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98 Cards in this Set

  • Front
  • Back
Definition of anovulation?
Failure of ovary to produce egg
Absence of ovulation
How does anovulation present?
Total lack of menstrual cycles, or irregular cycles
What are common causes of primary anovulation? (4)
Hypothyroid
Hypothalamic dysfxn
Wt related (too obese, too thin)
Dysgenic gonads
What are common causes of secondary anovulation? (7)
1) PCOS
2) Hypo/hyperTH
3) HyperPRL
4) Stress
5) Pregnancy
6) Premature ovarian failure
7) Hypothalamic issues
What is mechanism by which thyroid dysfunction causes anovulation?
Indirectly through causing increased PRL

Replacing TH should regulate cycles
How does adrenal function affect ovulation?
Increased adrenal androgen production can lead to central suppression of ovulation

Can treat via inducing ovulation w/ or w/o suppressing adrenal androgen production
How do elevated PRL levels affect ovulation?
Interfere w/ GnRH production -> decreases pituitary gonadotropin production

Can stem from HyperTH or PRL-secreting tumor (MC pituitary tumor, do MRI or CT)

Tx w/ DA agonists to decrease PRL levels
Difference btw microadenoma and macroadenoma (possible PRL-secreting tumor)?
Micro: <10mm, usu asymptomatic, can follow w/ imaging x1yr to ensure stability

Macro: >10mm, needs prompt therapy (med or surgical)
What is mechanism of significant wt loss causing anovulation?
Tend to be associated w/ eating disorders and endocrine abnormalities
Lead to hypothalamic anovulation + amenorrhea
What is mechanism of xs exercise causing anovulation?
Can get increased opioid production plus lose wt & body fat -> inhibit ovulation via positive effects on NE and GnRH

Tx: Nalaxone resumes normal cycles
What is mechanism of extreme stress causing anovulation?
Same as w/ xs exercise (opioid production and fat loss -> positive fx on NE and GhRH)

Tx: nalaxone to resume normal cycles
Pt w/ Primary amenorrhea and Anosmia. What syndrome?
Kallmann's syndrome

XL or AR -> inappropriate GnRH secretion
Women have normal ovaries, can get ovulation induction
What are dysgenic gonads?
Individuals w/ abnormal karyotype (45XO or 46XY pheno female)

May be mosaic
What is ovulation induction?
Use of meds to stimulate the ovary to produce an egg
Which classes of medication are used to induce ovulation? (3)
1) Clomiphene citrate (clomid)
2) Gonadotrophins (FSH +/- LH)
3) GnRH
What is primary indication for Clomid?

Dose & when to take?
Oligo-ovulation, esp 2/2 PCOS

Take PO QD of 5d-9d of cycle
Start @50mg for first cycle
When does ovulation occur after clomiphene?
5-12d after last pill
What are side effects of clomiphene?
Vasomotor flushes (10%)
Abdominal distension (5.5%)
Bloating, abd pain, breast tenderness (2%)
N/V
H/A
Hair loss

