Infertility

Question 1

What is the definition of infertility?

Answer 1

• Inability of a couple to achieve a clinical pregnancy within 12 months of beginning regular unprotected sexual intercourse

Question 2

What is primary infertility?

Answer 2

No previous pregnancies

Question 3

What is secondary infertility?

Answer 3

A couple have previously had a child but now can not

Question 4

What is fecundability?

Answer 4

The percentage of women exposed to the risk of pregnancy for one menstrual cycle who will subsequently produce a live born infant (Normal 15-28%)

Question 5

At what age do fecundity rates begin to decrease?

Answer 5

• Small but noticeable decrease at age 31, more pronounced at age 36 and very steep at 40

Question 6

What are the main categories for the causes of infertility?

Answer 6

• Ovulation disorders (25%)
• Male factors (25%)
• Tubal factors (15%)

Different book says

• Female (65%)
• Male (20%)
• Other (15)

Question 7

In men who have had infection to the testis or epididymis or who have had reversed vasectomies what may you be more concerned about regarding fertility?

Answer 7

• Antisperm antibodies

Question 8

What is the chromosomal abnormality found in Turner syndrome?

Answer 8

• 45,XO

Question 9

What is the pathophysiology behind weight-related anovulation

a) low weight
b) high weight

Answer 9

a) A minimum percentage of body fat is required to maintain ovulatory cycles (typically 22%ish)
- weight reduction leads to disappearance of normal 24h secretory pattern of GnRH resulting in anovulation

b) Overweight - likely due to excess androgen from adipose tissue converting androgens.
- Interferes with normal feedback mechanism in pituitary

Question 10

What is luteinized unruptured follicle syndrome?

Answer 10

• occurs when the oocyte is retained following the luteinizing hormone surge
• No studies have been done longitudinally to show if this is longstanding or recurring or if affects fertility

Question 11

What are some symptoms that would make you concerned about hyperprolactinemia?

Answer 11

• Galactorrhea (10-15%)

- Bitemporal hemianopia (if pituitary adenoma)

Question 12

What are the gonadotrophins?

Answer 12

• Luteinizing hormone

- Follicle stimulating hormone

Question 13

What is the mechanism behind anovulation in hyperprolactinemia?

Answer 13

• High levels of prolactin inhibit the release of gonadotrophins (LH and FSH) which are required for ovulation to occur

Question 14

Name 3 methods of determining if ovulation is occuring in a female

Answer 14

1) History: over 90% of women with regular menstrual cycles will ovulate spontaneously
2) Urine LH kit: Urine test which can pick up the mid-cycle LH surge that leads to ovulation
3) Mid-luteal (7-10 days before next cycle) progesterone level: Progesterone is produced by corpus luteum. Therefore levels over 28

Question 15

Explain how basal body temperature can be used to test for ovulation? What temperature change are you expecting?

Answer 15

• After ovulation the corpus luteum produces progesterone
• Progesterone is pyrogenic and increases body temperature which can be monitored
• 0.5 degree Celsius change after ovulation and during luteal phase

Question 16

What is a progesterone challenge? What does it test?

Answer 16

• 5 days of oral progesterone, followed by withdrawal
• A bleed following shows that the patient is well estrogenized (estrogen causing endometrial growth) and progesterone inducing it to shed.

Question 17

How can you induce ovulation in patients with hyperprolactinemia? What is the mechanism?

Answer 17

• You can use a dopamine agonist (bromocriptime, carergoline)
• Dopamine inhibits the secretion of prolactin allowing for ovulation to occur

Question 18

How can you treat anovulation in patients with polycystic ovarian syndrome?

Answer 18

• First line pharmacologic treatment is with anti-estrogen therapy
• Decreased estrogen -> stops it’s negative feedback on hypothalamus -> higher FSH levels
• Weight loss should be acheived or attempted prior in younger women with ovarian reserve *
• Many will ovulate spontaneously following and increases live-birth rate

Question 19

How do you treat anovulation in estrogen-deficient women?

Answer 19

• Exogenous gonadotrophins (LH, FSH)
• Monitor follicle growth with U/S
• Exogenous hCG to induce ovulation mid cycle (replaces LH surge)
• Start w low dose to decrease change of multiple pregnancy

Question 20

What treatment options exist for those with tubal disease looking to become pregnant?

Answer 20

• Tubal surgery

- In vitro fertilization (used more often due to advances in technique)

Question 21

What is one of the major risks of pregnancy after tubal surgery?

Answer 21

• Higher incidence of ectopic tubal pregnancy

Question 22

What is azoospermia?

Answer 22

• Medical condition of a man where the semen contains no sperm

Question 23

Why do you test FSH in a man with azoospermia? What do the results tell you?

Answer 23

1) High FSH: FSH encourages speratogenesis in males, if this is not occurring it will continue to produce more
- This indicates non-obstructive azoospermia
2) Low FSH: Signifies an obstructive azoospermia from a block of the vas deferens or epididymis. Most common in those who have had vasectomy

Question 24

What is in-vitro fertilization?

Answer 24

• In vitro: performed in test tube, culture plate or elsewhere outside of a living organism
• In this context mixing of egg and sperm occurs outside of the body

Question 25

What is intracytoplasmic sperm injection? What advantage does it have over IVF?

Answer 25

- Sperm is injected directly into the oocyte. - In IVF the two are just mixed - Advantage in being able to treat most male factor infertility problems

Question 26

When do you start investigating someone for infertility? What can change this?

Answer 26

1) Age under 35: 1 year 2) Age 35+: 6 months 3) Symptoms suggestive of underlying cause: right away (ex: signs of PCOS, Endometriosis, etc..) you would investigate for suspected cause