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98 Cards in this Set
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- Back
Definition of anovulation?
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Failure of ovary to produce egg
Absence of ovulation |
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How does anovulation present?
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Total lack of menstrual cycles, or irregular cycles
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What are common causes of primary anovulation? (4)
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Hypothyroid
Hypothalamic dysfxn Wt related (too obese, too thin) Dysgenic gonads |
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What are common causes of secondary anovulation? (7)
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1) PCOS
2) Hypo/hyperTH 3) HyperPRL 4) Stress 5) Pregnancy 6) Premature ovarian failure 7) Hypothalamic issues |
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What is mechanism by which thyroid dysfunction causes anovulation?
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Indirectly through causing increased PRL
Replacing TH should regulate cycles |
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How does adrenal function affect ovulation?
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Increased adrenal androgen production can lead to central suppression of ovulation
Can treat via inducing ovulation w/ or w/o suppressing adrenal androgen production |
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How do elevated PRL levels affect ovulation?
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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 |
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Difference btw microadenoma and macroadenoma (possible PRL-secreting tumor)?
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Micro: <10mm, usu asymptomatic, can follow w/ imaging x1yr to ensure stability
Macro: >10mm, needs prompt therapy (med or surgical) |
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What is mechanism of significant wt loss causing anovulation?
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Tend to be associated w/ eating disorders and endocrine abnormalities
Lead to hypothalamic anovulation + amenorrhea |
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What is mechanism of xs exercise causing anovulation?
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Can get increased opioid production plus lose wt & body fat -> inhibit ovulation via positive effects on NE and GnRH
Tx: Nalaxone resumes normal cycles |
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What is mechanism of extreme stress causing anovulation?
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Same as w/ xs exercise (opioid production and fat loss -> positive fx on NE and GhRH)
Tx: nalaxone to resume normal cycles |
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Pt w/ Primary amenorrhea and Anosmia. What syndrome?
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Kallmann's syndrome
XL or AR -> inappropriate GnRH secretion Women have normal ovaries, can get ovulation induction |
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What are dysgenic gonads?
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Individuals w/ abnormal karyotype (45XO or 46XY pheno female)
May be mosaic |
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What is ovulation induction?
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Use of meds to stimulate the ovary to produce an egg
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Which classes of medication are used to induce ovulation? (3)
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1) Clomiphene citrate (clomid)
2) Gonadotrophins (FSH +/- LH) 3) GnRH |
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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 |
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When does ovulation occur after clomiphene?
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5-12d after last pill
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What are side effects of clomiphene?
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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 |
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What are risks to pregnancy or fetus w/ clomid?
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NONE!!
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How does clomiphene work?
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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 |
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If pt's HPA is not intact, will clomiphene have an effect on her?
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Not likely - very low yield if her hypothalamic-pituitary axis isn't working
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If woman fails to ovulate on clomid, what can we do?
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Can increase dose to max of 250mg QD x5d
If this doesn't work, go to gonadotropin therapy |
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How to treat hypothalamic amenorrhea-caused anovulation?
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Induce w/ gonadotropins
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How to administer gonadotropins?
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Daily FSH +/- LH injections
Check ovary via US or serum E levels -> when +dominant follicle, induce ovulation w/ hCG |
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What is ovarian hyperstimulation?
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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! |
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What is incidence of ovarian hyperstimulation w/ gonadotropin therapy?
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1-2%
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Can hyperstimulation occur w/ clomiphene?
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YES!
But, rare |
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What is incidence of multifetal pregnancy after ovarian stimulation w/ gonadotrophins?
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10-40%
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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. |
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What is normal chance of conception per cycle?
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20% per cycle attempted
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What is pregnancy success rate in artificial insemination (women is normal) at age:
<30 30-35 >36 |
1) 70-75%
2) 60% 3) 50% |
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What is infertility rate (female) at age:
<30 30-35 35-40 >40 |
1) 10%
2) 15% 3) 30% 4) 60% |
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Definition of infertility?
