exam 2 - infertility, menopause, pelvic floor disorders

infertility

inability to conceive after 1 year

primary infertility

never conceived

secondary infertility

conceived in the past

fecundity

probability of achieving a live birth in 1 menstrual cycle

fecundability

likelihood of conception per month of exposure

reasons for increased fertility visits

voluntary delay in childbearing

increase in reproductive tech

public awareness

majority of female factors for infertility are

ovulatory dysfunction and tubal/peritoneal factors

prevention of infertility

weight extremes

folic acid use - start when you stop OCP

smoking cessation

no heavy alcohol or drug use

no vaginal lubricant

who gets an infertility evaluation after 12 months of unprotected and frequent intercourse

women under 35 w/o risk factors for infertility

who gets an infertility evaluation after 6 months of unprotected and frequent intercourse

women 35-40

at risk of infertility

who gets an infertility evaluation upon presentation less than 6 months of unprotected and frequent sex

women over 40

female PE for infertility

rectovaginal exam- uterosacral ligament nodularity related to endometriosis

acanthosis nigrans - insulin resistance and PCOS

4 keys aspects assessed by labs and radiology of fertility

sperm

oocyte

transport (fallopian tubes)

implantation of ova

semen analysis to lab

within 1 hour

normal semen analysis

excludes male factors

abnormal semen analysis

repeat in 4+ weeks

refer to: endocrine, urology, genetics

normal sperm count

>20 million/mL

normal sperm motility

>50%

DNA assays for male partner

quantifies DNA damage to suggest poor fertility

relevance of DNA assays for male partner

for couples w/ unexplained fertility and repeated IVF failure

2 common causes evaluated for male infertility

retrograde ejaculation - sperm backflow

variocele

most common factor of infertility

ovulatory

how to investigate ovulatory factor of infertility

historical review

signs and symptoms of thyroid disease, hirsutism, obesity, galactorrhea

exercise, weight loss, hot flashes

2 pieces to ovulatory factor

follicular pool

ovarian reserve

ovarian reserve should be evaluated in

women >35 trying to conceive

evaluating ovarian reserve

check FSH and estradiol in days 2-4 of cycle

antimullerian hormone

antral follicle count

ways to confirm ovulation

serum progesterone

pelvic US

LH surge

basal body temp

cervical mucus

endometrial bx

why would you do an endometrial bx to eval fertility

for IVF - is the uterus adequate for pregnancy?

only way to absolutely document ovulation

pregnancy

tests for a patient who is over 35 with oligomenorrhea, amenorrhea, short or irregular cycles, or no ovulation

FSH

estradiol

Prolactin

TSH

tests for any patient with oligomenorrhea, amenorrhea, short or irregular cycles, or no ovulation

prolactin

FSH

pelvic factor includes

uterus, fallopian tubes, ovaries, adjacent pelvic structures

conditions impacting pelvic factor of infertility

PID

appendicitis

IUD

endometritis

septic abortion

endometriosis

ectopic pregnancy

leiomyomas

most common cause of pelvic factor infertility

adhesions from endometriosis

tubal occlusion from salpingitis

pelvic factor - pelvic exam

fixed uterus

pelvic factor testing

TVUS

hysterosalpingogram

laparoscopy

cervical factor - indications

H/O abnormal pap

post-coital bleeding

cryotherapy

conization

DES exposure

speculum exam for cervical factor

cervicitis

cervical stenosis

diagnosis of unexplained infertility implies these 4 things:

1. normal uterine cavity

2. b/l patent tubes

3. normal semen

4. evidence of ovulation

approach to unexplained fertility couple

empiric stepwise approach

treatment of retrograde ejaculation

alpha sympathomimetics

intrauterine insemination from urine centrifuge

alpha sympathomimetics

impact smooth muscle to make ejaculation antegrade

intrauterine insemination (IUI)

selection of highly motile sperm, concentrate sperm, remove seminal fluid

transcervical injection into uterus

intracytoplasmic sperm injection (ICSI)

sperm injected into oocyte directly

how is sperm retrieved in intracytoplasmic sperm injection (ICSI)

testes via microsurgical epididymal sperm aspiration (MESA)

OR

testicular sperm aspiration (TESA)

stepwise fertility approach

-clomiphene citrate

-induction of ovulation w/ gonadotropins

-IVF

induction of ovulation is very successful in

chronic anovulation

normal ovarian reserve

absence of endocrine abnormalities

clomiphene citrate treats...