Note: Blurred vision or scotoma require d/c of med
What are risks to pregnancy or fetus w/ clomid?
NONE!!
How does clomiphene work?
Non-steroidal agent, distant relation to diethylstilbesterol
Acts as wk estrogen at pituitary
Bind E-Rs and occupies for long periods of time -> abolishes E's negative feedback on pituitary & causes increased FSH action on the ovary
If pt's HPA is not intact, will clomiphene have an effect on her?
Not likely - very low yield if her hypothalamic-pituitary axis isn't working
If woman fails to ovulate on clomid, what can we do?
Can increase dose to max of 250mg QD x5d
If this doesn't work, go to gonadotropin therapy
How to treat hypothalamic amenorrhea-caused anovulation?
Induce w/ gonadotropins
How to administer gonadotropins?
Daily FSH +/- LH injections
Check ovary via US or serum E levels -> when +dominant follicle, induce ovulation w/ hCG
What is ovarian hyperstimulation?
Ovaries are significantly enlarged 2/2 xs number of follicles
Fluid accumulates in abdomen -> wt gain + abd distentsion +/- severe fluid/'lyte imbalances
May need hospitalization!
What is incidence of ovarian hyperstimulation w/ gonadotropin therapy?
1-2%
Can hyperstimulation occur w/ clomiphene?
YES!
But, rare
What is incidence of multifetal pregnancy after ovarian stimulation w/ gonadotrophins?
10-40%
What are advantages of GnRH therapy for ovulation vs gonadotrophins?
What are disadvantages?
1) GnRH: less frequent ovarian hyperstimulation, may need less intense monitoring
2) GnRH: needs continuous SQ injections (rather than QD injections) - so must be on pump.
What is normal chance of conception per cycle?
20% per cycle attempted
What is pregnancy success rate in artificial insemination (women is normal) at age:
<30
30-35
>36
1) 70-75%
2) 60%
3) 50%
What is infertility rate (female) at age:
<30
30-35
35-40
>40
1) 10%
2) 15%
3) 30%
4) 60%
Definition of infertility?
How common?
1) Failure to conceive after 1 yr of unprotected intercourse
2) 10-15% of couples 15-44y/o
What are education goals for general OB/GYN working w/ infertile couple?
Educate about:
1) Reproduction basics
2) Chances of becoming pregnant
3) When best to have intercourse
4) Common infertility causes
5) Tests available
6) Cost & discomfort of tests
7) Therapies available
8) Expected tx success rates
What is pt eval goals for general OB/GYN working w/ infertile couple? (3)
1) Document ovulation & tubal patency
2) Assess peritoneal factors (adhesions, endometriosis)
3) Test for male factor problems
What emotional support & guidance goals for general OB/GYN working w/ infertile couple? (3)
Counsel on
1) how far to go w/ tests & procedures
2) when to go to more elaborate testing (refer)
3) when to consider adoption
What are general causes of infertility and how common are each? (5)
1) Ovulatory dysfunction: 10-25%
2) Pelvic issues (tubes, endometriosis): 30-50%
3) Male factor: 30-40%
4) Cervical factors: 5-10%
5) Idiopathic
Primary vs secondary infertility?
Primary: woman has never been pregnant despite >1yr of unprotected intercourse
Secondary: Has h/o proven pregnancy (live, ectopic, AB) but is currently unable to conceive despite >1yr unprotected sex
What are characteristics of normal semen analysis?
Vol >2mL
Motility >/= 50% w/ active progression
pH 7.2-7.8
Normal morphology >/= 30%
Count >/= 20million/mL
What important preconception things to tell a couple? (5)
1) 20% chance per cycle
2) Avoid smoking, limit caffeine
3) 400IU folic acid QD
4) Intercourse timing
5) When to return if not pregnant
How to test adequacy of ovulation?
Biphasic basal body temp chart
Elevated progesterone (>5ng/mL) in luteal phase
How to do the basal body temp chart?
Take temp every day
Record 1st thing in the morning
If >98 in 2nd half of cycle, is c/w ovulation
What is treatment success rate for ovulation disorders?
For other causes of infertility?
80-90%

