B6 CM repro Exam 5 (THE END)

primary infertility

•12 months of unprotected intercourse without successful pregnancy in women less than 35 years old

•6 months if over age 35

•Or need for 3rd party donor gametes

secondary infertility

infertility in woman who has given birth to a child

Fecundability

The probability of achieving pregnancy in one menstrual cycle

fecundity

the probability of achieving a live birth in one menstrual cycle

pre-testicular causes, testicular causes, post-testicular causes, sperm related factors

(foreman, factory, freeway)

male factors that may cause infertility

hypogonadotropic hypogonadism

endocrine disorder contributing to male infertility

primary testicular defects in spermatogenesis: hydrocele, varicocele

most common cause of male infertility

•testosterone (total and bioavailable)

•FSH and LH

•Estradiol, TSH, Prolactin

endocrine testing in assessment of male infertility

-pt has 2-5 days of ejaculatory abstinence, collect by masturbation at the office

-it needs to brought to lab within an hour

-two samples may be necessary due to inherent variability of spermatogenesis

how do you perform a semen analysis?

•Volume

•pH

•Concentration, count, motility and morphology

•Debris and agglutination

•Leukocyte count

•Immature germ cells

what do you look for in a semen analysis?

lower reference 1.5

what is a normal semen volume?

40%

reference range of total sperm motility?

Conc x volume x motility

how do you calculate sperm total motile count?

good

total motile count >40M is

10-40 M

what total motile count results in need for intrauterine insemination

<10 M

what total motile count results in need for IVF to obtain pregnancy?

•Quality / Quantity

•Menstrual cyclicity aka Ovulation

•General health / metabolism / preconception prep

egg abnormalities that may cause female infertility

•Fibroids / polyps / adhesions

•Anomalies

•Fallopian Tubes

•Endometriosis?

uterus abnormallites that may cause female infertility

age

30% until age 30

10% at 40

quality of eggs is based soley on

Unpredictable, variable, independent of age sometimes

-usually starts to drops off significantly at 37 y/o

what determines quantity of eggs?

ovulation induction

fertility method used to grow an egg

trigger shot

fertility method used to ovulate an egg

luteal support

fertility method used to implant an embryo

-hypergonadotropic hypogonadism ( menopause)

-eugonadotropic eugonadism (PCOS)

-hypo hypo ( athlete triad)

what are the 3 categories of ovulatory dysfunction

-previous cervical trauma via surgery can effect fertility, but less of a concern the more we learn

how does cervix factor into female fertility?

-hx of pelvic inflammatory disease

-endometriosis

-previous abdominal-pelvic surgery that may lead to pelvic adhesive disease

tubal abnormalities that may lead to female infertility

aneuploidy (meiotic nondysjunction)

most common cause of miscarriage

Anti-phospholipid syndrome

most common autoimmune cause of miscarriage

•Day 3 FSH and estradiol / Anti Müllerian hormone

•luteal phase progesterone levels to assess ovulatory function

•Thyroid stimulating hormone, Prolactin

•STI Screening

lab testing work up for female infertility

-treat underlying disorder!

ex: manage weight, tx hypothyroidism, tx hyperprolacinemia

best treatment for ovulatory disoredrs

clomiphene citrate

letrozole

metformin

drugs to treat ovulatory disorders by providing ovulation induction

clomiphene citrate

•Drug to tx ovulatory disorders

-Selective estrogen receptor modulator that competes for estrogen receptors at the hypothalamus and pituitary level

•Increases gonadotropin production from pituitary thus stimulates follicle production at the ovary

•Increased risk of twins, cysts, menopausal symptoms

pts with migraines with aura

contraindication of clomiphene citrate

letrozole

Rx for ovulatory disorders

-aromatase inhibitor to decrease peripheral estrogen

intrauterine insemination

in vitro fertilization

types of assisted reproductive technology (ART)

-assess for aneuploidy, monogenic disease, structural rearrangements (AMSR)

components of pre-implantation genetic screening (PGT)

premenstrual syndrome

A group of physical , mood related and behavioral changes that occur in a regular, cyclic relationship to the luteal phase of the menstrual cycle

•Interfere with some aspect of the patient's life.

