sexuality, female sexual dysfunction, infertility

primary dysfunction

predominantly psychogenic and lasts longer

secondary dysfunction

related to a disease(medical or psychological) or medication

sexual arousal disorder

lack of lubrication and vasocongestion of genitals, lack of sexual excitement and pleasure during sex, estrogen is responsible

vaginismus

persistent involuntary spasm of muscles of outer 1/3 of vagina, interferes w/ intercourse, may respond to desensitization

dyspareunia

genital pain associated w/ intercourse

-pain w/ intromission-vestibulitis, vaginismus, fissures

-mid vaginal pain-lack of lubrication, surgical scars, urethral diverticulosis

-deep thrust-endometriosis, interstitial cystitis, pelvic adhesions, neoplasms

hormonal therapy for sexual dysfunction

estrogen can decrease dyspareunia

testosterone may improve desire and arousal but use w/ caution(liver dysfunction)

viagra for sexual dysfunction

increases clitoral and vaginal smooth muscle relaxation and improves lubrication, not proven in controlled studies(can't use w/ nitrates or CVS disease)

clitoral vacuum device

improves clitoral blood flow and engorgement

flibanserin

multifunctional 5HTiA receptor agonist and 5HT2A receptor antagonist

-normalizes excitatory and inhibitory neurotransmitter levels to enhance desire

-lower serotonin, raise dopamine and norepinephrine

-SE: dizziness, sleepiness, hypotension and syncope with alcohol consumption

Bremanlotide

melanocortin receptor agonist, increases dopamine release, increases excitation in brain regions associated with sexual desire

definition of infertility

inability to conceive after 12 months of unprotected sex

-if over 35, initiate evaluation after 6 months

subfertility

decrease, not absence of fertility potential

sterility

complete inability to achieve fertility

fecundity

probability of achieving a live birth in one menstrual cycle

primary infertility

occurs without any prior pregnancy

secondary infertility

occurs after previous conception

male factors of infertility

-abnormal sperm function

-abnormal sperm production

-obstruction of ductal system

female factors of infertility

-ovulation problems(hypothalamic, pituitary, ovarian levels, PCOS, androgen excess, thyroid/liver disease, obesity)

-anatomic problems

-peritoneal problems(endometriosis, adhesions)

-cervical problems

group 1 ovulatory disorders

-hypogonadotropic hypogonadal anovulation

-pituitary insufficiency

group 2 ovulatory disorders

normogonadotropic normoestrogenic ovulation

-PCOS is most common

group 3 ovulatory disorders

hypergonadotropic normoestrogenic anovulation

-premature ovarian failure, advanced age

group 4 ovulatory disorders

hyperprolactinemic anovulation

anatomic problems of infertility

-uterine(fibroids, polyps, intrauterine synechiae, congenital malformation)

-endometrial(hyperplasia, endometriosis, cancer)

-tubal(PID, salpingitis, endometriosis, adhesion, adenomyosis)

structural cervical problems causing infertility

-mullerian duct abnormalities

-cervical stenosis(can be iatrogenic or due to miscarriage)

-inflammation

-mucus(can be watery or inadequate production)

pelvic exam findings for infertility

-signs of estrogen deficiency(vaginal atrophy)

-cervical stenosis, sign of infection or malformation

-endometriosis/adhesions-flexed/retroverted uterus, uterosacral nodularity

workup for ovulatory disorders

-basal body temp(increases during luteal phase bc of progesterone)

-mid luteal serum progesterone(day 21-23)

-LH predictor kits

-day 3 FSH(elevated if anovulatory)

-endocrine-FSH, LH, prolactin, thyroid

-clomiphene citrate challenge- give clomid on day 5-9 of menstrual cycle and measure FSH(elevation=decreased fecundity)

workup for anatomic problems causing infertility

-hysteroscopy

-hysterosalpingogram

-sonohysterogram

-pelvic US

-laparoscopy

workup for peritoneal problems causing infertility

laparoscopy can be diagnostic and therapeutic

workup for cervical problems causing infertility

-pap smear

-cervical culture for microorganisms

-spinnbarkeit(pH>6.5 and mucus stretch 6 cm indicates ovulation)

-post coital test(assess number and motility of sperm in the cervical canal 2-12 hrs after sex)

tx of pituitary insufficiency

clomiphene or IM LH/FSH

tx of hyperprolactinemia

bromocriptine

tx of PCOS infertility

clomiphene, weight loss, metformin

tx of hypothalamic amenorrhea

human menopausal gonadotropin

tx for uterine problems causing infertility

submucosal fibroids- resection, myomectomy

intrauterine septum/polyps-resection

estrogen therapy or IUD after surgical ligation to prevent adhesions

tx for tubal problems causing infertility

-tubal occlusion-microsurgical tuboplasty

-fimbrial occlusion- neosalpingostomy

tx of peritoneal problems causing infertility

-endometriosis-danazol, GnRH analogues, medroxyprogesterone

-laparoscopy if significant adhesions

-periadnexal adhesions-lysed by laparoscopy, place artificial tissue barrier to prevent recurrences

tx of cervical problems causing infertility

-abx for infection, stenosis-surgical or mechanical dilation

-can bypass cervix with intrauterine insemination(most effective)

intrauterine insemination

washed sperm injected into uterus, must have normal fallopian tube for fertilization to uccur

in vitro fertilization and embryo transfer

-eggs fertilized outside of uterus

-consists of ovarian stimulation, egg retrieval, fertilization, selection, embryo transfer

intracytoplasmic sperm injection

subtype of IVF

-injection of sperm into oocyte cytoplasm

-treats infertility in men w/ oligospermia, azoospermia, asthenospermia, teratospermia