Infertility.docx

**Infertility: The NP Role** - **What is the definition?** unable to conceive despite regular vaginal intercourse with sperm producing partner - \< 35 years old and trying for 12 months - \>35 years old and trying for 6 months - Women over 40 do immediate intervention because their t...

**Infertility: The NP Role** - **What is the definition?** unable to conceive despite regular vaginal intercourse with sperm producing partner - \< 35 years old and trying for 12 months - \>35 years old and trying for 6 months - Women over 40 do immediate intervention because their time is more limited - **Primary infertility**no prior pregnancies - **Secondary infertility** one or more prior pregnancies **Etiology- "Female" Factors:** - **Cause of [55% of cases]** - **Ovulatory Dysfunction (20-40%):** 1. Ovulation: monthly menses and molimina (breast tenderness, dysmenorrhea, bloating) 2. Etiologies: BMI (high or low), eating disorders, stress, pituitary tumors, PCOS, thyroid, hyperandrogenic disorders, hyperprolactinemia 3. Medications: hormones, antidepressants and antipsychotics, corticosteroids, chemotherapeutics - **Tubal and Pelvic Pathology (30-40%):** 1. **Pelvic Inflammatory Disease most common cause of tubal infertility** 2. Ectopic pregnancy 3. Endometriosis 4. Asherman syndrome (uterine trauma) 5. Fibroids **Etiology- "Male" Factors** - Gonadal disorder (30-40%)- chromosomal disorders (Klinefelter), cryptorchidism, varicoceles, infections, medications, radiation, environmental exposure, chronic illness - Sperm transport- congenital absence of vas deference or acquired obstruction of vas deferens - Idiopathic - Hypothalamic-pituitary disorders **Etiology- combined factors** - Anti-sperm antibodies: the sperm is unable to survive in cervical mucous which leads to sperm agglutinates and decreased motility - Simultaneous infertility disorders - Psychological stress - The rest of cases never explained History: - Medical History: chemo or radiation, STIs, medications, AMAB- testicular surgery and history of mumps, fertility in other relationships - GYN History- menstrual including presence of molimina or vasomotor symptoms, pregnancies, surgeries/procedures, contraception (esp if Depo-Provera use), cervical cancer screening, frequency of coitus and use of lubricants - Health Maintenance: diet and exercise - Family History: birth defects, developmental delay, reproductive problems (endometriosis, early menopause, fibroids, infertility) - Social history: occupation, environmental exposure (sauna/hottub use), tobacco, alcohol, substance use, including anabolic steroid use - ROS AFAB: nipple d/c, hirsutism, pelvic/abdominal pain, dyspareunia, changes in body weight, thyroid symptoms, change in vision AMAB: sexual dysfunction, impotence Physical Exam: - Full physical including pelvic exam in assigned female at birth - VS: BMI, BP, HR - Skin/hair/nails - Thyroid - Breasts/chest - Pelvic Diagnostic Testing: 1. **Ovulation detection: 3 CYCLE MINIMUM;** - BBT- use app to track the basal body temp; measure in AM before getting out of bed, greater than 0.4 increase is expected after ovulation - OTC urine test for LH because ovulation likely to occur 24-36 hours after LH surge, can have false positive results - **Fertile window is 5 days before ovulation and 1 day after ovulation** 2. Semen analysis: should be done early in infertility analysis b/c it's inexpensive and can spare women from more invasive diagnostic testing if the semen is the problem. - Abstain from ejaculating for 2-5 days prior to test - Test must be performed within 1 hour - Two tests at least 1 month apart - Perform early in infertility analysis 3. STI testing 4. Cervical cancer screening 5. Serum labs based on H and P: TSH, Luteal phase progesterone, signs of excess androgens (prolactin, free testosterone, DHEA-S), assessment of ovarian reserve, chlamydia antibody testing (tubal blockage when unable to do hysterosalpingography) 6. Imaging: antral follicle count: number of follicles \