-at least one affective and one somatic symptom

-has an identifiable dysfunction in social or economic performance

diagnostic criteria of pre-menstrual syndrome

•Depression

•Angry outbursts

•Irritability

•Anxiety

•Confusion

•Social withdrawal

affective behavioral symptoms of PMS

•Breast tenderness

•Abdominal Bloating

•Fatigue

•Headache

•Swelling of extremities

somatic symptoms of PMS

-mental disorder related to menstrual cycle

-specific set of at least 5 out of 11 possible symptoms with at least 1 core symptom

diagnostic criteria of premenstrual dysphoric disorder

luteal phase

during what menstrual phase does premenstrual dysphoric disorder symptoms occur?

•Mood swings, sudden sadness, increased sensitivity to rejection

•Anger, irritability

•Sense of hopelessness, depressed mood, self-critical thoughts

•Tension, anxiety, feeling on edge

list the core symptom options of premenstrual dysphoric disorder

•Aerobic exercise

•Stress reduction

•Calcium carbonate supplementation

•Magnesium supplementation

non-pharm treatments for PMDD

-NSAIDs

-ovulation suppression

-SSRI

Rx options for PMDD

•Combination oral contraceptive pills

•Drospirenone and ethinyl estradiol

ovulation suppression meds for PMDD

-increased risk of substance abuse, smoking

-decreased likelihood of attending prenatal visits

-chronic depression and/or anxiety

-increased complications of pregnancy

impacts of mood disorders on birthing pt

-increased likelihood of low birth weight and pre-term birth

-poor attachment to birthing person or primary caregiver

-increased dysregulation, irritability, crying, hypervigilance, low activity or tone

-increased level of stress hormones, including cortisol

impacts of maternal mood disorders on fetus

perinatal depression

the most common complication of childbirth

• Anxiety Disorders

• Life stress

• History of depression

• Lack of social or family support

• Unintended pregnancy

• Lower socioeconomic status

• Lower educational level

• Smoking and other substance use/abuse

• Poor relationship quality

risk factors of perinatal depression during pregnancy

•Depression during pregnancy

•Anxiety during pregnancy

•Stressful life events during pregnancy or postpartum

•Traumatic or difficult birth experience

•Infant admission to NICU

•Lack of social or family support

•Previous history of depression

•Problems with breastfeeding

risk factors of perinatal depression post partum

recommended!

Grade B

USPSTF recommendation on screening for mood disorders in general adult population, including pregnant and postpartum women

ACOG recommends that clinicians screen ALL women at least once during the perinatal periodmfor symptoms of depression and anxiety using a standardized validated tool

ACOG recommendation for screening for mood disorders

Edinburgh postnatal depression scale

most common tool to screen for perinatal depression

0-9= low depression symptoms

10-19= moderate depression symptoms

20-30= severe depression symptoms

score findings of EP depression scale

perinatal depression

major or minor depressive episode occuring during pregnancy or in the first 12 months after delivery

-at least 5 of listed DSM5 symptoms occuring most of the day or nearly every day

-must include depressed mood and or markedly diminished interest or ppleasure ina ll or almost all activities

criteria for major depressive episode

postpartum blues

mild transient depressive symptoms post partum

postpartum depression

depression after baby is born

postpartum psychosis

Most common in women with pre-existing disorders

•Treatment needs to occur quickly

•Can be a medical emergency

-presents 2-4 days postpartum

-resolution within 10 days

timing of postpartum blues

-presents at 2 weeks-12 months

-average duration 3-14 months

timing of postpartum depression

-presents 2-3 days postpartum

-average duration is variable

timing of postpartum psychosis

postpartum blues

postpartum symptoms: Mild insomnia, tearfulness, fatigue, irritability, poor concentration, depressed affect

postpartum depression

postpartum symptoms: Irritability, labile mood, difficulty falling asleep, phobias, anxiety symptoms worsen in the evening

postpartum psychosis

postpartum symptoms: Similar to organic brain syndrome: confusion, attention deficit, distractibility, clouded sensorium

none, self-limited

tx of postpartum blues

-personal or family hx of anxiety

-previous perinatal derpession or anxiety

-thyroid imbalance

risk factors for postpartum anxiety

postpartum OCD

post partum symptom:

•images are anxiety-based and not delusional; there is a very low likelihood that they will be acted upon

•Obsessions (intrusive thoughts or scary thoughts), which are persistent, repetitive thoughts or mental images related to the baby

•The thoughts are very upsetting and not something the person has experienced before.

postpartum OCD

postpartum symptoms:

• A sense of horror about the obsessions

• Fear of being left alone with the infant

• Hypervigilance in protecting the infant

• Those with the thoughts know their thoughts are bizarre and are very unlikely to ever act on them

•Delusions (often grandiose, but including paranoid)

•Impulsiveness, poor judgment, distractibility

•Grandiose thoughts, inflated sense of self-importance

•Severe cases: hallucinations & delusions

main symptoms of bipolar 1

-less severe than bipolar 1, no delusions

-anxiety, irritability

main symptoms of bipolar 2

usually triggered by trauma during the time leading up to, during delivery or shortly afterwards. It can effect up to 6-9 % of mothers. The trauma leaves the women feeling that either her life or the life of her baby is at risk.

