Infertility

Infertility definition

If

Contributing factors for infertility 4 (2 exercise, 2 history, 1 boomer)

Age (late teen-late 20 is peak reproduce, then decline by age 30)

History of pelvic infections/STD

Tobacco, alcohol, illicit drug use

Weight extremes

Excess exercises

5 Causes of Female infertility (1x4 disorders, 3 oofs of cat, alt name for early menopause?)

Ovulation disorders: PCOS, hyperprolactinemia, Thyroid Disorders, other hormonal disorders

Uterine/Cervical Abnormality

Fallopian tube damage/blockage

Endometriosis

Primary ovarian insufficiency=Early menopause

PCOS description

Imbalance of reproduction hormones, need at 2 of:

Irregular periods, hyperandrogenism, polycystic ovaries

Drug for PCOS+Infertility

Metformin (before), but now use Clomiphene

5 labs for female screening (2 women, 1 men, 2 both)

Ovarian Reserve Testing (Anti mullerian hormone, or Day 3 FSH+/- Estradiol)

Thyroid Levels

Prolactin Levels

DHEAS/Test Levels

Progesterone Levels (to hold onto that egg)

2 labs for males and 5 meds that inhibit spermatogenesis

Spermatogenesis=90 days

Semen analysis: Fluid volume, Sperm conc, motility, morphology

bad meds: Alcohol, anabolic/androgenic steroids, caffeine, CCBs, spironolactone

Follicular Phase description

1st part: Days 1-4 UP FSH

5-7: FSH down, Estradiol goes up in response

13-14: LH surge and small FSH spike

Ovulation Phase Description

is 24-36hours After LH surge of follicular phase, egg is fertile for 24 hours, sperm survives 48 hours

Day 10-17: MOST FERTILE PHASE (ovulation phase)

Of menstrual cycle phases

Luteal phase description

Up progesterone, estradiol (prepare for oocyte_

IF NOT FERTILIZED: Drop in hormones, endometrial tissue breaks down

End of menstrual phase

IUI Description and 3 parts

Sperm is washed and conc, then placed near top of uterus through catheter

Follicular stimulation with oral meds esp if only doing one cycle

Then trigger, and insemination if want, then endometrial support if need

IVF description and 4 parts

Fertilization occurs outside of body, have convention vs intracytoplasmic serum, and injection vs frozen Embryo transfer

Have follicular stim with injection ovulation suppression to stop premature ovulation

Then trigger, have egg retrieval/fertilization and then embryo transfer with support

IUI vs IVF

IUI has lower success rate but cheaper, good for PCOS and those who need donor sperm

IVF: Higher success, more meds, invasive and expensive, use if age or ovarian reserve is concern, fallopian tube damage/blockage, endometriosis

Letrozole (Femara) MOA, Dose (how long and range), ADE (better than clomiphene how?), and CIs

MOA: Reduce estrogen synthesis to increase FSH secretion and stimulate ovulation (Follicular stimulator)

Dose: 2.5-7.5mg orally QD for 5 days (cycle 3-7)

ADEs: hot flashes, fatigue, diarrhea, arthralgia, but pretty well tolerated (lower multiple gestation vs Clomiphene)

CIs: Pregnancy, premenopausal women not pursuing fertility treatment

Clomiphene (Clonid) Use, MOA, Dose (how much, when reduce, when start, higher bad why)

Used in IUI or timed intercourse, 1st line for anovulation/unexplained fertility

MOA: interfere with negative feedback of estradiol that normally suppress FSH/LH release (so stim FSH LH)

Dose: 50mg QD x 5 days (PO), star on 5th day, Lower for PCOS PATIENTS 25 MG/DAY, higher dose=higher chance of gestation oof

Clomiphene (Clonid) ADEs (1 BIG ONE REMEMBER), CIs (

ADEs: hot flashes (too much follicles), GI (NV), Vision changes, Ovarian hyperstimulation syndrome (Severe NVD, SoB, ab pain, Ovaries swell and become painful)

CIs: Liver disease, abnormal pus bleeding, ovarian cysts (not from PCOS, uncontrolled thyroid/adrenal dysfunction

Gonadotropins Use MOA and Dose (when start, and assess what)

Used in IVF cycles in combo, be used if refractory to clomiphene

Also used to increase sperm genesis, includes recombinant Follitropin, meno and urofollitropin

MOA: FSH/LH preparations used to promote Follicuogenesis, mature follic,e increase gonadal steroid production

Dose: SQ/IM INJECTION: 75-200 Units/day (MD choose based on FSH/LH levels)

START ON DAY 3 UNTIL OVULATION (~ 12 days)

assess follicle size regulalry (>18 mm)

Gonadotropin ADes (4), and CIs eh

ADE: headache, Gi: (N/V), Injection site reactions, OHSS/chance of multiple gestation (YIKES)

CIs: sex hormone dependent tumors, intracranial lesion (pit/Hypothalamus tumor), abnormal uterine bleeding, ovarian cysts not due to PCOS

Cetrorelix (cetrotide)/Ganirelix use, MOA

GnRH antagonists

Use in conjuction with stim meds to control ovarian hyperstim: Less OHSS compared to GnRH agonists

MOA: comp antag for PIT GnRH receptors, suppress LH production and surge

Cetrorelix (cetrotide)/ Ganirelix Dose (when?) and ADEs

SQ prefilled syringes, start 5-6 days after stimulation meds

ADE: Very few reported: headache injection site reaction, nausea

HCG use, MOA

Used with both IUI&IVF cycles, and timed intercourse (exogenousa nd recombinant products) (Novarel/Pregnyl and ovidrel)

MOA: high dose stimulates production of gonadal steroid hormones=> LH surge

Completes follicular maturation, induce ovulation, promote development of corpus luteum

HCG dose and ADEs

Dose: eh, but is usually 36 h after insemination/oocyte retrieval or

have intercourse 24-48 hours after

ADE: irritability, injection site, OHSS (OOf), headache

Progesterone use, MOA and formulations??

IUI sometimes, but mainly IVF (imp with IVF cause more use of meds, and esp if using leuprolide)

MOA: Prepare and maintain uterine lining

Formulation: avoid 1st pass hepatic metab: oil injections, suppositories, vaginal capsules vs inserts, gel

How to counsel for Infertility

Oral Success, rate, Cost, emotional burden, Risk, polypharmacy, pregnancy tests

Know about prophylaxis