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Repro / GU > SM_204b: Female Fertility > Flashcards

SM_204b: Female Fertility Flashcards

1
Q

Infertility is ____

A

Infertility is one year of unprotected intercourse without conception

  • Primary: no prior pregnancies
  • Secondary: at least one prior conception
  • Evaluate women > 35 years after 6 months of attempting conception
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2
Q

Cycle fecundability is when ____

A

Cycle fecundability is when a single menstrual cycle results in pregnancy

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3
Q

Cycle fecundity is when ____

A

Cycle fecundity is when a single menstrual cycle results in a life birth

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4
Q

Describe the scope of female infertility

A

Female infertility

  • 15% of all couples require evaluation / treatment and 50% of women over 40
  • Decline in US birth and fertility rates
  • Fertility peaks at 20-24 and decreases a little until 30-32 and then declines progressively
  • Miscarriage rates increase with maternal age
  • Aneuploidy rates increase with increasing maternal age
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5
Q

Describe requirements of a successful pregnancy

A

Successful pregnancy requires

  • Oocytes
  • Ovulation
  • Oocyte transport
  • Sperm of adequate number and quality
  • Fertilization
  • Transport of fertilized ovum into uterus
  • Implantation
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6
Q

Describe hypothalamic-pituitary-ovarian-axis

A

Hypothalamic-pituitary-ovarian-axis

  1. Hypothalamus releases GnRH
  2. Anterior pituitary releases FH and LH
  3. FSH stimulates ovarian follicles to grow and mature and LH stimulates ovulation and corpus luteum formation
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7
Q

Describe menstrual cycle

A

Menstrual cycle

  1. Hypothalamus secretes GnRH
  2. Anterior pituitary secretes FSH
  3. Ovary secretes estrogen
  4. Feedback to cause anterior pituitary to secrete LH
  5. FSH stimulates ovary to release progesterone
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8
Q

Describe differential diagnosis of infertility

A

Differential diagnosis of infertility

  • Anatomic disorders
  • Ovulatory dysfunction
  • Oocyte factors / decreased ovarian reserve
  • Male factors
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9
Q

Anatomic abnormalities of the uterine cavity can be ____ or ____

A

Anatomic abnormalities of the uterine cavity can be congenital or acquired

  • Congenital: mullerian duct abnormalities
  • Acquired: fibroids, polyps, Asherman’s syndrome (iatrogenic intrauterine adhesions)
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10
Q

Anatomic abnormalities of the fallopian tubes are usually related to ____ or ____

A

Anatomic abnormalities of the fallopian tubes are usually related to prior ascending infection or pelvic surgery

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11
Q

Ovulatory dysfunction is most commonly caused by ____ or ____

A

Ovulatory dysfunction is most commonly caused by polycystic ovary syndrome or hypothalamic amenorrhea

  • Less common: hyperprolactinemia, thyroid disease, primary ovarian insufficiency
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12
Q

Describe polycystic ovary syndrome

A

Polycystic ovary syndrome

  • Most common endocrinopathy of women
  • Oligo or amenorrhea
  • Hyperandrogenemia
  • Polycystic ovaries on ultrasound
  • Associated with insulin resistance and obesity
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13
Q

Describe hypothalamic amenorrhea

A

Hypothalamic amenorrhea

  • Usually a functional disorder
  • Associated with excessive exercise, inadequate nutrition, or stress
  • Common pathway is disruption of pulsatile GnRH secretion from hypothalamus
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14
Q

Maximum number of eggs (ovarian reserve) is at _____ and _____ over time

A

Maximum number of eggs (ovarian reserve) is at birth and decreases over time

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15
Q

Maternal age ____ significantly affect the uterus

A

Maternal age does NOT significantly affect the uterus

  • No adverse impact on endomtrial development or function
  • Overall live birth rate per transfer in donor egg IVF cycles 55%: does not vary with recipient age
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16
Q
A
17
Q

Male factors contributing to infertility are ____, ____, ____, and ____

A

Male factors contributing to infertility are hypothalamic-pituitary disorders, primary gonadal disorders, disorders of sperm transport, and idiopathic

  • Idiopathic are most common
18
Q

Unexplained infertility is a diagnosis of ____

A

Unexplained infertility is a diagnosis of exclusion

  • Implies bilateral tubal patency and normal uterine cavity, ovulatory function, and semen quality
  • Potential explanations: poor oocyte quality, another specific cause that cannot be identified with existing tests (abnormalities of sperm function, fertilization, implantation, or embryo development)
19
Q

Describe evaluation of female infertility

A

Female infertility evaluation

  • History and physical
  • Assess uterine cavity
  • Document tubal patency
  • Confirm ovulation
  • Assess ovarian reserve
  • Semen analysis
20
Q

Describe taking a female reproductive history

A

Female reproductive history

  • Obstetrical history
  • Duration of infertility
  • Menstrual cycle length
  • Dysmenorrhea
  • Moliminal symptoms
  • Coital frequency, sexual dysfunction
  • Gynecologic history: paps, STI
  • Meds, allergies
  • Occupation
  • Medical history: obesity
  • Surgical history
  • Social history: tobacco use (ever and current)
  • Fam Hx of birth defects, genetic diseases, cancers
  • Family reproductive history: # siblings, SAB / stillbirths, sibling reproductive history
  • ROS: symptoms of thyroid dysfunction, hyperprolactinemia, pelvic / abdo,minal pain, dyspareunia, dyschezia, hirsutism, weight gain / loss
21
Q

