

Metabolic abnormalities associated with PCOS are treated...

Answer 26

Similar to the normal population ## Footnote Including obesity, insulin resistance, dyslipidemia, OSA, depression/anxiety

Question 27

The 1st thing we should do to aid with fertility is...

Answer 27

Lifestyle modification + optimization of health ## Footnote Helps to restore ovulatory cycles as well as insulin resistance, CV risk, hirsutism

Question 28

Ovulation induction can be used to aid fertility - medications that can help with this include...

Answer 28

Letrozole Clomiphene citrate Metformin If these don't work... gonadotropins or IVF will be considered

Question 29

Letrozole MOA to help with anovulation is...

Answer 29

Aromatase suppression also decreases estrogen. Hypothalamus + pituitary gland increases FSH output, stimulating ovarian follicles to develop + mature, so ovulation can occur

Question 30

On average, letrozole will be tried for ____ cycles before pregnancy occurs

Answer 30

3

Question 31

Recall that letrozole AE's include...

Answer 31

Hypoestrogenic AE's - hot flashes, night sweats Nausea, fatigue *Multiple births are more likely*

Question 32

Letrozole and clomiphene are CI...

Answer 32

In pregnancy - do not want to be messing with estrogen hormone levels

Question 33

Letrozole is dosed...

Answer 33

For 5 days, usually on days 3-7 or 5-9 of the menstrual cycle

Question 33

Clomiphene is another drug used to induce ovulation. Its MOA is...

Answer 33

SERM - blocks estradiol receptors in hypothalamus, increasing FSH release = growth of ovarian follicles, and ovulation

Question 33

Clomiphene is dosed...

Answer 33

For 5 days, starting on day 5 of menstrual cycle (after spontaneous or progestin-induced menstruation) OR at anytime if amenorrheic and no recent bleeding has occurred

Question 34

Similar to letrozole, clomiphene AE's include...

Answer 34

Hot flashes/night sweats (low estrogen) Multiple gestations Abdominal pain Vision disturbances

Question 35

With letrozole and clomiphene, ovulation is expected ____ after the last dose

Answer 35

5-10 days

Question 36

Success with ovarian stimulation often declines with...

Answer 36

Age - IVF may be required

Question 37

Replenishment of ejaculate volume requires ____. The egg can survive for up to ____ after ovulation. Sperm can survive up to ____ in the female reproductive tract.

Answer 37

24-48 hours. 24 hours after ovulation. 5 days

Question 38

Metformin MOA for aiding fertility is not very well known, however it is usually used as an add-on to...

Answer 38

Clomiphene

Question 39

Luteal phase defect is caused by...

Answer 39

Insufficient progesterone levels - does not allow for preparation of endometrium for implantation, resulting in failure to implant

Question 40

This is the primary drug used for luteal phase support:

Answer 40

Progesterone ## Footnote Protocols for administration may depend on protocol for ovarian stimulation. Also recognize that optimal timing and dose is not entirely known

Question 41

Most common anatomical factor contributing to infertility is...

Answer 41

Blocked fallopian tubes - often relevant with endometriosis and pelvic inflammatory disease

Question 42

Many cases of male factor infertility are unknown. For other, infertility may be due to...

Answer 42

1. Obstructive/physical/genetic factors (trauma, surgery, STI) 2. Sexual intercourse factors (low libido, ED) 3. Endocrine factors (obesity, hypothalamic/pituitary dysfunction 4. Sperm factors

Question 43

Treatment options for male factor infertility may include...

Answer 43

Correcting modifiable risk factors Surgical repair Hormone therapy Sperm cryopreservation Assisted reproductive technologies

Question 44

Basal body temperature charting works because...

Answer 44

Progesterone is thermogenic - with ovulation, corpus luteam releases progesterone causing increase in temperature. Measure temp to find most fertile period

Question 45

Counselling tips on basal body temperature charting include...

Answer 45

Taking 1st measurement on 1st day of menstrual period Take upon awakening, before activity or getting out of bed Record information for 1-3 cycles to identify pattern ## Footnote CHART DAILY - indicate changes (intercourse, illness, changes in sleeping pattern)

Question 46

Ovulation prediction kits work by...

Answer 46

Detecting LH surge that precedes ovulation, by measuring its concentration in the urine

Question 47

We should provide the following information with ovulation prediction kits...

Answer 47

Chart menstrual cycle ahead of time so that ovulation may be predicted (most fertile period is 14 days before next menses) Begin testing 2-4 days before anticipated ovulation at the same time of day (usually AM)