OB- Infertility & PPD

What kind of infertility?

• Female partner has never been pregnany

• Couple unable to conceive after unprotected intercourse for atleast 1 year

Primary Infertility

What kind of infertility?

• Female partner has had atleast 1 prior conception

• Couple unable to conceive after unprotected intercourse for atleast 1 year

Secondary infertility

What is the probability that a singe cycle will result in pregnancy?

*20-25% per month but dec to 2-3% per month after 1 year of trying

Fecundability

When does fertility begin to decrease in a female?

Age 27, accelerates after age 35

What is a disease of the reproductive system that impairs the body’s ability to perform the basic function of reproduction & affects men and women equally?

Infertility

What is no sperm in ejaculate?

Azoospermia

What is low sperm count?

Oligospermia

What is low sperm motility?

Asthenospermia

What is a high percentage of abnormal forms of sperm?

Teratospermia

What is the MC female factor of infertility?

Ovulatory dysfunction → PCOS, CAH, streak ovaries, absence of ovaries w/ female phenotype & male karyotype, androgen insensitivity

When should infertility be evaluated if the female is > 35 years old?

After 6 months

What is the number 1 step in evaluation of male infertility?

Semen analysis

How should semen appear in a semen analysis?

1.5-5 mL, pH > 7.2, > 20 million sperm/mL, atleast 50% motility, 40% normal morphology

What is the workup for male infertility?

Semen analysis

PE → look for varicocele, hypospadias, cryptorchidism, testicular volume, penile length, extent of virilization

Hormonal → FSH, LH, testosterone, prolactin

What is the workup for female infertility?

Cycle day 3 FSH & LH for ovarian reserve (FSH > 10 → diminished)

Confirm ovulation w/ mid luteal (day 21) progesterone level > 5 (+ BBT & LH surge)

TSH & prolactin levels

US to r/o uterine or ovarian pathologies

HSG to evaluate uterus & tubal patency

Laparoscopy if pelvic pain, endometrioma, endometriosis or adhesions

What does a mid luteal (cycle day 21) progesterone level indicate?

Confirms ovulation

What does a cycle day 3 FSH level > 10 indicate?

Diminished ovarian reserve, predict poorer response to treatment, increased spontaneous abortion rate, & lower fecundity

When is donor sperm insemination used?

Azoospermia, IVF too expensive, single women, male carriers have heritable genetic disorder

What is ICF w/ intracystoplasmic sperm injection (ICSI)?

*used when total motile < 10 million or severe teratospermis < 4%

Sperm directly injected into cytoplasm of an egg outside uterus

When is intrauterine insemination (IUI) used?

Total motile sperm > 10 million/mL, adjunct to ovulation induction

When should urology be consulted for male infertility?

Azoospermia → extraction to evaluate for sperm in repro tract

Oligo or asthenospermia & varicocele → varicoelectomy

Hypogonadotropic hypogonadism → pulsatile GnRH or gonadotropins

Vasectomy reversal

What is the treatment for anovulation if due to PCOS?

Ovulation induction w / clomiphene citrate or gonadotropins (letrozole)

Metformin, ovarian drilling, aromatase inhibitors

What is the treatment for female infertility if due to hyperprolactinoma?

Bromocriptine or cabergoline

What is the treatment for female infertility if due to hypothalamic hypogonadism?

Pulsatile exogenous GnRH

What is the MC treatment modality for infertility d/t tubal disease?

IVF

Which uterine fibroids should be removed for infertility treatment?

Submucosal, intramural if large, subserosal if symptomatic

What is the treatment for infertility caused by endometriosis?

Mild → laparoscopic adhesion removal (inc spontaneous conception)

Severe → surgical or gonadotropins or IVF

what is the infertility treatment for premature ovarian failure?

HRT, donor egg, surrogate

What is the empirical treatment for unexplained infertility in women > 35?

Clomiphene citrate / letrozole + IUI w/ washed sperm; gonadotropin

What drug is a SERM that blocks estrogen receptors in the hypothalamus to increase FSH/LH production which induces ovulation?

Clomiphene citrate

What SEs are seen with clomiphene citrate (clomid)?

CRVO, photophobia, palinopsia, shimmering in peripheral field, irritability, breast tenderness, thickened cervical mucus, thinned endometrium

*take no more than 6 consecutive cycles → risk ovarian tumors

What drug is an aromatase inhibitor that prevents androgen conversion to estrogen via enzyme aromatase, has little/no effect on endometrial thickness and is now preferred over clomid?

Letrozole

What fertility drugs are DA agonists used in women with hyperprolactinemia to inhibit prolactin release at the level of the pituitary and is associated with causing orthostatic hypotension & HAs?

*d/c once pregnancy confirmed

Bromocriptine, cabergoline

What condition?

• large ovaries, often palpable

• transudate ascites - intense third spacing

• hemoconcentration & risk DVT/PE

• tx w/ paracentesis, anticoagulation

• MC cause by gonadotropins used to stimulate ovulation

Ovarian hyperstimulation syndrome (OHSS)

What assisted reproductive technology (ART)?

• Down regulation of HPO axis → controlled ovarian hyperstimulation w/ gonadotropins → trigger ovulation w/ hCG → retrieve oocytes → mix w/ sperm in Petri dish or directly inject sperm into egg → embryo matures in lab then transverse into uterus

• completed in embryology lab in strictly controlled environment

IVF w/ ET

What type of assisted reproductive technology (ART)?

• Controlled ovarian hyperstimulation → oocyte retrieval → oocytes mixed w sperm in test tube → mixture placed into fallopian tubes prior to fertilization via laparoscopy

GIFT

What type of ART?

• Controlled ovarian hyperstimulation → oocyte retrieval → oocytes mixed w sperm in test tube → fertilized oocytes transferred into fallopian tubes

ZIFT

When should a patient with postpartum blues seek evaluation for postpartum depression (PPD)?

Symptoms worsen or do not resolve w/in 2 weeks

What is a transient condition that is often mild & rapid mood swings that peak on the 5th PP day and resolve within 2 weeks?

Postpartum blues

What is the treatment for postpartum blues?

Conservative management, CBT, sleep, allow someone else to care for baby at night, low dose benzos for insomnia, avoid alcohol

What is the major risk factor for PPD?

Personal history of depression

*also after pregnancy loss, martial conflict, stressful life events, etc

What is the diagnosis for PPD?

Meet criteria for MDD in the DSM5 w/ “postpartum onset specifier” that arise w/in 4 wks PP (accepted as late as 12 mos PP)

The following symptoms are seen in what condition?

• changes in somatic functions (sleep, appetite, energy, etc)

• significant anxiety, panic attacks

• intense anger, feelings of guilt, inadequacy, overwhelmed

• obsessional thoughts about harming oneself or baby

• *occurs w/in 1 yr PP

Post partum depression

What is the first line medication for PPD?

SSRIs