Fertility And Infertility

Front 1

FSH stimulates:
1.
2.

Back 1

1. Follicle Development
2. Estrogen
-thickens endometrial lining
-thins cervical mucus

Front 2

LH stimulates:
1.
2.
3.

Back 2

1. Follicle maturation and ovulation
2. Androgens for estrogen
3. Progesterone from corpus luteum
-maintains endometrium
-thickens cervical mucus

Front 3

No fertilization causes:
1.
2.

Back 3

1. Corpus luteum degrades
2. Drop in estrogen and progesterone triggers menses

Front 4

Fertilization causes:
1.
2.

Back 4

1. hCG from blastocyst
2. Stimulates estrogen and progesterone from corpus luteum

Front 5

Probabilities of Conception:

1. Over 1 month:
2. Over 1 year:
3. Over 2 years:

Back 5

1. Over 1 month: 20%
2. Over 1 year: 84%
3. Over 2 years: 92%

Front 6

Factors affecting male fertility:
1.
2.
3.
4.

Back 6

1. Age
2. Smoking
3. Body weight
4. Excessive EtOH

Front 7

Factors affecting female fertility:
1.
2.
3.

Back 7

1. Age
2. Smoking
3. Body weight

Front 8

What are 4 ways to maximize chances of conception?

Back 8

1. Limits factors that affect fertility
2. Ensure a healthy lifestyle
3. Engage in frequent sexual intercourse (every 1-3 days particularly during fertile window - 6 day interval ending with day of ovulation)
4. Women: folic acid supplementation (0.4-0.8 mg/daily)

Front 9

Factors that may help maximize chances of conception that have limited/conflicted data:

Back 9

1. Alcohol (women)
2. Caffeine (greater than 5 cups/day)
3. Avoid exposure to high temps (men)
4. Lubricants
5. Sexual position
6. Female orgasm
7. Remaining supine after intercourse (women)
8. Gender of infant (depending on when conception occurs in cycle)

Front 10

Fecundity

Back 10

Probably of achieving a live birth in one menstrual cycle
(range 0.15-0.2 per month)

Front 11

Infertility

Back 11

1 year of unwanted non-conception with unprotected intercourse in the fertile phase of the menstrual cycle
-primary: couple has never been pregnant
-secondary: couple having trouble conceiving despite achieving previous pregnancy

Front 12

7 requirements for pregnancy:

Back 12

1. Woman who is ovulating
2. Man who has sufficient sperm
-number, motility, shape
3. Intercourse with ejaculation
4. Adequate sperm transport
5. Fertilization
6. Efficient embryo transport
7. Appropriate environment for implantation

Front 13

What are the characteristics of primary hypogonadism in male infertility?

Back 13

-low testosterone, high FSH
-includes: varicocele, cyptorchidism, medications, congenital/genetic disorders

Front 14

What are the characteristics of secondary hypogonadism in male infertility?

Back 14

-low testosterone, low FSH
-includes: tumor, congenital, medications

Front 15

What are the causes of disordered sperm transport?

Back 15

Obstruction, erectile dysfunction, retrograde ejaculation

Front 16

What are the 3 causes of male factor infertility?

Back 16

1. Primary hypogonadism
2. Secondary hypogonadism
3. Disordered sperm transport

Front 17

What are some male gonadotoxins?

Back 17

-alcohol
-allopurinol
-anabolic steroids
-chemo
-cimetidine
-colchicine
-cyclosporine
-erythromycin
-gentamicin
-marijuana
-neomycin
-nitrofurantoin
-sprinonolactone
-sulfasalazine
-tetracyclines
-environmental (cigarette smoke, heavy metals, organic solvents, pesticides, radiation)

Front 18

Initial evaluation of male infertility:

Back 18

1.History
- reproductive history
- sexual history
- co-morbid conditions
- use of OTC, rx, illicit drugs
- exposure to environmental toxins
2. Physical Exam
3. Lab evaluation (semen analysis)

Front 19

Semen Analysis

1. Azoospermia:
2. Oligospermia:

Back 19

1. Azoospermia: absence of sperm in ejaculate
2. Oligospermia: low sperm concentration

Front 20

When is a full evaluation of male infertility indicated and what should be included?