~30%
What evidence from pt's history is c/w ovulation?
Menses at regular intervals Q month
Mittelschmerz (LQ discomfort @ ovulation)
Breast tenderness & pelvic discomfort
Mild dysmenorrhea
What are moliminal symtoms?
Breast tenderness and pelvic discomfort during PMS/early menses
How does one document tubal patency?
Hysterosalpingogram (HSG)
= Inject radioopaque dye into uterine cavity, several days after onset of menses
What are contraindications to HSG?
Acute pelvic infection
Give women with adnexal tenderness or h/o pelvic infection a course of doxy before procedure
What are possible complications of HSG?
Pain
Acute salpingitis (1-3%)
What are common uterine lesions shown by HSG?
Intrauterine adhesions
Submucous fibroids
Polyps
Why is water-soluble HSG dye often preferred over an oil-based one?
Water-based allows ideal visualization of tubal mucosa (oil-based obscures this)
When to offer laparoscopy to infertile woman?
What use is it for infertility workup?
1) Offer after male factor and ovulatory functions have been shown to be normal or corrected
2) Can show & treat endometrial implants or distal tubal occlusion
What is best method for myomectomy, in terms of treating infertility?
No difference has been shown for laparotomy vs laparoscopy in fertility outcome.
Can remove submucosal myomas via hysteroscopy
What is association btw congenital uterine anomalies and infertility?
Are associated w/ pregnancy loss, not w/ infertility.
However, CUAs can be associated w/ severe endometriosis, which can impair fertility
How to manage women with uterine septum and fertility issues?
Resect septum w/ hysteroscopy.
Consider post-op treatment of uterine cavity w/ high-dose estrogen or IUD/Foley balloon insertion to prevent adhesions
How to manage bicornuate uterus in pt w/ fertility issues?
Controversial. Consider:
1) uterine reconstruction w/ Tompkins or Strassman metroplasty
2) prophylactic cerclage
What is relationship btw operative method of treating endometriosis & fertility outcome?
All are similar!
Cautery, excision, and laser ablation all have similar outcomes
What is the postcoital test in an infertility workup?
Done at midcycle, w/in 12hrs of intercourse, assess woman's cervical mucous for quality & quantity, and for # of motile sperm
Normal test shows abundant, clear, watery and relatively acellular mucous w/ >5 motile sperm per HPF
What is MCC of abnormal postcoital test?
Wrong timing!
Many normally fertile couples have abnormal tests, so this might not be the best assessment...
How to treat proximal tubal disease in infertility?
Distal tubal disease?
Both at once?
Very severe cases of either?
Case w/ hydrosalpinx?
1) Hysteroscopic or radiologic tubal canalizaton
2) Distal salpingosgtomy
3) Use IVF!
4) IVF
5) Remove hydrosalpinx, then IVF
What is clue in pt's infertility w/u that it might be a tubal factor?
History of:
Previous ectopic
Previous tubal surgery
Ruptured appy
TB
IUD use
Septic AB
STDs (GC/CT)
But, 50% of women w/ tubal dmg or pelvic adhesions have no history of these factors!!
What does assisted reproductive technology (ART) employ?
IVF
Intracytoplasmic sperm injection
Gamete intrafallopian transfer
Zygote intrafallopian transfer
What are the 3 primary tests in an infertility w/u?
Additional tests if woman >35
1) Semen analysis, document ovulation, assess tubal patency (HSG)
2) Assess ovarian reserve, laparoscopic eval of pelvis
What are secondary tests in an infertility w/u?
Assess:
Cervical factor (postcoital test)
Immunological defects
Luteal phase defects
Hamster egg penetration assay
Culture semen and cervix
Note: Treatment of these abnormal test results has NOT been shown to improve fertility outcomes!
What is IVF?
In vitro fertilization = fertilize egg w/ sperm outside body
Also includes Gamete intrafallopian transfer (GIFT) & Zygote intrafallopian transfer (ZIFT)
What is IVF success rate?
25% -> liveborn child

5% ectopic
How many IVF cycles are performed per year in the U.S.?
~60,000
What percent of couples undergoing infertility workup will need IVF?
~25%
What is risk of major congenital malformation in kid conceived via IVF vs spontaneously?
Both are ~3%

There is slightly higher risk w/ kid conceived through intracytoplasmic sperm injection (ICSI) - one sperm injected into an egg
What are indications for IVF? (7)
1) Tubal factor (26%)
2) Male factor (27%)
3) Endometriosis (14.7%)
4) Ovulatory dysfunction (12.4%)
5) Other (9%)
6) Unexplained (8.7%)
7) Uterine factor (2.2%)
What is relation btw maternal age and IVF success rate?
Declines with increasing maternal age
Which studies to do prior to IVF?
1) Semen analysis
2) Ovarian reserve (FSH levels on d3 of cycle)
3) HSG, hysteroscopy, or sonohysterography to assess uterine cavity
What test should pts >30y/o, w/ one ovary, prior ovarian surgery, or poor prior OI response undergo prior to IVF?
Clomiphene challenge test - 100mg PO d5-d9 of cycle, take FSH level on d3 and d10

If have single high FSH level, will have 1% success rate w/ IVF
What options for AMA women or w/ diminished ovarian reserve?
Donor eggs (~50% pregnancy rate)
What meds to mature eggs during IVF cycle?
1) GnRH agonist (leuprolide/Leupron) 1 wk after ovulation SQ
2) FSH-containing med for 10d SQ
How to monitory during IVF cycle for optimal egg quality & number?
serial TVUS
Measure E2 & progesterone
Tailor med doses to these levels!
When to administer hCG to trigger during IVF?
Lead follicles are ~18mm diameter + correct E2 lelve
How long after hCG trigger do you retrieve oocytes in IVF cycle?
~37 hrs after injection
How to do egg retrieval during IVF?
US-guided needle aspiration through vagina w/IV sedation
When is intracytoplasmic sperm injection indicated in IVF?
1) If male has severe abnormalities in sperm count, motility, &/or morphology
2) Couple w/ previous poor fertilization in prior IVF cycle
In a typical IVF cycle, what % of eggs fertilize?
What is criteria for an egg to go through ICSI?
1) ~70%
2) Must be mature and have gone to meiosis II w/ formation of polar body
What percent of embryos are chromosomally abnormal?
30-70%

