You give a patient a drug for fertility that binds estrogen receptors on the hypothalamus and pituitary. What drug did you give?
Clomiphene citrate, a SERM. Inhibiting the negative feedback from estrogen increases FSH levels and promotes the follicular phase.
Most common side effect of clomiphene citrate
Hot flashes (20%), scotoma (bright flashes in vision = stop vision) and twins (8-10%).
You give a patient a drug for fertility that inhibits the conversion of androgens to estrogen. This drug is not FDA approved for infertility. What drug did you give?
Letrozole, an aromatase inhibitor. Note that it prevents estrogen negative feedback to the hypothalamus and pituitary, causing an increase in FSH secretions. Also note that it is not FDA approved.
You give a patient with PCOS a drug for fertility. She loses weight, drops BP and cholesterol levels after being on the drug for a while. What drug did you give?
You give a patient a drug for fertility that acts directly on the ovary to stimulate follicular development. What drug did you give? What are side effects?
Gonadotropins (FSH/LH combination). These rescue atretic follicles. Risk of twins is increased.
Indications of intrauterine insemination
Mild male factor (> 10 million sperm), ejaculatory dysfunction, clomid/letrozole, HIV+ partner.
Steps of IVF
Down-regulate HPO axis w/OCPs (decrease corpus luteum formation) -> GnRH agonist suppression of ovulation -> FSH/LH combination after menses -> Estradiol/progesterone monitoring -> trigger ovulation with hCG -> 34-36 hrs later egg retrieval -> 3-5 days later implantation of blastocyst
General recommendations for fertility
Normal BMI, no tobacco/alcohol/caffeine, intercours every other day leading up to ovulation.
Determining ovulatory status
Basal body temperature and midluteal serum progesterone tell you after the fact. LH in urine is best predictor of ovulation.
When to not use ovulation predictor kit
Clomid can give false positives
Patients who have inadequate central gonadotropin function that require gonadotropin injections because clomid is unsuccessful.
WHO Group 1: Hypogonadotropic hypogonadal anovulation
Patient who have no eggs left in their ovaries and classically need a donor oocyte IVF.
WHO Group 3: Hypergonadotropic anovulation
A patient presents with acne, hirsutism and oligomenorrhea less than 9 cycles per year. Labs show high levels of androgens and U/S of her ovary is shown below. What does she have and how do you treat her?
WHO Group 2: Eugonadotropic Euestrogenic Anovulation = Classic PCOS. 1st line drug is clomiphene citrate to try to get her to ovulate. If patient is refractory add metformin or letrozole to achieve ovulation. Finally you can do laparoscopic ovarian drilling (can cause adhesions), gonadotropin injections or IVF if other treatments fail.
1st line recommendation for PCOS
Weight loss (via diet, exercise or even bariatric surgery)
A patient presents with this hysterosalpingogram. How do you treat her to increase fertility?
Tubal anastamosis if previously ligated. If tubal factor infertility is due to PID outcome is poor.
Fertility treatment for the different types of fibroids
Pedunculated = no treatment. Intramural = myomectomy. Submucosal/Intracavitary = removal.
A woman presents with oligomenorrhea. She has a history of D&C. She wants to get pregnant but can’t, how do you treat her?
She has Asherman’s Syndrome. You can treat with hysteroscopic resection of adhesions.
Male factor infertility causes
Oligospermia or vasectomy
Criteria required to diagnose unexplained infertility
Evidence of ovulation, normal ovarian reserve, normal uterine cavity, patent fallopian tubes and normal semen analysis.
Treatment options for unexplained infertility
CC + IUI, injectable gonadotropins + IUI or IVF. Try for 3-6 months then do IVF if medications fail.