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112 Cards in this Set
- Front
- Back
FSH stimulates:
1. 2. |
1. Follicle Development
2. Estrogen -thickens endometrial lining -thins cervical mucus |
|
LH stimulates:
1. 2. 3. |
1. Follicle maturation and ovulation
2. Androgens for estrogen 3. Progesterone from corpus luteum -maintains endometrium -thickens cervical mucus |
|
No fertilization causes:
1. 2. |
1. Corpus luteum degrades
2. Drop in estrogen and progesterone triggers menses |
|
Fertilization causes:
1. 2. |
1. hCG from blastocyst
2. Stimulates estrogen and progesterone from corpus luteum |
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Probabilities of Conception:
1. Over 1 month: 2. Over 1 year: 3. Over 2 years: |
1. Over 1 month: 20%
2. Over 1 year: 84% 3. Over 2 years: 92% |
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Factors affecting male fertility:
1. 2. 3. 4. |
1. Age
2. Smoking 3. Body weight 4. Excessive EtOH |
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Factors affecting female fertility:
1. 2. 3. |
1. Age
2. Smoking 3. Body weight |
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What are 4 ways to maximize chances of conception?
|
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) |
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Factors that may help maximize chances of conception that have limited/conflicted data:
|
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) |
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Fecundity
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Probably of achieving a live birth in one menstrual cycle
(range 0.15-0.2 per month) |
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Infertility
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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 |
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7 requirements for pregnancy:
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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 |
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What are the characteristics of primary hypogonadism in male infertility?
|
-low testosterone, high FSH
-includes: varicocele, cyptorchidism, medications, congenital/genetic disorders |
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What are the characteristics of secondary hypogonadism in male infertility?
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-low testosterone, low FSH
-includes: tumor, congenital, medications |
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What are the causes of disordered sperm transport?
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Obstruction, erectile dysfunction, retrograde ejaculation
|
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What are the 3 causes of male factor infertility?
|
1. Primary hypogonadism
2. Secondary hypogonadism 3. Disordered sperm transport |
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What are some male gonadotoxins?
|
-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) |
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Initial evaluation of male infertility:
|
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) |
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Semen Analysis
1. Azoospermia: 2. Oligospermia: |
1. Azoospermia: absence of sperm in ejaculate
2. Oligospermia: low sperm concentration |
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When is a full evaluation of male infertility indicated and what should be included?
|
-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 |
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Treatment of primary hypogonadism in male infertility:
|
1. Possible surgical correction (ex: varicocele)
2. Rx: IUI or ART |
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Treatment of secondary hypogonadism in male infertility:
|
1. Goal is to restore spermatogenesis
2. Rx: hormonal therapy |
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Treatment of disordered sperm transport in male infertility:
|
1. Possible surgical correction (ex: obstruction)
2. Rx: IUI or ART |
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Mild Male Infertility due to Primary Hypogonadism or Disordered Sperm Transport
Sperm count: Motility: Treatment: |
Sperm count: 15-20 million/mL
Motility: normal Treatment: expectant management |
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Moderate Male Infertility due to Primary Hypogonadism or Disordered Sperm Transport
Sperm count: Motility: Treatment: |
Sperm count: 10-15 million/mL
Motility: 20-40% Treatment: IUI +/- clomiphene or gonadotropin in female; may require IVF +/- ISCI |
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Severe Male Infertility due to Primary Hypogonadism or Disordered Sperm Transport
Sperm count: Motility: Treatment: |
Sperm count: less than 10 million/mL
Motility: 10% Treatment: IVF + ICSI or donor sperm |
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Treatment Options for Secondary Hypogonadism:
1. a) b) c) 2. a) |
1. Gonadotropins
a) hCG b) rFSH c) hMG (contains LH and FSH) 2. GnRH a) Gonadorelin (Factrel) |
|
hCG (Novarel, Pregnyl)
CI: Warnings: AEs: |
CI: prostatic carcinoma
Warnings: cardiovascular disease, migraines AEs: injection site, edema, depression, fatigue, HA, irritability, gynocomastia |
|
rFSH: Follitropin alfa (Gonal-f, Gonal-f RFF)
CI: AEs: |
CI: increased FSH, tumor of hypothalamus, pituitary or testis, uncontrolled thyroid/adrenal disorders
AEs: injection site, abdominal pain, nausea, HA, upper respiratory infection |
|
hMG: Menotropins (Menopur, Repronex)
CI: AEs: |
CI: pituitary tumor, uncontrolled thyroid/adrenal disorders
AEs: injection site, abdominal pain, HA, nausea |
|
GnRH: Gonadorelin (Factrel)
CI: AEs: |
CI: any condition worsened by reproductive hormones
AEs: cutaneous infection, abdominal pain, flushing, HA, nausea, lightheadedness |
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What is the average amount of time it takes for spermatogenesis to be restored?
|
6-12 months
(occasionally 18-24 mos) |
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What should be monitored when treating male infertility?
