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Questions and Answers
What is the primary cause of luteal phase defect?
Which medication acts as a selective estrogen receptor modulator (SERM) to stimulate ovulation?
What is a common symptom of ovarian hyperstimulation syndrome (OHSS)?
Which uterine disorder is considered most common and related to pregnancy loss?
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What is the typical cause of hydrosalpinx, a common tubal factor in infertility?
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What is the most appropriate action for a woman over 35 experiencing infertility due to ovarian factors?
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Which statement accurately describes the role of Metformin in infertility treatment?
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What is a severe consequence of overproduction of large follicles in ovarian hyperstimulation syndrome?
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What is the definition of infertility in couples under 35 years of age?
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Which factor is considered the sole cause of infertility in approximately 20% of cases?
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At what age should couples immediately begin infertility evaluation?
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Which of the following is NOT a sign of potential male infertility?
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What percentage of infertility cases can be attributed to ovarian factors?
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Which test is most important in assessing male infertility?
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When assessing ovarian reserve in women over 40, which laboratory test is recommended?
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What is a common diagnostic indicator for hormonal imbalance associated with infertility in women?
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Which of the following conditions can lead to an earlier evaluation for infertility in women?
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What is a common risk factor for male infertility linked to past medical history?
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Which assessment is crucial for determining ovarian function in women who are experiencing infertility?
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What is the primary factor attributed to female infertility in approximately 40% of cases?
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At what point does fecundity begin to decrease significantly in women?
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Which male factor is the most critical parameter in semen analysis?
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Which condition signifies a potential hormonal imbalance in women that may affect fertility?
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What significant change occurs in ovarian reserve as women age beyond 40?
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What is the primary mechanism by which Clomiphene Citrate aids in ovulation?
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What potential condition can arise from prolonged use of Clomiphene Citrate?
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What is a common characteristic of Uterine Factors related to infertility?
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What is the most serious consequence of severe Ovarian Hyperstimulation Syndrome (OHSS)?
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What describes a common complication of a hydrosalpinx?
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Which hormone is typically elevated in patients with luteal phase defect during the luteal phase?
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What is a potential reason for infertility in women with Polycystic Ovary Syndrome (PCOS) who do not respond to Clomiphene Citrate?
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What is the primary treatment for luteal phase defect?
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Which factor is associated with a significant increase in infertility rates, particularly after the age of 35?
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What is the first step in evaluating a male partner's infertility risk based on history?
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What percentage of couples face infertility as a result of male factors alone?
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Which laboratory test is an essential indicator of ovarian reserve in women over 40?
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In investigating causes of female infertility, which sign may indicate androgen excess?
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Which hormonal changes are typically associated with ovarian factors in infertility?
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At what age should women with a history of oligomenorrhea seek an infertility evaluation?
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Which condition could require an earlier infertility assessment besides age?
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What is a key therapeutic approach for luteal phase defect?
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What is a significant feature of ovarian hyperstimulation syndrome (OHSS)?
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In what situation is Metformin especially recommended as a treatment?
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What is the primary diagnostic method to assess uterine and tubal factors in infertility?
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What is the underlying issue in a luteal phase defect?
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What condition is most likely to result from severe ovarian hyperstimulation syndrome (OHSS)?
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Which condition is considered the most common female anatomical issue associated with infertility?
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What is the recommended course of action for a woman exhibiting signs of hydrosalpinx?
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Study Notes
Infertility Definition
- Infertility: A couple's failure to achieve pregnancy after one year of regular, unprotected intercourse.
- Diagnosis can be made after 6 months for women over 35 years old.
- Incidence: 15-20% of couples in the United States.
When to Evaluate for Infertility
- Evaluate couples who meet the definition of infertility.
- Earlier evaluation for women over 35 years old due to the rapid increase in infertility after 35, especially after 42.
- Evaluate earlier for individuals with a history of amenorrhea, oligomenorrhea, suspected tubal disease, endometriosis, Mullerian variations, risk factors for ovarian insufficiency (chemotherapy, radiation, autoimmune diseases, ovarian surgery), and male risk factors (testicular torsion/cancer, orchitis/mumps, unsuccessful conception).
Infertility Causes
- Male factor (20% of cases).
- Ovarian/Tubal factors (more than 45% of cases).
- Infertility often results from more than one factor.
Infertility Workup: Exam
- Female:
- Evaluate weight, BMI, and blood pressure.
- Assess for signs of systemic illnesses like diabetes, autoimmune disorders, and metabolic syndrome.
- Examine the thyroid for enlargement, nodules, and tenderness.
- Assess for galactorrhea in the breasts.
- Look for signs of androgen excess, including acne, hirsutism, and male escutcheon.
- Evaluate for pelvic abnormalities.