ovulatory factor

clomiphene citrate is good for women

how does clomiphene citrate work

blocks feedback inhibition of estradiol on hypothalamus and pituitary to increase FSH

dosing of clomiphene citrate

PO x5d starting day 3-5 of cycle

50mg/day

100mg/day

side effects of clomiphene citrate

hot flashes

depression

bloating

visual changes

letrozole treats

ovulatory factor

how for letrozole work

inhibits estrogen synthesis = prevention of hypothalamus/pitutitary negative feedback

INCREASES FSH

dosing of letrozole

5.0mg 1 PO x5 days start on day 3-5 of cycle

benefit of letrozole over clomiphene citrate

less side effects

better success rates

metformin on infertility

anovulation can be associated with insulin resistance

-metformin could help with ovulation

-higher rates of live births and pregnancy

when to use gonadotropins and hCG

no response to clomiphene citrate or letrozole

gonadotropins and hCG are often used in conjugation with

IUI

human menopausal gonadotropin + hCG

Synthetic FSH and LH

Synthetic hCG triggers ovulation

use of gonadotropins require

close monitoring with US and estradiol levels

risk of gonadotropins

multiple gestation

Ovarian hyperstimulation syndrome (OHSS)

if pregnancy is not achieved with gonadotropins and hCG...

IVF

steps of IVF

ovarian stimulation

oocyte retrieval

fertilization with capacitated sperm and ICSI

embryo culture

embryo transfer

how to increase fecundity in endometriosis

resection or ablation - only for period immediately post-surgery

2 other ways to alleviate pelvic factors

reverse tubal ligation

surgically resect leiomyomas

how to treat absence of nurturing mucus - cervical factor

IUI

how to treat cervicitis and inflammatory changes - cervical factor

empiric doxycycline

how to treat congenial malformation/surgical changes - cervical factor

IUI

couples who have normal results of standard infertility workup

unexplained infertility

what do you try for patients with unexplained infertility

observation w/ timed intercourse

ovarian stimulation w/ IUI

-clomiphene w/ IUI for 4 cycles

-gonadotropin stimulation with IUI for 3 cycles

options for unexplained infertility

IVF

donor oocytes/sperm

adoption

complications of ovarian stimulation

ovarian hyperstimulation syndrome:

swollen and painful ovary

N/V

abdominal pain

SOB

complications of gonadotropins and IVF

multiple gestation

early stage perimenopause

cycle length changes

late stage perimenopause

amenorrhea for >60 days

average menopause age

50-51

premature menopause is

before 40

artificial menopause caused by

surgery or radiation

androgens

androstenedione, testosterone, DHEA, DHEAS

androgens in menopause

all decrease slightly

estrogens in menopause

ovarian production decreases

-can occur up to 1yr after last menstrual cycle

most estrone comes from adrenals

progesterone in menopause

decreases w/ loss of functional follicles

adrenals secrete a small amount

gonadotropins in menopause

LH and FSH rise

no feedback from ovarian hormones

repro tract menopause change

atrophy of vagina and uterus

cervix and ovaries get smaller

less mucus

urinary tract menopause change

atrophy of bladder and urethra

urinary frequency, incontinence, dysuria

recurrent UTIs

mammary glands menopause change

regression in breast size

vulvovaginal atrophy (VVA) sx

burning soreness

dyspareunia

thin watery discharge

minimal trauma = vaginal bleeding

urinary sx associated with vulvovaginal atrophy

increased UTIs, frequency, and incontinence

treating vulvovaginal atrophy

vaginal estrogens - local and daily

water-soluble lubricant

systemic estrogen, but topical preferred

vasomotor sx of menopause

hot flashes

hot flash

-sensation of pressure in head

-increases until flush occurs

-feeling of heat/burning on face, neck, upper chest, back

-averages 4min, can be up to 10

3 main treatments for vasomotor sx (hot flashes)

behavioral therapy

hormonal therapy

non-hormonal therapy

hormonal therapy for vasomotor sx of menopause

estrogen - principle medication (cannot give alone)

progestins - monotherapy for those who cant take estrogen

testosterone - only for libido

non-hormonal therapy for vasomotor sx of menopause

SSRIs and SNRIs (paxil for hot flashes)

Gabapentin

Vezoah (monitor liver function)

peak bone mass

25-30 yo

most common site of osteoperosis fracture

vertebral body

proximal femur

distal forearm/wrist

most predictive test of osteoperosis

DXA

-FRAX score to assess 10-yr probability of hip fx

most common sx of vaginal atrophy

dyspareunia

first line treatment of vaginal atrophy

vaginal lubricant and moisturizer