How common? |
1) Failure to conceive after 1 yr of unprotected intercourse
2) 10-15% of couples 15-44y/o |
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What are education goals for general OB/GYN working w/ infertile couple?
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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 |
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What is pt eval goals for general OB/GYN working w/ infertile couple? (3)
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1) Document ovulation & tubal patency
2) Assess peritoneal factors (adhesions, endometriosis) 3) Test for male factor problems |
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What emotional support & guidance goals for general OB/GYN working w/ infertile couple? (3)
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Counsel on
1) how far to go w/ tests & procedures 2) when to go to more elaborate testing (refer) 3) when to consider adoption |
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What are general causes of infertility and how common are each? (5)
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1) Ovulatory dysfunction: 10-25%
2) Pelvic issues (tubes, endometriosis): 30-50% 3) Male factor: 30-40% 4) Cervical factors: 5-10% 5) Idiopathic |
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Primary vs secondary infertility?
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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 |
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What are characteristics of normal semen analysis?
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Vol >2mL
Motility >/= 50% w/ active progression pH 7.2-7.8 Normal morphology >/= 30% Count >/= 20million/mL |
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What important preconception things to tell a couple? (5)
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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 |
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How to test adequacy of ovulation?
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Biphasic basal body temp chart
Elevated progesterone (>5ng/mL) in luteal phase |
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How to do the basal body temp chart?
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Take temp every day
Record 1st thing in the morning If >98 in 2nd half of cycle, is c/w ovulation |
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What is treatment success rate for ovulation disorders?
For other causes of infertility? |
80-90%
~30% |
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What evidence from pt's history is c/w ovulation?
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Menses at regular intervals Q month
Mittelschmerz (LQ discomfort @ ovulation) Breast tenderness & pelvic discomfort Mild dysmenorrhea |
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What are moliminal symtoms?
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Breast tenderness and pelvic discomfort during PMS/early menses
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How does one document tubal patency?
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Hysterosalpingogram (HSG)
= Inject radioopaque dye into uterine cavity, several days after onset of menses |
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What are contraindications to HSG?
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Acute pelvic infection
Give women with adnexal tenderness or h/o pelvic infection a course of doxy before procedure |
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What are possible complications of HSG?
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Pain
Acute salpingitis (1-3%) |
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What are common uterine lesions shown by HSG?
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Intrauterine adhesions
Submucous fibroids Polyps |
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Why is water-soluble HSG dye often preferred over an oil-based one?
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Water-based allows ideal visualization of tubal mucosa (oil-based obscures this)
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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 |
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What is best method for myomectomy, in terms of treating infertility?
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No difference has been shown for laparotomy vs laparoscopy in fertility outcome.
Can remove submucosal myomas via hysteroscopy |
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What is association btw congenital uterine anomalies and infertility?
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Are associated w/ pregnancy loss, not w/ infertility.
However, CUAs can be associated w/ severe endometriosis, which can impair fertility |
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How to manage women with uterine septum and fertility issues?
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Resect septum w/ hysteroscopy.
Consider post-op treatment of uterine cavity w/ high-dose estrogen or IUD/Foley balloon insertion to prevent adhesions |
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How to manage bicornuate uterus in pt w/ fertility issues?
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Controversial. Consider:
1) uterine reconstruction w/ Tompkins or Strassman metroplasty 2) prophylactic cerclage |
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What is relationship btw operative method of treating endometriosis & fertility outcome?
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All are similar!
Cautery, excision, and laser ablation all have similar outcomes |
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What is the postcoital test in an infertility workup?
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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 |
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What is MCC of abnormal postcoital test?
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Wrong timing!
Many normally fertile couples have abnormal tests, so this might not be the best assessment... |
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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 |
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What is clue in pt's infertility w/u that it might be a tubal factor?
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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!! |
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What does assisted reproductive technology (ART) employ?
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IVF
Intracytoplasmic sperm injection Gamete intrafallopian transfer Zygote intrafallopian transfer |
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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 |
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What are secondary tests in an infertility w/u?