Infertility Workup: Testing
- Female:
- Conduct testing and schedule a preconception counseling appointment.
- Perform hemoglobin A1C and fasting glucose tests for women with a history of diabetes or risk factors.
- Screen for genetic disorders as indicated.
Infertility Workup: Prenatal Optimization
- Begin preconception care immediately.
Infertility Workup: Male Factor
- History:
- Gather past medical, surgical, illness, and injury history.
- Pay special attention to a history of mumps, as mumps orchitis is a known cause of infertility.
- Semen Analysis:
- The #1 factor to assess.
- Total sperm number (10^6 per ejaculate): 39 (33-46)
- Total motility (%): 40 (38-42)
- Normal forms (%): 4 (3-4)
Infertility Workup: Ovarian Factor
- Responsible for up to 40% of infertility in women.
- Fecundity decreases gradually around 32 years old and rapidly after 37.
- Associated with increased FSH and decreased AMH and Inhibin B.
- Assess:
- Patient age.
- Evidence of disordered ovulation.
- Menstrual history, Basal Body Temperature (BBT), OTC ovulation test, luteal phase progesterone (day 21 or 23), and day 3 FSH for patients over 40 (an indicator of ovarian reserve).
- Day 3 FSH levels above 13 indicate difficulty in stimulating ovulation.
- If disordered ovulation is present, determine the underlying cause.
- Labs:
- TSH and PRL: assess for thyroid issues and prolactin levels.
- Luteal phase progesterone: should be high if ovulation is occurring.
Luteal Phase Defect
- Definition: Shortened time between ovulation and menses.
- Cause: Corpus luteum involutes earlier than expected.
- Treatment: Supplemental progesterone.
Infertility Treatment: Ovarian Factor
- Most/all treatments require referral to a specialist.
- Refer quickly for women over 35 years old.
Infertility Treatment: Clomiphene Citrate
- Clomid (Clomiphene Citrate): Selective estrogen receptor modulator (SERM).
- Mechanism of action: Blocks estrogen receptors in the hypothalamus, leading to increased pulsatile release of GnRH and subsequently increased FSH.
- Effect: Recruitment of follicles and increased likelihood of reaching the estrogen level needed for ovulation.
- Side effects: Over-ovulation, menopausal symptoms (hot flashes, vaginal dryness), and OHSS (rare).
Infertility Treatment: Metformin
- Indication: Women with PCOS who do not ovulate on clomiphene citrate.
- Use for ovulation: Helpful for PCOS patients as a supplement to clomiphene citrate.
- Refer to a reproductive specialist for any other use.
- Evidence for metformin's efficacy is unclear.
Ovarian Hyperstimulation Syndrome (OHSS)
- Overproduction of large follicles.
- Results in increased capillary permeability in ovarian tissue with poor reabsorption.
- Severe OHSS: Ascites, hemoconcentration, and increased risk of clotting.
Infertility Treatment: Uterine and Tubal Factors
- Most common uterine issues: Asherman's syndrome, leiomyomata, congenital abnormalities (Mullerian).
- Most common tubal issues: Prior tubal ligation/surgeries, prior infection/PID.
- Assessment for both: Hysterosalpingography (HSG).
Mullerian Fusion Disorders
- Uterine septum is the most common disorder associated with pregnancy loss, and it's treatable.
- Resection of the septum can improve delivery rates.
Hydrosalpinx
- A common tubal factor.
- Always (99%) due to infection.
- No “spill” = blockage.
- Referral is critical.
- Some recommend immediate salpingectomy and assisted reproductive technology (ART).
- Others might attempt tubal reconstruction.
Infertility Definition
- Infertility is defined as a couple's inability to conceive after one year of regular, unprotected intercourse.
- For women over 35, the diagnosis can be made after 6 months.
- It affects 15-20% of couples in the United States.
When to Evaluate for Infertility
- Evaluate couples who meet the definition of infertility.
- Evaluate sooner for women over 35 years old.
- Consider earlier evaluation for women with a history of amenorrhea or oligomenorrhea, suspected tubal disease, endometriosis, Mullerian variations, or risk factors for ovarian insufficiency such as prior chemo/radiation, other autoimmune diseases, or significant ovarian surgery.
- Evaluate males with a history of testicular torsion/cancer, orchitis/mumps, or unsuccessful conception.
Causes of Infertility
- Male factors account for 20% of infertility cases.
- Ovarian/Tubal factors are present in over 45% of cases.
- More than one factor is often involved.
Infertility Workup: Examination for Females
- Assess weight, BMI, and blood pressure.
- Look for signs of systemic illness like diabetes, autoimmune disorders, and metabolic syndrome.
- Examine the thyroid for enlargement, nodules, or tenderness.
- Check for galactorrhea in the breasts.
