Term
| what constitutes a "normal" couple in terms of fertility? |
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Definition
| 25% conceive after 1 month of trying, 60% conceive after 6 months, and 85% conceive after 12 months. |
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Term
| why does a woman's fertility decrease as she ages? |
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Definition
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Term
| what is the definition of infertility under 35 y/o? |
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Definition
| failure to conceive after 1 year of trying |
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Term
| what is the definition of infertility over 35 y/o? |
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Definition
| failure to conceive after 6 months of trying (do not want to wait a full year before evaluating - time is more of an issue) |
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Term
| what are other considerations which may affect how soon infertility evaluation is initiated besides age? |
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Definition
| high degree of anxiety/stress and hx: menstrual/STD/pelvic sx or path/male reproductive disease |
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Term
| what are the types of infertility? |
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Definition
| primary: failure to conceive for a couple who never has been pregnant before. secondary: failure to conceive for a couple that has been pregnant before. |
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Term
| what is the breakdown for infertility etiology? |
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Definition
| **40% male problem**, 40% female problem, 10% combined, and 10% unknown (there are ways to tx unknown reasons, just no definitive etiology) |
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Term
| what characterizes why male-related reasons for infertility? |
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Definition
| *37% varicocele*, semen disorders, tube obstruction, and testicular failure |
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Term
| what characterizes why female-related reasons for infertility? |
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Definition
| 40% ovulatory dysfunction/anovulation, mechanical factors (scar tissue, anatomical abnormalities, tubal occlusion, endometriosis - inflammatory/fibrosis), cervical abnormalities (rarer causes: fibroids/polyps/stenosis/mucous/congenital abnormalities), and tubal factors (primarily due to PID/STIs = scarring, adhesions, may be congenital) |
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Term
| what would lead to decreased sperm production in males? |
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Definition
| varicocele, testicular failure, stress, smoking, and heat |
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Term
| what would lead to ductal obstruction in males? |
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Definition
| infection, congenital absence of the vas deferens (CAVD) |
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Term
| what would lead to failure of sperm delivery in males? |
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Definition
| ejaculatory dysfunction, hypospadias, sexual dysfunction |
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Term
| what would lead to abnormal semen in males? |
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Definition
| high viscosity, abnormal volume |
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Term
| what is the single most common cause of female infertility? what are the different etiologies for this cause? |
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Definition
| *ovulatory dysfunction*, of which PCOS is the most common cause (an endocrinopathy affecting 10% of all reproductive age women). ovarian failure/premature menopause is also possible (these pts require egg donation). diminished ovarian reserve (newer concept - poor oocyte quality/advanced biological age). and hypothalamic hypogonadism, where signals from the hypothalamus (for estrogen production/egg development) are nonexistent/distorted (seen in ballet dancers, anorexics) |
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Term
| what are the cysts in PCOS? how does an ovary affected by this appear? how are PCOS ovaries best visualized? |
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Definition
| multiple immature egg sacs. an ovary affected by this has an unusually smooth exterior (due to anovulation). PCOS ovaries are best visualized via US (pearl necklace sign - multiple egg sacs peripherally arranged in the ovary). |
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Term
| what does the dx for male infertility rest on? |
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Definition
| semen analysis, characterized by: concentration, motility, and morphology |
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Term
| what is evaluated in terms of semen concentration? |
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Definition
| a male should have > 20 million sperm/mL to be fertile |
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Term
| what is evaluated in terms of semen motility? |
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Definition
| more than 50% sperm moving |
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Term
| what is evaluated in terms of semen morphology? |
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Definition
| using kruger strict criteria for perfectly shaped sperm, > 14% should match this in a fertile male's sample |
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Term
| what instructions are given to a male prior to semen analysis? |
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Definition
| abstinence from ejaculation for 2-3 days and the sample needs to be at the lab w/in an hour and kept at body temperature in a sterile container |
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Term
| how is ovulation evaluated? |