Back 20

-Indicated if patient has abnormal reporductive hx or semen analysis
-Should include:
1. Complete medical and reproductive hx
2. PE by urologist/specialist
3. At least 2 semen analyses
-Possible additional tests:
1. Endocrine evaluation
2. Post-ejaculatory urinalysis
3. Transrectal ultrasound
4. Scrotal ultrasound
5. Genetic screening

Front 21

Treatment of primary hypogonadism in male infertility:

Back 21

1. Possible surgical correction (ex: varicocele)
2. Rx: IUI or ART

Front 22

Treatment of secondary hypogonadism in male infertility:

Back 22

1. Goal is to restore spermatogenesis
2. Rx: hormonal therapy

Front 23

Treatment of disordered sperm transport in male infertility:

Back 23

1. Possible surgical correction (ex: obstruction)
2. Rx: IUI or ART

Front 24

Mild Male Infertility due to Primary Hypogonadism or Disordered Sperm Transport

Sperm count:
Motility:
Treatment:

Back 24

Sperm count: 15-20 million/mL
Motility: normal
Treatment: expectant management

Front 25

Moderate Male Infertility due to Primary Hypogonadism or Disordered Sperm Transport

Sperm count:
Motility:
Treatment:

Back 25

Sperm count: 10-15 million/mL
Motility: 20-40%
Treatment: IUI +/- clomiphene or gonadotropin in female; may require IVF +/- ISCI

Front 26

Severe Male Infertility due to Primary Hypogonadism or Disordered Sperm Transport

Sperm count:
Motility:
Treatment:

Back 26

Sperm count: less than 10 million/mL
Motility: 10%
Treatment: IVF + ICSI or donor sperm

Front 27

Treatment Options for Secondary Hypogonadism:
1.
a)
b)
c)
2.
a)

Back 27

1. Gonadotropins
a) hCG
b) rFSH
c) hMG (contains LH and FSH)
2. GnRH
a) Gonadorelin (Factrel)

Front 28

hCG (Novarel, Pregnyl)

CI:
Warnings:
AEs:

Back 28

CI: prostatic carcinoma
Warnings: cardiovascular disease, migraines
AEs: injection site, edema, depression, fatigue, HA, irritability, gynocomastia

Front 29

rFSH: Follitropin alfa (Gonal-f, Gonal-f RFF)

CI:
AEs:

Back 29

CI: increased FSH, tumor of hypothalamus, pituitary or testis, uncontrolled thyroid/adrenal disorders
AEs: injection site, abdominal pain, nausea, HA, upper respiratory infection

Front 30

hMG: Menotropins (Menopur, Repronex)

CI:
AEs:

Back 30

CI: pituitary tumor, uncontrolled thyroid/adrenal disorders
AEs: injection site, abdominal pain, HA, nausea

Front 31

GnRH: Gonadorelin (Factrel)

CI:
AEs:

Back 31

CI: any condition worsened by reproductive hormones
AEs: cutaneous infection, abdominal pain, flushing, HA, nausea, lightheadedness

Front 32

What is the average amount of time it takes for spermatogenesis to be restored?

Back 32

6-12 months
(occasionally 18-24 mos)

Front 33

What should be monitored when treating male infertility?

Back 33

Serum testosterone and semen analysis

Front 34

What should be included in the evaluation of female infertility?

Back 34

1. History
2. Physical Exam
3. Ovulatory Dysfunction
4. Cervical Factors
5. Uterine Factors
6. Tubal Factors
7. Peritoneal Factors

Front 35

What should be included in a patient's history when evaluating female infertility?

Back 35

1. menstrual history
2. reproductive history
3. sexual history
4. current medications
5. use of tobacco, alcohol, illicit drugs
6. family hx

Front 36

What should be included in a physical exam when evaluating a female infertility?

Back 36

1. thyroid
2. breasts
3. abdomen and pelvis

Front 37

What ovulatory characteristics should be considered when evaluating female infertility?

Back 37

1. menstrual history
2. basal body temp
3. urinary LH
4. serum progesterone
5. transvaginal ultrasound
6. endometrial biopsy
7. other: serum TSH, FSH and prolactin

Front 38

What cervical factor is considered when evaluating female infertility?

