Infertility

Infertility is diagnosed after how many months of unprotected intercourse?

12 months

How often should intercourse occur to optimize conception?

Every 2-3 days

When should infertility be evaluated earlier?

Women ≥35 years or with risk factors

Do male and female factors contribute equally to infertility?

Yes

What is primary infertility?

No prior pregnancy achieved

What is secondary infertility?

At least one prior pregnancy achieved

What happens to fertility with age?

Decreases due to ovarian aging, hormonal changes, and gynecologic disease (endometriosis, PCOS)

What is the ovarian reserve?

Number of follicles remaining in ovaries

How many eggs are females born with?

1-2 million

What lab marker assesses ovarian reserve?

Anti-Mullerian hormone (AMH)

What Day 3 FSH level suggests decreased fertility?

>15

What BMI in females decreases fertility and increases risk of miscarriage?

>29

What BMI in males affects sperm motility?

>24

What BMI in females is associated with irregular cycles and decreases chance of fertility?

<19

Which medications cause infertility in women?

- NSAIDs (decrease ovulation)

- Chemotherapy

- Thyroid Replacement

- Antidepressants

- Asthma medications

Which medications cause infertility in men?

- Beta blockers

- Psychotropics

- Chemotherapy

- Cimetidine & Sulfasalazine (may decrease sperm quality)

What should be initially evaluated in infertility?

Both partners concurrently

What lifestyle factors should be assessed?

Weight, stress, smoking, illicit drugs, caffeine, STI management, alcohol

What occupational hazards increase chances of infertility?

Long shift hours, Antineoplastics, Nitrous oxide (anesthesia), Solvents, High heat, X-ray/ high electromagnetic fields/vibrations, Pesticides, Solvents

How long does an egg survive?

~24 hours

How long can sperm survive?

Up to 7 days

What are the signs of ovulation?

- Increase 0.5 to 1 degree basal body temp

- LH surge (can be measured with home test)

- Cervical mucus changes (clearer, thinner, stretchy)

- Breast tenderness

- Abdominal bloating

- Unilateral abdominal pain or ache

What are common causes of ovulatory dysfunction?

PCOS, thyroid disease, hyperprolactinemia, tubal disease, uterine abnormalities, age-related decline in ovarian reserve

What WHO class includes 85% of ovulation disorders?

Group II (hypothalamic-pituitary dysfunction caused by decreased gonadotropins but normal estrogen)

How is male infertility assessed?

Semen analysis

How long should abstinence occur before semen analysis?

3-5 days

What is the sperm count?

>20 million/mL

What causes infertility in PCOS?

Insulin resistance leading to increased androgens and disrupted LH/FSH

What are key features of PCOS?

Androgen excess, small ovarian cysts, oligoovulation/anovulation, insulin resistance

What is first-line treatment for ovulatory dysfunction in PCOS?

- Letrozole (preferred over Clomiphene or Metformin)

- Clomiphene

- Metformin

What is the MOA of Letrozole?

Aromatase inhibitor that decreases estrogen

What is the dosing for ovulation induction with Letrozole?

2.5-5 mg daily for 5 days

What are the common side effects of Letrozole?

- Flushing

- Muscle pain

- Nausea

- Headache

- Decrease estrogen levels

- Vaginal dryness

What is the MOA of Clomiphene?

Blocks estrogen feedback leading to increased FSH and LH and enhances the normal follicular maturation process and ovulation (does not stimulate the ovaries directly)

How many ovulatory cycles should Clomiphene be used?

Maximum of 6 cycles

What is the associated risk if Clomiphene used >12 months?

Ovarian cancer

What are the side effects for Clomiphene?

- Hot Flashes (10%)

- Abdominal/ pelvic discomfort

- Ovarian enlargement

- Headaches 1%

- Nausea/ Vomiting (2%)

- Mood swings

- Multiple births

What are the dose-related side effects of Clomiphene?

Visual disturbances

What are the contraindications for Clomiphene?

- Liver disease

- Abnormal uterine bleeding

- Ovarian cysts not caused by PCOS

- Uncontrolled thyroid disorder

- Adrenal dysfunction

- Organic intracranial lesion (rare)

What is Metformin used for in infertility?

Insulin sensitizer especially in PCOS

What is the seoncd line treatment for PCOS?

Gonadotrophins

What is the MOA of Gonadotropins?

Acts via GnRH receptors within the anterior pituitary stimulating synthesis and secretion of LH and FSH

What are the 2 Gonadotrophins medications used to treat PCOS?

Menotropins (hMG, Menopur, Repronex) and Urofollitropin (Bravelle)

How are Gonadotropins administered?

Subcutaneous or intramuscular

What are the major risk of gonadotropins?

Ovarian hyperstimulation syndrome (OHSS)

What are the complications with ovarian stimulation?

OHSS, multiple pregnancy, ovarian cancer

What are risk factors for OHSS?

PCOS, age <30, high estrogen, multiple follicles, lean physique, HCG use, > 20 oocytes retrieved, multiple pregnancy

How is OHSS treated?

Supportive care, IV fluids, monitor renal function, thromboprophylaxis, drainage of third space accumulation

What is the first-line treatment for hyperprolactinemia?

Dopamine agonists

What are the 2 main dopamine agonists?

Bromocriptine and Cabergoline

What aer the side effects for Bromocriptine and Cabergoline?

Nausea and vomiting

What are the steps of IVF?

1. Pituitary down regulation (prevent natural ovulation cycle)

2. Ovarian stimulation (control development of several follicles)

3. Egg retrieval followed by semen collection or sperm recovery

4. In vitro fertilization

5. Transfer of embryo to uterus

6. Luteal support to help implantation

What are the maternal risks of IVF?

- Hyperemesis gravidarum

- Gestational diabetes

- Pre-eclampsia

- Preterm labor

- Cesarean delivery

- Postpartum hemorrhage

What are the pregnancy risks associated with IVF?

- Intrauterine growth restriction

- Preterm delivery

- Increased risk of perinatal and infant morbidity and mortality

- Higher risk for congenital anomalies in identical twins