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3.30 Infertility workup
By Dr. McGoey
84
Pathology
Professional
04/09/2012

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Term
What is the definition of infertility?
Definition
inability to conceive a pregnancy after 12 months of unprotected intercourse
Term
Wha is the prevalence of infertility among reproductive age couples?
Definition
15%
Term
What causes infertility?
Definition
35% female, 30% male, 20% combined factors, 15% idiopathic
Term
Waht are teh causes of female infertility?
Definition
MC= anatomic or mechanical (adhesions/endometriosis), 2nd MC= endocrine or menstrual
Term
What are the 2 most common causes of male infertility?
Definition
1= varicocele, 2= idiopathic (then semen disorders, testicular failure, other, obstruction= cryptorchidism)
Term
What are the risk factors for infertility?
Definition
advanced age, infections, teratogens, past abdominopelvic surgeries
Term
Reduced fertility occurs after age ____.
Definition
36
Term
What causes reduced fertility in females after age 36?
Definition
changing ovulation/menses
Term
What causes reduced fertility in males after age 36?
Definition
decreased levels of testosterone
Term
What infections put you at risk for infertility?
Definition
STDs, mycoplasma, male TB
Term
What teratogens are a risk factor for infertility?
Definition
EtOH (alters ovulatory cycle and decreases testosterone), and tobacco and marijuana (alters cervical mucus and decreases sperm motility)
Term
Why is past abdominopelvic surgeries a risk factor for infertility?
Definition
causes adhesions/obstruction
Term
What quesitons should be asked before working up a couple for infertility?
Definition
pregnancy history, sexual history (frequency of intercourse, dysfunctions, contraceptive techniques), menstural history, social history (STDs, EtOH/drugs, occupation= radiation, heavy metal and pesticide exposures, exercise patterns), surgical history, medicines (tetracycline= decreased testosterone, HTNive and chemotx meds)
Term
What is primary amenorrhea?
Definition
never had a menstrual cycle; not considered until more than 14-16 years of age
Term
Is primary or secondary amenorrhea more common?
Definition
secondary is more common (1% of reproductive age women)
Term
What are the common causes of primary amenorrhea?
Definition
40%=Turner syndrome, 25%= hypothalamus/pituitary, 20%= anatomical defects (mullerian agenesis, imperforate hymen), androgen insensitivity syndrome (5%)
Term
What are the causes of secondary amenorrhea?
Definition
pregnancy, menopause, hypothalamic/pituitary, asherman syndrome, other= celiac sprue, crohns
Term
What are the causes of either primary or secondary amenorrhea?
Definition
pregnancy, androgen secreting tumors, autoimmune disease, chemotherapy/meds, hypo/hyperthyroidism, PCOD, eating disorders, excessive exercise, cushing disease, hyperprolactinemia
Term
What are the general components of the infertility physical exam?
Definition
height/weight/BMI (eating disorders--> hypothalamic dysfunction; obesity--> ovulatory and sperm dysfunction), any dysmorphisms (face, neck, extremities, hair), thyroid exam (hypo and hyperTH signs and symptoms)
Term
What are the components of the GU exam infertility exam?
Definition
secondary sexual development, female= pelvic exam +/- invasive testing; male= inguinal/scrotal exam
Term
What signals gonarche?
Definition
development of external genitalia in boys and breast development in girls
Term
Gonadarche is under the influence of...
Definition
pituitary hormones (gonadotropins, e.g. FSH/LH)
Term
What is adrenarche?
Definition
development of pubic hair, loose association with putberty, under control of adrenal cortical homones (androgens from the zona reticularis)
Term
What are the tanner stages of adrenarche for boys?
Definition
1= prepubertal
2= enlargment of scrotum and testes; scrotal skin reddens and changes in texture
3= enlargment of penis (length at first), further growth of testes
4= increased size of penis with growht in breadth and development of glans; testes and scrotom larger; scrotum skin darker
5= adult genitalia
Term
What are the tanner stages of gonadarche for girls?
Definition
1= prepubertal
2= breast bud with elevation of breast and papilla; enlargment of areola
3= further enlargment of breast and areola; no separation of their contour
4= areola and papilla form a seoncary mound above level of breast
5= mature stage= projection of papilla only, related to recession of areola
Term
What are the tanner stages of adrenarche?
Definition
1= prepubertal velus hair
2= sparse groth of long slightly pigmented hair at base of penis or along labia
3= darker, coarse and more curled hair, spreading sparsely over junciton of pubes
4= hair adult in type but covering smaller area than in adult; no spread to medial surface of thighs
5= adult in type and quantity with horizontal distribution
Term
What are the types of invasive female GU exams used in an infertility exam?
Definition
transvaginal pelvic U/S, hysterosalpingogram, laparoscopy/hysteroscopy
Term
What is a testicular varicocele?
Definition
dilated and tortuous testicular veins (pampiniform plexus)
Term
40% of infertile men are infertile due to...
Definition
varicocele
Term
Where are testicular varicoceles most commonly located?
Definition
left > right but 80% bilateral
Term
How does a varicocele cause infertility?
Definition
increased scrotal temperature or tissue hypoxia
Term
Laboratory work up for infertility in female=
Definition
documentation of ovulation and luteal phase assessment
Term
What is the laboratory w/u for male infertility?
Definition
semen analysis, anti-sperm antibody
Term
What is the laboratory work up for infertility in a couple?
