Infertility

Question 1

definition of infertility by insurance companies

Answer 1

inability to achieve pregnancy after one year of unprotected intercourse

Question 2

infertility statistics

Answer 2

• 8 mil couples in the US affected
• 1 in 8
• 12% of reproductive age pop

Question 3

what causes infertility? in a general sense

Answer 3

-disruption of any of the developmental steps between gametogenesis and implantation

Question 4

ratio of male to female infertility problems

Answer 4

1:1

Question 5

causes of ovulation defects 5

Answer 5

• changes in GnRH from the hypothalamus
• reduced FSH and LH from the anterior pituitary
• stress and extreme athletic activity
• eating disorders
• thyroid and adrenal hormonal imblances

Question 6

Polysistic Ovary Syndrome

• symptoms
• problems
• statistics

Answer 6

• excessive growth of face and body hair due to increased androgen hormones
• irregular ovulation and involution
• increased LH relative to FSH
• most common hormonal disturbance in women of child bearing age (1 in 10 in this age group)

Question 7

abnormalities of the female reproductive tract

Answer 7

• anatomical abnormalities can interfere with transport of the gametes or embryos or blastocyst implantation
• common examples include: endometriosis, chronic pelvic inflammatory disease, tubal obstruction, uterine abnormalities, usually fibroids

Question 8

types of uterine abnormalities

Answer 8

• uterine fibroids (leiomyomas)
• congenital uterine developmental anomalies (mayer-rokitansky-kutser-hauser syndrome)
• excessive scar tissue (ashermans syndrome)
• excessive scar tissue from STI’s

Question 9

most male infertility causes

Answer 9

• azoospermia: no sperm cells

- oligospermia: few sperm cells

Question 10

causes of abnormally low sperm number and low sperm function

Answer 10

• hormonal abnormalities (HPT axis)

- abnormally high testis temperature caused by varicocele in the scrotum (dilated internal spermatic veins)

Question 11

Aging and infertility in women

Answer 11

• advanced age is the leading risk for infertility in women in the US (over 35)
• by age 40, over half of the ovulated oocytes are aneuploid and unable to support normal embryonic development
• in some women, these losses occur earlier and cause premature ovarian failure (menopause before age 40)

Question 12

aging and infertility in men

Answer 12

-recent data suggests that men over 50 are more likely to have children with autism and certain other conditions

Question 13

success rate of IVf is

Answer 13

similair to normal fertile population until mid 30’s

Question 14

unexplained infertility

Answer 14

-approximately one third of couples go through infertility treatment and are diagnosed with this

Question 15

first step in treating/diagnosing infertility

Answer 15

-determining whether it is explained or unexplained

Question 16

when do you do surgery?

Answer 16

• endodetriosis
• ashermann’s
• fibroids
• fallopian tube defects
• varicoceles in males

Question 17

when do you prescribe FSH?

Answer 17

-if its PCOS

Question 18

if the sperm are immotile, what do you do?

Answer 18

IVF using ICSI

Question 19

if the couple has no trouble getting pregnant but the woman has miscarriages, what do you do?

Answer 19

-prescribe progesterone

Question 20

When do you prescribe GnRH therapy?

Answer 20

-if a defect in GnRH production is found

Question 21

-if the woman has gone throuhg menopause, what do you do?

Answer 21

-donor egg IVF and adoption

Question 22

if the infertility is unexplained…

Answer 22

• consider the age of the women first
• if she is young, you would ideally start with clomiphene treatment, probably with IUI, and go on from there to add in more complex, expensive, and invasive treatments if it does not work
• if she is over 35 then going straight to IVF would be the best choice as the fertility of your patient will rapidly decline with time

Question 23

fertility drugs

Answer 23

• colmiphene citrate
• human menopausal gonadotropins (FSH and LH)
• FSH
• GnRH
• hCG (LH mimetic)

Question 24

clomiphene citrate

Answer 24

• inexpensive, orally administered
• blocks estrogen receptors in the hypothalamus
• used to regulate ovulation or induce ovulation in women who are anovulatory

Question 25

human menopausal gonadotropins

Answer 25

- given by daily injection and contains LH and FSH - requires monitoring of follicle size by ultrasound and blood estrogen levels - mimis LH surge - FSH and LH stimulate the ovaries to produce multiple dominant follicles in one cycle - used for anovulatory women who have have not had success with clomiphene citrate - used for women with amenorrhea who do not produce enough FSH and LH

Question 26

FSH

Answer 26

administered by subcutaneous injection | -used for PCOS patients (high LH, low FSH)

Question 27

GnRH

Answer 27

- can be administered at 90 minute intervals by a special drug delivery pump system - used for patients that are anovulatory because of abnormalities in both FSH and LH

Question 28

hCG

Answer 28

- administered by subcutaneous injection at the end of ovulation induction treatment - monitoring with US and serum estrogen levels are used - hCG mimics LH - used to trigger multiple ovulations

Question 29

intrauterine insemination (IUI)

Answer 29

- used for couples with unexplained infertility, minimal male infertility factors, and women with cervical mucus abnormalities - usually done in conjunction with ovulatory induction, in which case monitoring is essential - sperm are first washed to removed surface glycoproteins and seminal proteins - this mimics capacitation

Question 30

-IVF overview

Answer 30

- ovulation induction using gonadotropins is done to produce multiple eggs - mature eggs are removed from the ovary and fertilized in vitro by incubation with sperm - fertilization and early embryonic cleavages are observed in the lab for 2-3 days using a microscope - embryos that appear healthy with 8 blastomeres are placed into the uterus, unless PGD has been performed, in which case a 5-day embryo (blastocyst) will be implanted

Question 31

fertilization and embryo culture

Answer 31

- after washing sperm to mimic capacitation, sperm are mixed with oocyte and incubated - embryologist looks for fertilized oocyte that have two pronuclei, indicating that normal fertilization has occurred - 2-3 days after mixing sperm and oocyte, the embryos are examined and assessed for the number of blastomeres present (hopefully 8) and overall embryo symmetry and morphology

Question 32

ICSI

Answer 32

intra cytoplasmic sperm injection

Question 33

IVF follow up

Answer 33

- smallest number of embryos are transferred to avoid multiple gestations - if the women is under 35, only one or two high quality embryos are transferred - if the women is over 40 and has a history of failed IVF cycles, up to 4-5 high quality embryos are transferred - extra embryos are cryopresevered and saved for future IVF cycles for the same couple - these are the source of major ethical/social/political controversy surrounding stem cell research

Question 34

key points of IVF

Answer 34

- invasive - expensive - produces many more embryos than are used, kept frozen - ICSI gives highest take-home baby rate but is more expensive and by-passes important steps in fertilization - ICSI is not the most commonly performed IVF procedure in most US clinics

Question 35

what comes after normal IVF

Answer 35

- IVF with donor eggs | - adoption

Question 36

problems/risk with infertility treatments

Answer 36

- multiple births, this increases nearly all medical risks for pregnancy an abnormal fetal development, particularly when delivery is premature - reduction of multiple pregnancies created ethical issues - limited access due to high cost (limited to upper middle class couples) - unknown medical risks, especially for ICSI: too early to have much data, some data shows greatly increased risk of type 2 diabetes