Back 38

Cervical mucus

Front 39

What uterine factors should be considered when evaluating female infertility?

Back 39

1. hysterosalpingography (HSG)
2. ultrasound
3. hysteroscopy

Front 40

What tubal factors should be considered when evaluating female infertility?

Back 40

1. HSG
2. laparoscopy
3. tubal cannulation

Front 41

What peritoneal factors should be evaluated when evaluating female infertility?

Back 41

1. ultrasound
2. laparoscopy

Front 42

How does basal body temperature help to predict ovulation?

Back 42

Temperature will rise 0.4-0.8 degrees F after ovulation due to increase in progesterone released from corpus luteum

Front 43

True or False: Basal body monitoring chart can be used prospectively in confirming ovulation.

Back 43

FALSE: can only confirm ovulation retrospectively based on an overall sustained temperature shift

Front 44

True or False: Any type of thermometer can be used to monitor basal body temperature.

Back 44

FALSE: must use basal body thermometer because it measures temperature in 0.1 or 0.01 degree increments.

Front 45

How should basal body temperature be measured?

Back 45

1. begin on first day of menstrual cycle
2. take temperature at the same time each day after at least 3 hrs sleep
3. take temp upon waking while still lying in bed (can be orally or vaginally but stay consistent)

Front 46

LH surge occurs __-__ hrs prior to ovulation and is detectable in urine _-__ hrs after surge.

Back 46

12-24; 8-12

Front 47

True or False: Intensity of color change in urine directly correlates with concentration of LH.

Back 47

TRUE: darker color = higher LH

Front 48

What are some factors that interfere with urinary LH testing?

Back 48

Endometriosis, PCOS, ovarian failure, menopause, hyperthyroidism, pregnancy, menotropins, danazol, clomiphene, hCG

Front 49

What time of day should urinary LH testing be completed and what should be done prior to testing?

Back 49

Anytime of day at the same time (although first thing in the morning may not be best) and patient should reduce liquid intake for 2 hrs before the test

Front 50

What are the treatment options for ovulatory dysfunction?

Back 50

1. weight management
2. medications
3. laparoscopic surgery
4. ART

Front 51

What are treatment options for cervical factors attributing to female infertility?

Back 51

1. IUI
2. ART

Front 52

What are treatment options for tubal factors attributing to female infertility?

Back 52

1. tubal flushing
2. surgery
3. ART

Front 53

What is the treatment for uterine factors attributing to female infertility?

Back 53

Possible surgical intervention

Front 54

What are the treatment options for endometriosis?

Back 54

1. laparoscopic surgery
2. ovulation induction and IUI

Front 55

Treatment of amenorrhea/ovulatory dysfunction

Goal:

Causes of anovulation suitable for induction:

Causes of anovulation NOT suitable for induction:

Back 55

Goal: ovulation induction if possible

Causes of anovulation suitable for induction:
1. hypothalamic (low GnRH, amenorrhea, stress, idiopathic)
2. pituitary (hyperprolactinemia, pituitary failure)
3. ovarian (polycystic ovarian syndrome)
4. other endocrine (hypothyroidism)

Causes of anovulation NOT suitable for induction:
1. ovarian failure (idiopathic, chemo/XRT, surgical removal, genetic, autoimmune)
2. chromosomal abnormalities

Front 56

Treatment of amenorrhea/ovulatory dysfunction due to hypothalamic/pituitary causes:
1. hypogonadotropic hypogonadism:
2. hypothalamic:

Back 56

1. hypogonadotropic hypogonadism: gonadotropins
2. hypothalamic: pulsatile GnRH

Front 57

What is the treatment for PCOS?

Back 57

1. clomiphene citrate
2. metformin

Front 58

What is the treatment for premature ovarian failure?

Back 58

1. IVF with donor oocyte
2. adoption

Front 59

What is the treatment for tubal defect?

Back 59

1. laparoscopy with tubal lavage +/- hysteroscopy
2. IVF

Front 60

What should be used to achieve follicle development?