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Serum testosterone and semen analysis
|
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What should be included in the evaluation of female infertility?
|
1. History
2. Physical Exam 3. Ovulatory Dysfunction 4. Cervical Factors 5. Uterine Factors 6. Tubal Factors 7. Peritoneal Factors |
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What should be included in a patient's history when evaluating female infertility?
|
1. menstrual history
2. reproductive history 3. sexual history 4. current medications 5. use of tobacco, alcohol, illicit drugs 6. family hx |
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What should be included in a physical exam when evaluating a female infertility?
|
1. thyroid
2. breasts 3. abdomen and pelvis |
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What ovulatory characteristics should be considered when evaluating female infertility?
|
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 |
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What cervical factor is considered when evaluating female infertility?
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Cervical mucus
|
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What uterine factors should be considered when evaluating female infertility?
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1. hysterosalpingography (HSG)
2. ultrasound 3. hysteroscopy |
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What tubal factors should be considered when evaluating female infertility?
|
1. HSG
2. laparoscopy 3. tubal cannulation |
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What peritoneal factors should be evaluated when evaluating female infertility?
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1. ultrasound
2. laparoscopy |
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How does basal body temperature help to predict ovulation?
|
Temperature will rise 0.4-0.8 degrees F after ovulation due to increase in progesterone released from corpus luteum
|
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True or False: Basal body monitoring chart can be used prospectively in confirming ovulation.
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FALSE: can only confirm ovulation retrospectively based on an overall sustained temperature shift
|
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True or False: Any type of thermometer can be used to monitor basal body temperature.
|
FALSE: must use basal body thermometer because it measures temperature in 0.1 or 0.01 degree increments.
|
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How should basal body temperature be measured?
|
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) |
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LH surge occurs __-__ hrs prior to ovulation and is detectable in urine _-__ hrs after surge.
|
12-24; 8-12
|
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True or False: Intensity of color change in urine directly correlates with concentration of LH.
|
TRUE: darker color = higher LH
|
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What are some factors that interfere with urinary LH testing?
|
Endometriosis, PCOS, ovarian failure, menopause, hyperthyroidism, pregnancy, menotropins, danazol, clomiphene, hCG
|
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What time of day should urinary LH testing be completed and what should be done prior to testing?
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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
|
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What are the treatment options for ovulatory dysfunction?
|
1. weight management
2. medications 3. laparoscopic surgery 4. ART |
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What are treatment options for cervical factors attributing to female infertility?
|
1. IUI
2. ART |
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What are treatment options for tubal factors attributing to female infertility?
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1. tubal flushing
2. surgery 3. ART |
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What is the treatment for uterine factors attributing to female infertility?
|
Possible surgical intervention
|
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What are the treatment options for endometriosis?
|
1. laparoscopic surgery
2. ovulation induction and IUI |
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Treatment of amenorrhea/ovulatory dysfunction
Goal: Causes of anovulation suitable for induction: Causes of anovulation NOT suitable for induction: |
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 |
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Treatment of amenorrhea/ovulatory dysfunction due to hypothalamic/pituitary causes:
1. hypogonadotropic hypogonadism: 2. hypothalamic: |
1. hypogonadotropic hypogonadism: gonadotropins
2. hypothalamic: pulsatile GnRH |
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What is the treatment for PCOS?
|
1. clomiphene citrate
2. metformin |
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What is the treatment for premature ovarian failure?
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1. IVF with donor oocyte
2. adoption |
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What is the treatment for tubal defect?
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1. laparoscopy with tubal lavage +/- hysteroscopy
2. IVF |
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What should be used to achieve follicle development?
|
FSH
|
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If sufficient follicle maturation is achieved, what should be given to stimulate ovulation?
|
LH (as hCG)
|
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What warnings are associated with using LH and FSH in treating infertility?
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-multiple gestation, ovarian hyperstimulation syndrome (OHSS), thromboembolic events
|
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When treating hypothalamic/pituitary causes of infertility, if there is an adequate response with follitropins and menotropins, what should be administered?
|
hCG
|
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When should hCG be withheld?
|
estrogen > 2,000 pg/mL
ovarian enlargement abdominal pain |
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Follitropins and menotropins:
CIs: AEs: Monitoring: |
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 |
|
Chorionic Gonadotropin (human)
CIs: AEs: Monitoring: |
CIs: previous hypersensitivity rxn, pregnancy
AEs: injection site rxns, hypersensitivity rxn, edema, fatigue, depression, HA, irritability, restlessness Monitoring: progesterone, estrogen, ultrasound, evidence of ovulation |
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Chorionic Gonadotropin (recombinant)
CIs: AEs: Monitoring: |
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 |
|
Pulsatile GnRH (Factrel, Lutrepulse)
When to use: CIs: AEs: Monitoring: Compared to gonadotropins has less risk of: Rate of ovulation: |
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% |
|
PCOS
Cardinal features: Clinical manifestations: Greater risk of: |
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) |
|
What are the diagnostic criteria for PCOS?
