DA II - Reproductive Eval - Exam 4

Infertility

an involuntary reduction in the ability to produce children after engaging in regular, unprotected intercourse for at least 1 year

Hormonal (female), Structural (female, male factor)

what are the three main areas of clinical fertility workup?

Clinical Fertility Workup

-Detailed Hx -> PMH, meds, substance use, activity/exposure, in depth sexual history

-labs

-imaging

-can take 1-3 months

General Clinical Workup Fertility

-Pelvic US

-Hysterosalpingogram

-Labs -> FSH, LH, E2, Progesterone, prolactin, TSH, A1C, Rubella, GC, Trich, Hep B, Syphilis, HIV

-Semen Analysis for male

Female Workup - US

-structural eval -> rule out abnormalities of uterus, tubes, ovaries, cervix

-can be helpful in assessing ovarian reserve (quantity and quality of remaining eggs)

-standard part of workup and good place to start (cheaper/less invasive than other tests)

Hysterosalpingogram - Indications

-Infertility

-Confirm tubal occlusion

-assess endometrial cavity shape

-assess for hydrosalpinx

Hysterosalpingogram - CI

-allergy to contrast

-pregnancy

-pelvic infection

-active uterine bleeding

Hysterosalpingogram patient prep

-educate patient (painful, pre-medicate, occasional pre-procedure rx)

-obtain consent

-patient is dressed in hospital gown

-bladder emptied

Hysterosalpingogram - Comp

-infection

-allergic reaction to contrast

-hemorrhage

-uterine perforation

HSG - Procedure Description

-pt put in lithotomy position on exam table

-speculum placed in vagina

-cervix may be anesthetized

-cannula is inserted through vaginal canal and contrast is introduced into uterus

-speculum is removed

-fluoroscopic and conventional x-rays are obtained

HSG - Implications

-Normal

-Abn with uterus -> polyps, leiomyoma, bicornuate uterus

-Abn with fallopian tubes -> tortuosity, tubal obstruction, hydrosalpinx

-obstruction d/t adhesions or previous PID

Endometrial Biopsy Patient Prep

-UPT negative

-explain procedure to patient

-patient may experience cramping

-obtain written consent

Endometrial Biopsy Indications

-post-menopausal bleeding

-evaluation of abnormal uterine bleeding

-evaluation of abnormal endometrial cells found on pap

-NOT GENERALLY PART OF INITIAL INFERTILITY WORKUP

Endometrial Biopsy CI

-untreated infection

-severe cervical stenosis

-if hysteroscopy more appropriate

-pregnancy

Endometrial Biopsy Procedure

-insert speculum

-use iodine or other antiseptic to clean cervix

-anesthetic may be administered

-use tenaculum to stabilize cervix

-cervix may have to be dilated for procedure

-sample endometrium with z-sampler

-place sample in appropriate container for pathology

-make sure patient is comfortable and stable

Endometrial Biopsy Implications

-detect tumor (cancerous vs noncancerous)

-endometrial hyerplasia

Endometrial Biopsy Comp

-abnormal bleeding

-infection

-vasovagal reaction

CBC - Fertility

ability to rule out different types of anemia and possible infection

TSH - Fertility

-hypothyroidism

-hyperthyroidism

-can cause ovulatory dysfunction

Gonorrhea/Chlamydia Testing

detects infection and possible PID (possible tubal or structural concern)

FSH

measure of ovarian reserve

Progesterone Level

-check for ovulation

->=3 ng/mL confirms that ovulation has occurred - but for fertility purposes ideally >10

Testosterone Levels

-Men: hypothalamic or pituitary dx, genetic dz, hx of mumps, chronic dz, testicular or adrenal tumors

-Women: PCOS, ovarian or adrenal tumors

Prolactin

evaluation of menstrual irregularities and possible pituitary disorder/tumor

Estradiol/DHEAS

-establishes baseline for FSH/LH

-evaluates menstrual problems, estrogen-producing tumors, pregnancy, and menopause

-DHEAS helps assess adrenal gland function

Semen Analysis Indications

-no conception after 12 months of unprotected intercourse or 6 months of unprotected intercourse if the woman is 35 years or older

Semen Analysis pt prep

collected after 2-7 days after abstinence

Semen Analysis Procedure

-collection in private room near lab, sample must be complete, sample obtained by masturbation

-void to empty bladder

-wash hands and penis with soap

-ejaculate into sterile container

Testicular US - Indications

-acute, painful testicular swelling

-eval of injury, trauma, tumors, masses

-infertility

-undescended testis

-male hypogonadism

Testicular US Pt Prep

-supine position

-adducts thighs or place towels or sheet under scrotum

-secure penis to abdomen or ask patient to shift penis if obstructs visual field

-drape patient appropriately

Testicular US Implications

-Abn Testes -> volume, masses, decreased blood flow, infxn/inflammation, possible need for intervention

-normal testes

Pituitary MRI Indications

-elevated prolactin (amenorrhea or irregular cycles, >100-150)

-pituitary hypofunction, hormone hypersecretion

-Amenorrhea, galactorrhea

-many more

Pituitary MRI CI

-electrical, magnetic, or mechanically activated implant

-intracranial aneurysm clips (unless titanium)

-magnetic surgical clips of stables

-metal shrapnel or bullet

no

is a pituitary MRI part of routine infertility workup?

Pituitary MRI pt Prep

-measure creatinine if giving contrast

-remove metal objects from patient

-explain procedure to patient

-patient must remain still

-place in head first supine position

Pituitary MRI Comp

-Reactions to contrast -> allergy, hypotension, asthma

-claustrophobia