Back 60

FSH

Front 61

If sufficient follicle maturation is achieved, what should be given to stimulate ovulation?

Back 61

LH (as hCG)

Front 62

What warnings are associated with using LH and FSH in treating infertility?

Back 62

-multiple gestation, ovarian hyperstimulation syndrome (OHSS), thromboembolic events

Front 63

When treating hypothalamic/pituitary causes of infertility, if there is an adequate response with follitropins and menotropins, what should be administered?

Back 63

hCG

Front 64

When should hCG be withheld?

Back 64

estrogen > 2,000 pg/mL
ovarian enlargement
abdominal pain

Front 65

Follitropins and menotropins:

CIs:

AEs:

Monitoring:

Back 65

CIs: primary ovarian failure, thyroid/adrenal dysfunction, ovarian cyst, abnormal uterine bleeding, pregnancy

AEs: injection site rxn, ovarian cyst, HA, nausea, abdominal pain

Monitoring: estrogen, ultrasound, evidence of ovulation

Front 66

Chorionic Gonadotropin (human)

CIs:

AEs:

Monitoring:

Back 66

CIs: previous hypersensitivity rxn, pregnancy

AEs: injection site rxns, hypersensitivity rxn, edema, fatigue, depression, HA, irritability, restlessness

Monitoring: progesterone, estrogen, ultrasound, evidence of ovulation

Front 67

Chorionic Gonadotropin (recombinant)

CIs:

AEs:

Monitoring:

Back 67

CIs: primary ovarian failure, thyroid/adrenal dysfunction, abnormal uterine bleeding, ovarian cyst, pregnancy

AEs: injection site rxns, N/V, abdominal pain, ovarian cyst

Monitoring: progesterone, estrogen, ultrasound, evidence of ovulation

Front 68

Pulsatile GnRH (Factrel, Lutrepulse)

When to use:

CIs:

AEs:

Monitoring:

Compared to gonadotropins has less risk of:

Rate of ovulation:

Back 68

When to use:patients with idiopathic hypogonadotrophic hypogonadism, weight-loss related amenorrhea

CIs:ovarian cysts, non-hypothalamic anovulation, conditions worsened by pregnancy

AEs:pain at injection site

Monitoring: FSH, LH, progesterone, ultrasound

Compared to gonadotropins has less risk of: multiple folliculogenesis, multiple pregnancy, ovarian hyperstimulation syndrome

Rate of ovulation > 90%

Front 69

PCOS

Cardinal features:

Clinical manifestations:

Greater risk of:

Back 69

Cardinal features: hyperandrogenism, polycystic ovary

Clinical manifestions: menstrual irregularities, signs of androgen excess, obesity

Greater risk of insulin resistance (compared to women with hyperandrogenism and regular cycles)

Front 70

What are the diagnostic criteria for PCOS?

What should obese women with PCOS be screened for?

Back 70

Diagnostic criteria (2 out of 3):
1. oligo- and/or anovulation
2, clinical or biochemical signs of hyperandrogenism
3. polycystic ovaries
-exclusion of other etiologies

Obese women with PCOS should be screened for metabolic syndrome

Front 71

What are the possible treatments for PCOS?

Back 71

1. Lifestyle Modifications
*weight loss is first line*
2. Clomiphene citrate
3. Metformin
4. Gonadotropins and GnRH analogs
5. Ovarian surgery
6. ART (IVF), IUI

Front 72

What drug is first line for ovulation induction in PCOS?

Back 72

Clomiphene citrate

Front 73

Clomiphene Citrate

MOA:

Metabolism:

CI:

Warnings:

AEs:

Monitoring:

Back 73

MOA: SERM (inhibits normal estrogenic negative feedback)

Metabolism: hepatic

CI:liver disease, uterine bleeding, ovarian cyst, pituitary tumor, thyroid/adrenal dysfunction, pregnancy

Warnings:ovarian enlargement, OHSS, multiple gestation, visual disturbance

AEs:hot flashes, breast discomfort, GI distension/bloating/discomfort

Monitoring: BBT, progesterone, urinary LH, follicular growth and endometrial thickness

Front 74

True or False: Metformin is as effective as clomiphene citrate for ovulation induction.

