9:Infertility

definition of infertility:

<_ years: evaluate after _ months of regular, unprotected intercourse

>/=_ years: evaluate after _ months

>/= _ years: begin evaluation _

35; 12

35; 6

40; immediately

do not wait if infertility is suspected because of:

• _ dysfunction (irregular or absent menses)

• known or suspected _ disease or prior _

• known or suspected _

• known or suspected _ factor infertility

• _ dysfunction

ovulatory

tubal/PID

endometriosis

male

sexual

successful conception requires all of the following:

• _- release of mature oocyte

• normal sperm _ and _

• _ fallopian tubes- fertilization occurs here

• a _ endometrium - supports implantation

ovulation

production and transport

patent

receptive

the _ axis coordinates ovulation

• _ stimulates release of FSH and LH

• _ promotes follicular development

• _ surge triggers ovulation

GnRH

FSH

LH

infertility occurs when one or more steps in _ fail

reproduction

what are common causes of problems with ovulation?

• _

• irregular _

anovulation

irregular ovulation

what are common causes of sperm problems?

• low _

• poor _

• abnormal _

count

motility

morphology

common causes of problems with the fallopian tubes?

• _

• _

• prior _

obstruction

adhesions

PID

common causes of problems with uterus?

congenital or acquired _ abnormalities

structural

common causes of problems with hormonal regulation?

• _ disease

• _

• diminished _ reserve

thyroid

hyperprolactinemia

ovarian

the first step in evaluation of ovulatory function is asking the key question of:

is the patient _?

ovulating

clinical clues that ovulation is occuring:

• regular _ cycles (_-_ days)

• predictable cyclic _ (breast tenderness, mittelschmerz, premenstrual symptoms)

menstrual ; 21-35

symptoms

if ovulation is uncertain

• _ _ approximately _ week before the expected menses

• home _ ovulation predictor kit may help identify the surge

serum progesterone; 1 week

LH

common causes of ovulatory dysfunction:

• _ _ _ (most common cause of chronic anovulation)

• _ _ _ (stress, significant weight loss, excessive exercise)

• _

• _ disorders

polycystic ovarian syndrome

functional hypothalamic amenorrhea

hyperprolactinemia

thyroid

irregular or absent menses should always prompt evaluation for _ dysfunction

ovulatory

in regards to hormonal evaluation, initial laboratory evaluation may include:

• _-_ _ _ → confirms recent ovulation

• _ → evaluates thyroid dysfunction

• _ → screens for hyperprolactinemia

• _-_ _ → estimates ovarian reserve (estimates ovarian reserve but does not predict natural fertility or guarantee response to treatment)

• _ ± _ (day2-4) → assess ovarian reserve and ovarian function

• _ → limited role; may help characterize selected endocrine disorders (PCOS)

mid-luteal serum progesterone

TSH

prolactin

Anti-Mullerian hormone

FSH ± estradiol

LH

purposes of testing different hormones:

• confirm whether _ is occurring

• identify _ causes of infertility

• estimate ovarian _ to guide counseling and referral

ovulation

endocrine

reserve

what does ovarian reserve mean?

• estimate of the remaining _ pool ( _ quantity)

• does it measure the egg quality or guarantee fertility?

follicle, egg

NO

common markers of ovarian reserve:

• _-_ hormone → reflects the number of _ follicles

• _-_ hormone (day_-_)→ elevated levels suggest _ reserve

anti-mullerian hormone; remaining

Follicle-stimulating (day 2-4); diminished

ovarian reserve declines with _, but _ remains the strongest predictor of fertility

age

_ factor infertility should be evaluated early

male

initial evaluation of male factor infertility:

• _ analysis (first line test)

• focused _ and _ exam

semen

history/physical

a semen analysis assesses:

• sperm _ (count)

• _ (ability to swim)

• _ (normal shape)

concentration

motility

morphology

male factors contribute to approximately _-_% of infertility cases and are involved in about _-_ of infertile couples. evaluate both partners _.

30-40%

one-half

simultaneously

common abnormalities of semen analysis:

• low sperm _ → decreased sperm production or obstruction

• reduced _ → impaired ability to reach the oocyte

• abnormal _ → may reduce fertilization potential

concentration

motility

morphology

a _ abnormal semen analysis should be confirmed with _ testing before making a diagnosis

single

repeat

common causes of tubal factor infertility:

• _ _ _→ tubal scarring and adhesions

• prior pelvic or tubal _→ postoperative adhesions

• _→ distortion of pelvic anatomy and tubal function

pelvic inflammatory disease

surgery

endometriosis

clinical consequence of tubal factor infertility:

blocked or damaged _ _ prevent sperm and oocyte from mmeting, preventing _

fallopian tubes

fertilization

a history of pelvic inflammatory disease, ectopic pregnancy, or tubal surgery should immediately raise suspicion for _ _ _

tubal factor infertility

a _ is used to evaluate fallopian tube patency .

hysterosalpingography (HSG)

a hysterosalpingography assesses the _ cavity for _ abnormalities (septum, adhesions, polyps, submucosal fibroids)

uterine/structural

how does Hysterosalpingography work?

• _ _-_ performed after contrast is injected through the cervix

• contrast should spill freely from both fallopian tubes if they are _

fluoroscopic x-ray

patent

you should avoid performing hysterosalpingography if:

• _ is possible

• active pelvic _

• active uterine _

pregancy

infection

bleeding

_ is the first line test for suspected tubal infertility

HSG

unexplained fertility is defined as:

• regular _

• normal _ analysis

• _ fallopian tubes

• no significant _ abnormality

no _ cause despite a standard infertility evaluation

ovulation

semen

patent

uterine

identifiable

initial management of infertility is directed at the _ cause

• _ dysfunction→ induce _

  • _ is the first-line therapy for most patients with PCOS; clomiphene citrate remains an alternative

• _ factor infertility → repeat abnormal _ analysis, address _ causes, consider _ referral

• _ factor infertility → refer to _ _; assisted reproductive technologies (often _) may be required depending on severity

• _ infertility → discuss expectant management versus referral for fertility based on age, duration of infertility, and patient preferences

ovulatory; ovulation

letrozole

male; semen;reversible;urology

tubal; reproductive endocrinology;IVF

unexplained

clinical pearls for infertility:

• treat _ causes whenever possible

• DO NOT delay _ when advancing maternal age or diminished ovarian reserve reduces the likelihood of spontaneous conception

reversible

referral

when to refer:

• refer to a _ _ if:

  • age >/= _ years and pregnancy has not occurred after _ months of regular, unprotected intercourse

  • age >_ years or markedly diminished ovarian _

  • _ disease, severe _, or significant _ factor infertility

  • persistent _ despite appropriate initial evaluation and management

  • patient _ or is likely to benefit from _ _ _ (ART)

reproductive endocrinologist

35; 6

40; reserve

tubal disease, severe endometriosis, male factor infertility

infertility

desires; assisted reproductive technologies

evaluate infertility after:

• _ months of regular, unprotected intercourse (< _years)

• _ months (>/= _ years)

• _ evaluation if >_ years or significant risk factors are present

• evaluate _ partners from the beginning

12; 35

6; 35

immediate; 40

both

when evaluating infertility, start with the fundamentals:

• confirm _

• _ analysis

• assess _ patency

• use laboratory testing to identify _ causes when indicated

• management is directed at the _ cause, early referral when appropriate

ovulation

semen

tubal

endocrine

underlying