Therefore, in IVF it's important to observe all the fertilized eggs and pick the ones that seem the most fit!
Which embryos can benefit from assisted hatching in IVF? (4)
1) AMA women
2) Pts with elevated d3 FSH levels
3) Couples w/ prior failed IVF cycles
4) Eggs w/ subjectively thick zonas
What is assisted hatching in IVF?
Cleaved embryo needs help in hatching out of its zona pellucida (protective covering), so we can thin the zona with an acid solution prior to uterine transfer
How many embryos are typically returned to uterine cavity in IVF?
2-4 per cycle.
More if embryos are of lesser quality
What are rates of multiple births in IVF with:
7+ embryos transferred?
6?
5?
4?
3?
2?
1?
1) 10.3%
2) 10.5%
3) 11.2%
4) 14.1%
5) 14.1%
6) 6.9%
7) 0 - duh!
What are live birth rates in IVF with:
7+ embryos transferred?
6?
5?
4?
3?
2?
1?
1) 25.9
2) 27.0
3) 29.7
4) 34.1
5) 35.7
6) 26.0
7) 8.1
Note: these figures are from 1998
Is successful pregnancy possible with frozen embryos?
When to freeze embryos?
Any increased risk for congenital malformations or mental retardation?
1) YES! Up to 10-yrs frozen have resulted in successful pregnancy. But, frozen egg transfer is only 50% as successful as fresh transfer
2) Freeze 1d after oocyte retrieval at two-pronuclear stage or several days later at blastocyst stage. Dehydrate eggs prior to freezing!!
3) NOPE!
How to optimize uterine receptivity in IVF cycle?
Give supplemental progesterone after oocyte retrieval
?Glucocorticoids, ABX, hCG injections MAY help
How to treat ovarian hyperstimulation syndrome? (OHSS)
Hospitalize!
Aggressive hydration (even if worsens ascites)
Paracentesis PRN
When does OHSS typically occur in IVF cycle?
Who most commonly gets it in IVF?
1) 1 week after oocyte retrieval
2) Young women with very high E2 concentrations
What are the more severe complications of OHSS? (3)
Prerenal azotemia
Hemoconcentration
DIC
What are reasons some couples fail IVF?
1) Less than optimal ovarian stimulation (AMA, decreased reserve, or just inadequate med doses)
2) Poor fertilization
3) Poor embryo quality
4) Poor embryo transfer technique
What is max # of IVF cycles a couple should undergo?
No set number - success varies with IVF lab.
Usually no more than 3 cycles.
(Success is about equal with 1-2 prior failures, though, so keep trying up to 3!)
What are possible advantages of using GnRH ANTagonist in IVF cycle?
1) May shorten stimulation protocol (need fewer injections and less FSH med amounts)
2) Women with fewer eggs or high FSH levels may make more eggs!
3) Pregnancy rates are similar w/ GnRH agonists and antagonists
T or F: It helps to remove hydrosalpinxes prior to IVF cycle?
TRUE!

Even though procedure bypasses the tube, meta-analyses have shown that the presence of hydrosalpinxes lower pregnancy rates by 50%
Presence often leads to implantation failure.
At what stage are embryos transfered to uterus in IVF?
Usually 3d after retrieval (have 4-8 cells)

But, if are kept 5-6d after retrieval (=blastocyst stage), fewer are usually transferred
What is endometrial glandular integrin αυβ3 and what is its role in infertility?
Seems to be closely tied to normal uterine receptivity
Its expression is decreased in women with endometriosis, hydrosalpinges, primary unexplained infertility, recurrent pregnancy loss, and PCOS
Name 4 FSH-containing drugs
1) Pergonal
2) Gonal-F
3) Repronex
4) Follistim