Back 74

FALSE: Metformin is NOT as effective; there is no advantage in adding metformin to clomiphene and metformin should only be used in patients with glucose intolerance.

Front 75

Gonadotropins and GnRH analogs

(First/second) line for ovulation induction in PCOS

PCOS patients have increased risk of:

Duration should not exceed:

Requires:

Back 75

SECOND line for ovulation induction in PCOS

PCOS patients have increased risk of: excessive follicle development and OHSS

Duration should not exceed: 6 weeks

Requires: intense monitoring and strict cycle cancellation criteria

Front 76

Compared to conventional dose regimens, low-dose regimens result in:

1.
2.
3.
4.

Back 76

1. 70% ovulation rate
2. 20% pregnancy rate
3. 6% multiple low birth rate
4. <1% OHSS rate

Front 77

True or False: It is recommended to add GnRH analog in treatment of PCOS.

Back 77

FALSE. Not recommended - no increase in pregnancy rate, higher hyperstimulation rate, increased risk of multiple pregnancies, and inconvenience and cost regimen

Front 78

Ovarian surgery as infertility treatment is (first/second) line and involves multiple ______ _________.

Back 78

Ovarian surgery as infertility treatment is second line and involves multiple ovarian punctures (laser or diathermy).

Front 79

True or False: There is no risk of OHSS or high-order multiples associated with ovarian surgery.

Back 79

TRUE.

Front 80

ART-IVF is ____ line for PCOS, has (lower/higher) risk of multiples and a pregnancy rate ______ to non-PCOS women.

Back 80

ART-IVF is third line for PCOS, has lower risk of multiples and a pregnancy rate similar to non-PCOS women.

Front 81

When is IUI used?

Back 81

Used for women with PCOS and male factor infertility or failed to conceive despite infection. There is a risk of excessive stimulation.

Front 82

What are the causes of tubal defects?

Back 82

1. pelvic infection
a) chlamydia trachomatis
b) gonorrhea
c) genital tuberculosis
d) postpartum sepsis
e) intrauterine device
2. endometriosis
3. surgery
a) post-op complications
b) tubal ligation

Front 83

What are the management options for tubal defects?

Back 83

1. expectant management
2. transcervical tubal cannulation
a) restores tubal patency
b) first line for proximal occlusion
3. surgery
a) laproscopic adhesiolysis
b) reversal of tubal ligation
4. ART-IVF
a) limited data but routinely offered

Front 84

Endometriosis

Symptoms:

Infertility:

Back 84

Symptoms: dysmenorrhea, dyspareunia, chronic non-menstrual pain

Infertility: oocyte development, embryogenesis, implantation, pelvic anatomy

Front 85

Endometriosis - Treatment of Infertility

1.
2.
3.
4.

Back 85

1. Surgical treatment
-improves fertility for minimal/mild disease (also likely improves for mod/sev disease)
2. Medical treatment
-does NOT improve fertility, but may be a role for GnRH analogs prior to IVF
3. Ovulation induction + IUI
-improves fertility for minimal/mild disease (no studies for mod/sev)
4. ART (IVF)
-limited date but routinely offered

Front 86

What type of infertility is not seen on a basic infertilty workup (ie; evidence of ovulation, patency of fallopian tubes, adequate sperm production)?

Back 86

Unexplained infertility

Front 87

Unexplained Fertility - Treatment

1.
2.
3.
4.

Back 87

*treatment is empiric*

1. intrauterine insemination (IUI)
2. ovulation induction (clomiphene or gonadotropin)
3. IUI + ovulation induction
4. assisted reproductive technology (ART)

Front 88

What is IUI?

Back 88

Intrauterine insemination

Prepared sperm deposited in uterus at the time of ovulation (natural or induced)

Front 89

What is IVF-ET?

Back 89

In vitro fertilization embryo transfer

Fertilization aided by mixing sperm/egg in lab

Front 90

What is ICSI?

Back 90

Intracytoplasmic sperm injection

Single sperm injected into egg cytoplasm

Front 91

What is GIFT?

Back 91

Gamete intrafallopian transfer

Sperm and egg placed in fallopian tube

Front 92

What is ZIFT?