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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! |
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What is IVF?
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In vitro fertilization = fertilize egg w/ sperm outside body
Also includes Gamete intrafallopian transfer (GIFT) & Zygote intrafallopian transfer (ZIFT) |
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What is IVF success rate?
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25% -> liveborn child
5% ectopic |
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How many IVF cycles are performed per year in the U.S.?
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~60,000
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What percent of couples undergoing infertility workup will need IVF?
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~25%
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What is risk of major congenital malformation in kid conceived via IVF vs spontaneously?
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Both are ~3%
There is slightly higher risk w/ kid conceived through intracytoplasmic sperm injection (ICSI) - one sperm injected into an egg |
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What are indications for IVF? (7)
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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%) |
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What is relation btw maternal age and IVF success rate?
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Declines with increasing maternal age
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Which studies to do prior to IVF?
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1) Semen analysis
2) Ovarian reserve (FSH levels on d3 of cycle) 3) HSG, hysteroscopy, or sonohysterography to assess uterine cavity |
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What test should pts >30y/o, w/ one ovary, prior ovarian surgery, or poor prior OI response undergo prior to IVF?
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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 |
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What options for AMA women or w/ diminished ovarian reserve?
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Donor eggs (~50% pregnancy rate)
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What meds to mature eggs during IVF cycle?
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1) GnRH agonist (leuprolide/Leupron) 1 wk after ovulation SQ
2) FSH-containing med for 10d SQ |
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How to monitory during IVF cycle for optimal egg quality & number?
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serial TVUS
Measure E2 & progesterone Tailor med doses to these levels! |
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When to administer hCG to trigger during IVF?
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Lead follicles are ~18mm diameter + correct E2 lelve
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How long after hCG trigger do you retrieve oocytes in IVF cycle?
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~37 hrs after injection
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How to do egg retrieval during IVF?
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US-guided needle aspiration through vagina w/IV sedation
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When is intracytoplasmic sperm injection indicated in IVF?
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1) If male has severe abnormalities in sperm count, motility, &/or morphology
2) Couple w/ previous poor fertilization in prior IVF cycle |
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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 |
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What percent of embryos are chromosomally abnormal?
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30-70%
Therefore, in IVF it's important to observe all the fertilized eggs and pick the ones that seem the most fit! |
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Which embryos can benefit from assisted hatching in IVF? (4)
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1) AMA women
2) Pts with elevated d3 FSH levels 3) Couples w/ prior failed IVF cycles 4) Eggs w/ subjectively thick zonas |
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What is assisted hatching in IVF?
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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
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How many embryos are typically returned to uterine cavity in IVF?
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2-4 per cycle.
More if embryos are of lesser quality |
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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! |
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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 |
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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! |
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How to optimize uterine receptivity in IVF cycle?
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Give supplemental progesterone after oocyte retrieval
?Glucocorticoids, ABX, hCG injections MAY help |
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How to treat ovarian hyperstimulation syndrome? (OHSS)
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Hospitalize!
Aggressive hydration (even if worsens ascites) Paracentesis PRN |
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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 |
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What are the more severe complications of OHSS? (3)
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Prerenal azotemia
Hemoconcentration DIC |
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What are reasons some couples fail IVF?
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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 |
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What is max # of IVF cycles a couple should undergo?
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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!) |
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What are possible advantages of using GnRH ANTagonist in IVF cycle?
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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 |
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T or F: It helps to remove hydrosalpinxes prior to IVF cycle?
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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. |
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At what stage are embryos transfered to uterus in IVF?
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Usually 3d after retrieval (have 4-8 cells)
But, if are kept 5-6d after retrieval (=blastocyst stage), fewer are usually transferred |
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What is endometrial glandular integrin αυβ3 and what is its role in infertility?
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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 |
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Name 4 FSH-containing drugs
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1) Pergonal
2) Gonal-F 3) Repronex 4) Follistim |