Describe physical exam for female infertility

A

Female infertility physical exam

  • Height, weight, BMI, blood pressure
  • Thyroid (enlargement, nodules, tenderness)
  • Hirsutism
  • Breast mass / galactorrhea
  • Pelvic tenderness / mass
  • RV nodularity
22
Q

Assessment of uterine cavity involves ____, ____, ____, and ____

A

Assessment of uterine cavity involves hysteroscopy, transvaginal ultrasound, HSG, and sonohysterogram

23
Q

Assessment of tubal patency involves ____ or ____

A

Assessment of tubal patency involves hysterosalpinogram or saline infused sonohistogram

  • Hysterosalpinogram: oil or water based dye injected through cervix and pictures of uterus and fallopian tubes are taken under fluoroscopy
  • Saline infused sonohistogram: ability to demonstrate tubal patency as high as 80% but inferior to hysterosalpinogram when evaluated for tubal factor infertility
  • Historical gold standard: laparoscopy with chromoperturbation
24
Q

Describe assessment of ovulation

A

Assessment of ovulation

  • History consistent with ovulation: regular cycles and moliminal symptoms before menses
  • Basal body temperatures charting
  • Serum progesterone on day 21 of a 28 day cycle
  • Home ovulation predictor kits

Various methods acceptable

25
Q

Ovarian reserve is ____

A

Ovarian reserve is quantity of good quality oocytes

  • Decrease in fertility in order women is related to decreasing quantity of good quality oocytes
  • Most common tests performed: day 3 FSH (FSH > 10-15 on day 2 or 3 is abnormal), anti-mullerian hormone, antral follicle count
26
Q

Anti-mullerian hormone is from ____

A

Anti-mullerian hormone is from granulosa cells of the preantral and small antral follicles

  • # of small antral follicles correlates with size of residual follicular pool
  • Anti-mullerian hormone levels decrease as menopause approaches
27
Q

Antral follicle count is an ___ measure of ovarian reserve

A

Antral follicle count is an indirect measure of ovarian reserve

  • Transvaginal ultrasound measurement of follicles measuring 2-10 mm in both ovaries
28
Q

Describe evaluation of male factors contributing to infertility

A

Male factors contributing to infertility evaluation

  • Previous paternity
  • Trauma, surgeries, infections, toxins
  • Seuxal function
  • Habits: tobacco, marijuana, wet heat, underwear
  • Fam Hx: genetic disorders, birth defects, infertility
  • Semen analysis: seminal volume > 1.5 mL, sperm concentration > 15 million/mL, motility > 40%, morphology >4% using strict criteria
29
Q

Describe treatment for anatomical problems contributing to female infertility

A

Anatomical problems contributing to female infertility treatment

  • Uterus: surgery, gestational carrier
  • Fallopian tubes: surgery, IVF
30
Q

Treatment for ovulatory dysfunction involves ____ or ____

A

Treatment of ovulatory dysfunction involves treating the underlying endocrinopathy and inducing ovulation with medications

  • Ovulation induced with medications: clomiphene citrate, letrozole, injectable gonadotropins
31
Q

Clomiphene citrate is a ____ used to treat ____

A

Clomiphene citrate is a selective estrogen receptor modulator used to treat ovulatory dysfunction

32
Q

Letrozole is a ____ used to treat ____

A

Letrozole is an oral non-steroidal aromatase inhibitor used to treat ovulatory dysfunction

  • First line for PCOS
  • Slightly higher pregnancy rates than clomiphene
33
Q

Injectable gonadotropins are ____ effective

A

Injectable gonadotropins are highly effective

  • Purified urinary FSH, LH
  • Recombinant FSH, LH, hCG
  • Costly
  • Increased risk of multiple pregnancy and ovarian hyperstimulation syndrome
34
Q

There is ____ therapy for decreased ovarian reserve or age related infertility

A

There is no good therapy for decreased ovarian reserve or age related infertility

  • Consider oocyte donation
35
Q

Treatment of male factors contributing to infertility is ____, ____, or ____

A

Treatment of male factors contributing to infertility is

  • Intrauterine insemination for modest abnormalities
  • IVF with intracytoplasmic sperm injection
  • Donor insemination
36
Q

Describe treatment for unexplained female infertility

A

Unexplained female infertility treatment

  • Approximate cycle fecundability 2-4% without treatment
  • Evidence-based treatments: clomiphene + intrauterine insemination, IVF
37
Q

Success of IVF depends on ____

A

Success of IVF depends on patient selection

  • Age is very predictive of success
  • IVF more successful if female partner has adequate ovarian reserve (even in setting of male factor)
  • Antral follicle count (antral follicles 2-10 mm) are a good predictor of response
  • Anti-mullerian hormone reduced with increasing age and is another useful marker of ovarian reserve

Repro / GU (46 decks)

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