- Observe for signs of androgen excess like acne, hirsutism, and male escutcheon.
- Conduct a pelvic examination to assess for any abnormalities.
Infertility Workup: Testing for Females
- Perform testing and schedule a preconception counseling appointment.
- Test for hemoglobin A1C and fasting glucose in women with a history of diabetes or risk factors.
- Conduct genetic screening as indicated.
Infertility Workup: Preconception Care
- Start preconception care immediately.
Infertility Workup: Male Factor
- Obtain a detailed medical, surgical, and illness history, particularly focusing on any history of mumps.
- Perform a semen analysis.
- Aim for a total sperm number of 39 million per ejaculate (33-46 million).
- Target a total motility of 40% (38-42%).
- Look for 4% of normal forms (3-4%).
Infertility Workup: Ovarian Factor
- Responsible for up to 40% of female infertility.
- Fecundity gradually declines after age 32, rapidly decreasing after age 37.
- An increase in FSH and decreases in AMH and Inhibin B are associated with ovarian aging.
- A decrease in ovarian reserve is indicated by a day 3 FSH level over 13.
- Consider checking day 3 FSH levels in women over 40.
- Assess the patient's age and search for evidence of disordered ovulation.
- Analyze menstrual history, basal body temperature (BBT), over-the-counter ovulation tests, and luteal phase progesterone levels (on day 21 or 23).
- Investigate suspected causes of disordered ovulation by checking TSH and PRL levels.
Luteal Phase Defect
- A shortened period between ovulation and menses.
- The corpus luteum involutes earlier than it should.
- Treatment involves supplemental progesterone.
Infertility Treatment: Ovarian Factor
- Referral to a specialist is generally required for most or all ovarian factor infertility treatments.
- Quickly refer women over 35 years old.
Infertility Treatment: Ovarian Factor: Clomiphene Citrate
- Clomiphene citrate (Clomid) is a selective estrogen receptor modulator (SERM).
- Blocks estrogen receptors in the hypothalamus.
- Increased pulsatile release of GnRH, leading to increased FSH.
- Increased follicle recruitment, making ovulation more likely.
- Side effects include over-ovulation, menopausal symptoms (hot flashes, vaginal dryness), and OHSS (rare).
Infertility Treatment: Ovarian Factor: Metformin
- Used for women with PCOS who don't ovulate with clomiphene citrate.
- Helpful as a supplement to Clomid for PCO patients.
- Referral to a reproductive specialist is required for any use other than ovulation.
Infertility Treatment: Ovarian Factor: Ovarian Hyperstimulation Syndrome (OHSS)
- Excess production of large follicles.
- Increased capillary permeability in ovarian tissue with poor reabsorption.
- Severe OHSS can lead to ascites, hemoconcentration, and a risk of clotting.
Infertility Treatment: Uterine and Tubal Factors
- Most common uterine issues: Asherman's syndrome, leiomyomata, and congenital abnormalities (Mullerian).
- Most common tubal issues: prior tubal ligation/surgeries and prior infection/pelvic inflammatory disease (PID).
- Hysterosalpingogram (HSG) is used to assess uterine and tubal factors.
Mullerian Fusion Disorders
- Uterine septa are the most common disorder associated with pregnancy loss.
- Resection of the septum can improve delivery rates.
Infertility Treatment: Uterine and Tubal Factors: Hydrosalpinx
- Almost always caused by infection.
- A blocked fallopian tube with no "spill".
- Referral for immediate salpingectomy and assisted reproductive technology (ART) may be recommended.
- Tubal reconstruction may be attempted.
Infertility Definition
- Infertility is defined as a couple’s inability to conceive after 1 year of regular, unprotected intercourse.
- For women over 35 years old, the diagnosis can be made after 6 months of attempting conception.
Infertility Incidence
- Approximately 15-20% of couples in the United States experience infertility.
When to Evaluate for Infertility
- Evaluate couples who meet the definition of infertility.
- Evaluate earlier for women over 35 years old.
- Consider earlier evaluation for individuals with a history of amenorrhea or oligomenorrhea, suspected tubal disease, endometriosis, Müllerian variations, risk factors for ovarian insufficiency like prior chemo/radiation, other autoimmune diseases, or history of significant ovarian surgery.
- Evaluate males with risk factors such as history of testicular torsion/cancer, orchitis/mumps, or unsuccessful conception.
Infertility Causes
- Infertility can be caused by male factors, ovarian/tubal factors, or a combination of both.
- Male factor is the sole cause in 20% of cases.
- Ovarian/tubal factors are present in over 45% of cases.
Infertility Workup: Exam
- Evaluate weight, BMI, and blood pressure.
- Assess for signs of systemic illness like diabetes, autoimmune disorders, or metabolic syndrome.