PTSD following childbirth is usually triggered

3-14 days following birth

-within the 1st two weeks postpartum

when do symptoms of postpartum psychosis present?

•Rare compared to postpartum anxiety and depression

•Occurs in about every I or 2 out of 1.000 deliveries, or .1%-2% of births

prevalance of postpartum psychosis

ego-dystonic thoughts

Thoughts or impulses and behaviors that are felt to be distressing, unacceptable, or inconsistent with one's self concept.

-not indicative of psychosis

ego-syntonic thoughts

upsetting thoughts are compatible with your values and beliefs

- a sign of psychosis that should be assessed quickly

-personal or family hx of bipolar

-a previous psychotic episode -

MOST people will not harm themselves or others

risk factors of postpartum psychosis

SSRI: paroxetine, sertraline (amount secreted in breast milk is low)

initial treatment for postpartum mood disorders in breastfeeding pts

-SNRI: duloxetine, venlafaxine

-atypical antidepressant: buproprion, mirtazapine

-tricyclic: nortriptyline

treatments for postpartum mood disorders in breast feeding pts who are resistant to initial treatment

•use the general population treatment

•Start with SSRI's or restart previous therapy.

tx of postpartum mood disorders inn pts who are not breast feeding

domestic abuse (per department of justice)

felony or misdemeanor crimes of violence committed by a current or former spouse or intimate partner of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse or intimate partner, by a person similarly situated to a spouse of the victim under the domestic or family violence laws of the jurisdiction receiving grant monies, or by any other person against an adult or youth victim who is protected from that person's acts under the domestic or family violence laws of the jurisdiction.

domestic abuse (per the state of louisiana)

the intentional use of force or violence committed by one household member or family member upon the person of another household member or family member.

psychological aggression

the use of verbal and non-verbal communication with the intent to harm another partner mentally or emotionally and/or to exert control over another partner

sexual coercioin

unwanted sexual penetration that occurs after a person iis pressured in a nonphysical way

unwanted sexual contact

unwanted sexual experiences involving touch but not sexual penetration, such as being kissed in a sexual way or having sexual body parts fonndled, groped, or grabbed

contact sexual violence

a combined measure that includes rape, beingn made to penetrate someone else, sexual coercion, and /or unwanted sexual contact

rape

being made to penetrate someone else (asked of males only)

sexual coercion

unwanted sexual contact

what are the 4 types of intimate partner violence?

unwanted sexual contact

what type of sexual violence is most common

college age women who do NOT attend college

what population of women are most likely to experience sexual violence?

college age men in college

what population of men are most likely to experience sexual violence?

of all victims under 18, 2/3 are ages 12-17

most common age range of children who are victims of sexual abuse

individual, relationships, community, societal

what are the 4 categories of risk factors for victimization

1. tensions building

2. incident

3. reconciliation

4. calm

what are the 4 components of the cycle of abuse

tensions building

what stage of abuse cycle?

-breakdown of communincation, becomes fearful and feels the need to placate abuser

-victim feels uneasy and a need to watch every move

incident

what stage of abuse cycle?

-any type of abuse occurs: physical, sexual, emotional

-threats, intimidation, blaming, arguing

reconciliation phase

what stage of abuse cycle?

-abuser apologizes for abuse, some beg forgiveness orr show sorrows

-abuser may promise it will never happen agian, blames victim for provoking the abuse or denies abuse occur

-minimizing, denying or claiming the abuse wasn't as bad as the victim claims

the calm

what stage of abuse cycle?

-before the tension starts again

-abuses slow or stop, abuser acts like the abuse never happened

-promises made during honeymoon stage may be met

-abuser gets gifts for victim

-victim believes or wants to believe the abuser will change

chronic pain, IBS, headaches, and MSK papin

somatic complaints associated with IPV

Health practitioners, including physicians, surgeons, physical therapists, dentists, residents, interns, hospital staff, podiatrists, chiropractors, nurses, nursing aides, dental hygienists, emergency medical technicians, paramedics, optometrists, medical examiners, or coroners.

who are mandatory reporters for children in the state of Louisiana?