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Definition
| all evaluations revolve around *progesterone (hormone secreted w/and after ovulation/luteal phase): basal body temp charts, ovulation predictor kits, endometrial bx, hormone testing, and US. |
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Term
| how are basal body temp charts used to evaluate ovulation? |
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Definition
| this looks at the thermogenic effects of progesterone on body temperature - temp will rise and remain elevated until the next period (or if you become pregnant, it will remain elevated). |
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Term
| how are ovulation/predictor kits used to evaluate ovulation? |
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Definition
| this relies on the *LH surge just prior to ovulation which pts can can check prospectively for |
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Term
| how are endometrial bxs used to evaluate ovulation? |
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Definition
| not practical/pleasant - this looks at histologic changes which occur in the lining of the uterus (becomes thicker/glands become more prominent) related to progesterone secretion |
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Term
| how hormone testing used to evaluate ovulation? |
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Definition
| serum progesterone levels are drawn |
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Term
| how are transvaginal USs used to evaluate ovulation? |
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Definition
| this allows evaluation of follicle, follicular rupture and corpus luteum development |
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Term
| when does progesterone peak in the menstrual cycle? |
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Definition
| at the point between ovulation and the next period (if the egg is not fertilized). this correlates w/highest temperature and thickest endometrium. |
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Term
| when does LH surge during the menstrual cycle? |
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Definition
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Term
| what does utero-tubal evaluation consist of? |
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Definition
| hysterosalpingogram (HSG), hysteroscopy, saline infusion sonography, and laparoscopy |
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Term
| how is an HSG used in utero-tubal evaluation? |
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Definition
| an HSG involves injection of radiopaque dye into the reproductive tract and following this via fluoroscopy or x-ray. |
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Term
| how is hysteroscopy used in utero-tubal evaluation? |
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Definition
| this allows direct visualization of the uterine cavity, but cannot give tubal evaluation |
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Term
| how is saline infusion sonography used in utero-tubal evaluation? |
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Definition
| the uterine cavity is distended w/fluid, allowing visualization of the uterus via US |
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Term
| how is laparoscopy used in utero-tubal evaluation? |
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Definition
| this is the *only way to r/o endometriosis (can only be diagnosed surgically) and is also the best way to visualize pelvic adhesions. |
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Term
| how is the cervical factor evaluated? |
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Definition
| the post-coital test (PCT), where intercourse should have happened 2-12 hrs prior (timed mid-cycle). cervical mucus amount/quality and sperm-mucus interactions are evaluated. this may need repeating. |
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Term
| what should the first couple consultation visit include? |
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Definition
| medical hx (including reproductive/sexual/surgical hx), description of testing modalities, counseling (correct misinformation, outline therapies, discuss alternatives), and physical exam/hormonal studies |
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Term
| what tests are run on the initial visit? |
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Definition
| ovulation evaluation which 40% of the time will find the cause (BBT, LH kit, *mid-luteal P4 levels*, midcycle US, endometrial bx), semen analysis - which 40% of the time will find the cause, post-coital test, SIS and/or HSG (HSG if tubal disease is suspected), and day 3 tests of ovarian reserve (blood test). |
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Term
| what are additional (2nd line) tests run for infertility dx? |
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Definition
| genetic screening, laparoscopy, hysterectomy, and sperm function testing |
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Term
| what is all female testing dependent on? |
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Definition
| the menstrual cycle. day 3: FSH levels (determines if diminished ovarian reserve), day 5-9: SIS/HSG (shortly after menstrual phase), day 14: PCT, mid cycle US (look for dominant follicle), cxs (r/o infection), day 21: mid luteal P4 (progesterone should be at peak, this will determine if ovulation occurred and if fertility drugs are indicated). |
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Term
| what is very important to do at the beginning of a infertile couple work up? |
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Definition
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Term
| what % of infertility can be traced to specific causes? |
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Definition
| 90% w/proper evaluation - tx is available for most pts and most couples who seek tx succeed in getting pregnant. |
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