- Examine the thyroid for enlargement, nodules, or tenderness.
- Check breasts for galactorrhea.
- Look for signs of androgen excess, such as acne, hirsutism, or a male escutcheon.
- Conduct a pelvic exam and consider all previously discussed disorders.
Infertility Workup: Testing in Females
- Perform testing and schedule a preconception counseling appointment.
- Check hemoglobin A1C and fasting glucose levels for women with a history of diabetes or risk factors.
- Screen for genetic disorders as indicated.
Infertility Workup: Preconception Optimization
- Initiate preconception care immediately.
Infertility Workup: Male Factor
- History: Gather past medical, surgical, illness, and injury history.
- Specifically inquire about a history of mumps, as it is a known cause of mumps orchitis.
-
Semen Analysis: This is the primary assessment for male factor infertility.
- Total Sperm Number: 39 million per ejaculate (33-46 million)
- Total Motility: 40% (38-42%)
- Normal Forms: 4% (3-4%)
Infertility Workup: Ovarian Factor
- Responsible for up to 40% of female infertility.
- Fecundity gradually declines around 32 years of age and rapidly after 37 years.
- Associated with increased FSH and decreased AMH and Inhibin B levels.
- Assess patient age and evidence of disordered ovulation.
- Menstrual History: Retrieve information about menstrual cycles.
- Basal Body Temperature (BBT): Analyze BBT charts to identify potential ovulation patterns.
- Over-the-Counter Ovulation Test: Evaluate results for ovulation detection.
- Luteal Phase Progesterone: Measure levels on day 21 or 23 to assess ovulation.
- Day 3 FSH: Assess ovarian reserve, particularly in women over 40 years old. A value of 13 or higher indicates very difficult stimulation.
- Labs: Evaluate TSH and PRL if disordered ovulation is suspected.
Luteal Phase Defect
- Definition: A shortened time between ovulation and menstruation.
- Cause: The corpus luteum involutes earlier than it should.
- Treatment: Supplemental progesterone.
Infertility Treatment: Ovarian Factor
- Referral: For most/all treatment options, refer to a specialist.
- Immediate referral: For women over 35 years old.
Infertility Treatment: Ovarian Factor - Clomiphene Citrate
- Mechanism of Action: Clomiphene Citrate (Clomid) is a selective estrogen receptor modulator (SERM).
- Clomiphene blocks estrogen receptors in the hypothalamus, leading to an increase in pulsatile GnRH release and subsequently increased FSH.
- This enhanced FSH recruitment increases the likelihood of follicles reaching the estrogen level required for ovulation.
-
Side Effects:
- Over-ovulation.
- Menopausal symptoms, such as hot flashes and vaginal dryness.
- Ovarian hyperstimulation syndrome (OHSS) - rare.
Infertility Treatment: Ovarian Factor - Metformin
- Indication: Women with PCOS who do not ovulate with clomiphene citrate.
- Ovulation Use: Metformin can be utilized as a supplement to Clomid for PCOS patients.
- Referral: For any use beyond ovulation induction, refer to a reproductive specialist.
- Evidence: The evidence regarding metformin's efficacy for infertility is unclear.
Infertility Treatment: Ovarian Factor - Ovarian Hyperstimulation Syndrome (OHSS)
- Definition: Overproduction of very large follicles.
- Mechanism: Increased capillary permeability in ovarian tissue with poor reabsorption.
- Severe OHSS: Can lead to ascites, hemoconcentration, and an increased risk of clotting.
Infertility Treatment: Uterine and Tubal factors
-
Most Common Uterine Issues:
- Asherman's syndrome.
- Leiomyomata (fibroids).
- Congenital abnormalities (Müllerian).
- Most Common Tubal Issues:
- Prior tubal ligation or surgeries.
- Previous infection or pelvic inflammatory disease (PID).
- Assessment for Uterine and Tubal Factors: Hysterosalpingography (HSG).
Mullerian Fusion Disorders
- Most Common: Uterine septum.
- Association: Increased pregnancy loss.
- Treatment: Resection of the septum, which can improve delivery rates.
Infertility Treatment: Uterine and Tubal Factors - Hydrosalpinx
- Definition: Fluid accumulation in a fallopian tube.
- Cause: Almost always (99%) due to infection.
- Characteristic: Blockage preventing fluid outflow.
- Referral: Recommended for further evaluation and management.
- Consideration: Some recommend immediate salpingectomy and assisted reproductive technologies (ART).
- Alternative: Some attempt tubal reconstruction.
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Description
Explore key concepts of infertility, including its definition, causes, and evaluation guidelines. This quiz covers essential information for understanding infertility in couples, focusing on age-related factors and specific health risks. Test your knowledge on the prevalence and workup related to infertility.