Definition
post coital test, endocrine axis labs in specific situations
Term
At what day of the cycle does ovulation occur?
Definition
day 13-15
Term
What causes the LH surge?
Definition
estrogen increases
Term
What causes ovulation?
Definition
LH surge
Term
How long after the LH surge does ovulation occur?
Definition
36 hours
Term
What days of the cycle is the luteal phase?
Definition
day 15-28
Term
What happens to the ovaries int eh luteal phase?
Definition
empty ovarian follicle degenerates into corpus luteum which secretes progesterone
Term
Progesterone reaches its peak and its trough during what phase of the menstural cycle?
Definition
luteal phase
Term
What happens to the uterus during the luteal phase?
Definition
thick endometrium ready for mensturation; "secretory phase" of endometrium
Term
How do you evaluate ovulation and the luteal phase with labs?
Definition
detect LH surge with urine LH, progesterone levels, basal body temperature chart, endometrial biopsy
Term
What progesterone levels indicate a normal ovulation and luteal phase?
Definition
>4-8 on day 21
Term
What happens to the basal body temperature during the menstural cycle?
Definition
rises due to rising progesterone during the luteal phase
Term
What finding on endometrial biopsy indicates that both ovulation and the luteal phase took place?
Definition
secretory glands after day 15
Term
What is a normal change in BBT for a menstrual cycle?
Definition
rise more than .4 degrees farenheit that stays elevated for more than 10 days and then returns to baseline
Term
What happens to your BBT if you become pregnant?
Definition
increase by .4 degrees stays elevated for more than 3 weeks
Term
How should a semen analysis be collected?
Definition
after 3 days of abstinence, sterile plastic container, room temperature, must be analyzed within 30 minutes
Term
What are the parameters for semen analysis?
Definition
volume, pH, WBCs, concentration, % motile, morphology
Term
What is the normal semen volume?
Definition
5 mL
Term
What is a normal semen pH?
Definition
7.2-7.8
Term
What is a normal WBC count for semen?
Definition
<2000/mL
Term
What is a normal semen concentration?
Definition
approx 15 million sperm/mL
Term
What is a normal motility on semen analysis?
Definition
1/2 should be motile after 1 hour
Term
What is a normal morphology for semen analysis?
Definition
more than half normal
Term
What is the term for abnormal amounds of WBC in semen?
Definition
leucocytospermia
Term
What is the term for abnormally low concentration of sperm in semen?
Definition
azo or oligospermia
Term
What is the term for sperm that are not motile?
Definition
asthenospermia
Term
What is the term for sperm with abnormal morphology?
Definition
teratospermia
Term
Anti-sperm antibodies causes ___% of male infertility.
Definition
5
Term
Agglutination on semen analysis suggests....
Definition
anti-sperm antibodies
Term
What are the risk factors for anti-sperm antibodies?
Definition
infection, trauma, or post vasectomy (70%)
Term
IgA anti-sperm antibodies interferes with...
Definition
sperm-egg interactin
Term
IgG anti-sperm abs interferes with...
Definition
sperm motility
Term
Post coital test is also known as the...
Definition
Sims-Huhner test
Term
The post coital test is testing for...
Definition
cervical mucus and sperm interaction
Term
What is the protocal for the post coital test?
Definition
performed within 1-2 days of ovulation and within 12 hours of intercourse, swab cervical mucus, gross and microscopic examination
Term
What do you call a normal PCT?
Definition
positive= normal; negative= abnormal
Term
Normal cervical mucus on PCT=
Definition
>0.5 mL that stretches (max 8 cm at ovulation) and "ferns"
Term
What is a normal sperm evaluation on PCT?
Definition
>10-20/hpf
Term
What is the most common cause of an abnormal or negative PCT?
Definition
improper timing of test
Term
WHen is an endocrine evluation for infertility indicated?
Definition
women with menstrual abnormalities or men with an abnormal semen analysis
Term
What hormones are evaluated in infertility?
Definition
FSH, LH, prolactin, testosterone, estrogen
Term
What is the more common type of endocrine cause of infertility?
Definition
primary hypogonadism (secondary hypogonadism is less common)
Term
What is primary versus secondary hypogonadism?
Definition
primary hypogonadism is failure at the level of the gonads, secondary is a failure at the level of the hypothalamus pituitary axis
Term
increased FSH/LH with a decreased testosterone/estrogen suggests=
Definition
primary hypogonadism
Term
low FSH/LH with low testosterone/estrogen suggests=
Definition
secondary hypogonadism
Term
Name some physical dysmorphisms suggestive of turner's.
Definition
normal pubic and axillary hair, low posterior hairline, little breast development, short stature, short 4th metacarpals
Term
What are the laboratory findings in PCOS?
Definition
increased testosterone, increased LH with decreased FSH (LH:FSH >2:1)
Term
What do polycystic ovaries look like grossly?
Definition
oyster shell ovaries with 3-7 mm cysts
Term
What percent of women have PCOS?
Definition
5%; 30% of amenorrheic women; 90% of oligomenorrheic women
Term
What are the complications of PCOS?
Definition
infertility, hirsutism, endometrial cancer, obesity (50%), DM (40%)
Term
What is the probability of conception for fertile couples in 1 cycle? 3 cycles? 6 cycles? 12 cycles? 2 years?
Definition
1 cycle= 20%; 2=57%; 3=72%; 12= 85%; 2 years= 93%
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