Back 92

Zygote intrafallopian transfer

Diploid cell placed in fallopian tube

Front 93

What is TET?

Back 93

Tubal embryo transfer

Embryo placed in fallopian tube

Front 94

What are the requirements for assisted conception?

Back 94

1. superovulation
-pharmacological stimulation of the ovary to promote production of more than one egg (higher doses of FSH and hMG used compared to ovulation induction)
2. sperm preparation
-lab preparation of the semen sample to yield a highly motile, morphologically normal population of sperm for inseminatino or injection
3. assisted fertilization
-techniques to aid the union of egg and sperm

Front 95

What techniques are considered assisted conception?

Back 95

IUI and ART

Front 96

What techniques are considered ART?

Back 96

Generally IVF, ISCI, GIFT and ZIFT

Front 97

Unexplained Fertility - Treatment

1.
2.
3.
4.

Back 97

*treatment is empiric*

1. intrauterine insemination (IUI)
2. ovulation induction (clomiphene or gonadotropin)
3. IUI + ovulation induction
4. assisted reproductive technology (ART)

Front 98

What is IUI?

Back 98

Intrauterine insemination

Prepared sperm deposited in uterus at the time of ovulation (natural or induced)

Front 99

What is IVF-ET?

Back 99

In vitro fertilization embryo transfer

Fertilization aided by mixing sperm/egg in lab

Front 100

What is ICSI?

Back 100

Intracytoplasmic sperm injection

Single sperm injected into egg cytoplasm

Front 101

What is GIFT?

Back 101

Gamete intrafallopian transfer

Sperm and egg placed in fallopian tube

Front 102

What is ZIFT?

Back 102

Zygote intrafallopian transfer

Diploid cell placed in fallopian tube

Front 103

What is TET?

Back 103

Tubal embryo transfer

Embryo placed in fallopian tube

Front 104

What are the requirements for assisted conception?

Back 104

1. superovulation
-pharmacological stimulation of the ovary to promote production of more than one egg (higher doses of FSH and hMG used compared to ovulation induction)
2. sperm preparation
-lab preparation of the semen sample to yield a highly motile, morphologically normal population of sperm for inseminatino or injection
3. assisted fertilization
-techniques to aid the union of egg and sperm

Front 105

What techniques are considered assisted conception?

Back 105

IUI and ART

Front 106

What techniques are considered ART?

Back 106

Generally IVF, ICSI, GIFT and ZIFT

Front 107

What should be taken in the cycle prior to preceding ART?

Back 107

Oral contraceptives and GnRH agonist

Front 108

What is involved in ART?

Back 108

1. baseline pevlic ultrasound
2. ovarian stimulation (gonadotropins)
3. monitoring of follicle development
(ultrasound/serum hormone levels)
4. final oocyte maturation and hCG administration
5. transvaginal oocyte retrieval
6. insemination of oocyte
7. embryo transfer
8. progesterone supplements
9. hormone studies and pregnancy test

Front 109

What is ovarian hyperstimulation syndrome?

Back 109

-exaggerated response to ovulation induction
-self-limiting, usually resolves in several days
-hallmark manifestation is increased capillary permeability resulting in fluid shifts
-risk factors: young age, low body weight, PCOS, higher doses of gonadotropins, previous episode of OHSS, risk rises with number of developing follicles

Front 110

Mild Ovarian Hyperstimulation Syndrome

Symptoms:

Treatment:

Back 110

Symptoms: abdominal pain and nausea

Treatment: increase oral intake, report worse sx

Front 111

Moderate Ovarian Hyperstimulation Syndrome

Symptoms:

Treatment;

Back 111

Symptoms: mild sx + V/D, ascites on US

Treatment: increase fluids, VTE prophylaxis, monitor BMP, LFT, CBC, coags

Front 112

Severe Ovarian Hyperstimulation Syndrome

Symptoms:

Treatment:

Back 112

Symptoms: moderate sx + clinical ascites, hydrothorax, hemoconcentration, coagulopathy, VTE, renal/hepatic dysfunction

Treatment: increase fluids to at least 3 L/day, may need albumin, drain ascites if sx