What should obese women with PCOS be screened for? |
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 |
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What are the possible treatments for PCOS?
|
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 |
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What drug is first line for ovulation induction in PCOS?
|
Clomiphene citrate
|
|
Clomiphene Citrate
MOA: Metabolism: CI: Warnings: AEs: Monitoring: |
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 |
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True or False: Metformin is as effective as clomiphene citrate for ovulation induction.
|
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.
|
|
Gonadotropins and GnRH analogs
(First/second) line for ovulation induction in PCOS PCOS patients have increased risk of: Duration should not exceed: Requires: |
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 |
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Compared to conventional dose regimens, low-dose regimens result in:
1. 2. 3. 4. |
1. 70% ovulation rate
2. 20% pregnancy rate 3. 6% multiple low birth rate 4. <1% OHSS rate |
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True or False: It is recommended to add GnRH analog in treatment of PCOS.
|
FALSE. Not recommended - no increase in pregnancy rate, higher hyperstimulation rate, increased risk of multiple pregnancies, and inconvenience and cost regimen
|
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Ovarian surgery as infertility treatment is (first/second) line and involves multiple ______ _________.
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Ovarian surgery as infertility treatment is second line and involves multiple ovarian punctures (laser or diathermy).
|
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True or False: There is no risk of OHSS or high-order multiples associated with ovarian surgery.
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TRUE.
|
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ART-IVF is ____ line for PCOS, has (lower/higher) risk of multiples and a pregnancy rate ______ to non-PCOS women.
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ART-IVF is third line for PCOS, has lower risk of multiples and a pregnancy rate similar to non-PCOS women.
|
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When is IUI used?
|
Used for women with PCOS and male factor infertility or failed to conceive despite infection. There is a risk of excessive stimulation.
|
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What are the causes of tubal defects?
|
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 |
|
What are the management options for tubal defects?
|
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 |
|
Endometriosis
Symptoms: Infertility: |
Symptoms: dysmenorrhea, dyspareunia, chronic non-menstrual pain
Infertility: oocyte development, embryogenesis, implantation, pelvic anatomy |
|
Endometriosis - Treatment of Infertility
1. 2. 3. 4. |
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 |
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What type of infertility is not seen on a basic infertilty workup (ie; evidence of ovulation, patency of fallopian tubes, adequate sperm production)?
|
Unexplained infertility
|
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Unexplained Fertility - Treatment
1. 2. 3. 4. |
*treatment is empiric*
1. intrauterine insemination (IUI) 2. ovulation induction (clomiphene or gonadotropin) 3. IUI + ovulation induction 4. assisted reproductive technology (ART) |
|
What is IUI?
|
Intrauterine insemination
Prepared sperm deposited in uterus at the time of ovulation (natural or induced) |
|
What is IVF-ET?
|
In vitro fertilization embryo transfer
Fertilization aided by mixing sperm/egg in lab |
|
What is ICSI?
|
Intracytoplasmic sperm injection
Single sperm injected into egg cytoplasm |
|
What is GIFT?
|
Gamete intrafallopian transfer
Sperm and egg placed in fallopian tube |
|
What is ZIFT?
|
Zygote intrafallopian transfer
Diploid cell placed in fallopian tube |
|
What is TET?
|
Tubal embryo transfer
Embryo placed in fallopian tube |
|
What are the requirements for assisted conception?
|
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 |
|
What techniques are considered assisted conception?
|
IUI and ART
|
|
What techniques are considered ART?
|
Generally IVF, ISCI, GIFT and ZIFT
|
|
Unexplained Fertility - Treatment
1. 2. 3. 4. |
*treatment is empiric*
1. intrauterine insemination (IUI) 2. ovulation induction (clomiphene or gonadotropin) 3. IUI + ovulation induction 4. assisted reproductive technology (ART) |
|
What is IUI?
|
Intrauterine insemination
Prepared sperm deposited in uterus at the time of ovulation (natural or induced) |
|
What is IVF-ET?
|
In vitro fertilization embryo transfer
Fertilization aided by mixing sperm/egg in lab |
|
What is ICSI?
|
Intracytoplasmic sperm injection
Single sperm injected into egg cytoplasm |
|
What is GIFT?
|
Gamete intrafallopian transfer
Sperm and egg placed in fallopian tube |
|
What is ZIFT?
|
Zygote intrafallopian transfer
Diploid cell placed in fallopian tube |
|
What is TET?
|
Tubal embryo transfer
Embryo placed in fallopian tube |
|
What are the requirements for assisted conception?
|
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 |
|
What techniques are considered assisted conception?
|
IUI and ART
|
|
What techniques are considered ART?
|
Generally IVF, ICSI, GIFT and ZIFT
|
|
What should be taken in the cycle prior to preceding ART?
|
Oral contraceptives and GnRH agonist
|
|
What is involved in ART?
|
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 |
|
What is ovarian hyperstimulation syndrome?
|
-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 |
|
Mild Ovarian Hyperstimulation Syndrome
Symptoms: Treatment: |
Symptoms: abdominal pain and nausea
Treatment: increase oral intake, report worse sx |
|
Moderate Ovarian Hyperstimulation Syndrome
Symptoms: Treatment; |
Symptoms: mild sx + V/D, ascites on US
Treatment: increase fluids, VTE prophylaxis, monitor BMP, LFT, CBC, coags |
|
Severe Ovarian Hyperstimulation Syndrome
Symptoms: Treatment: |
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 |