From Iusmicm

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Revision as of 23:35, 12 December 2011

Note that the testable material is in a doc on angel; this stuff from lecture is simply what she went over verbally. 

Contents 1 Infertility 1.1 Causes and Diagnosis 1.2 Objectives 1.3 Definition 1.4 Prevalence 1.5 What does it take to get pregnant 1.6 Components of Normal Fertility 1.7 Pathophys of Female Infertility 1.7.1 EStrogen Deficiency 1.7.2 FSH 1.7.3 Polycystic ovaries 1.7.4 Lean Anovulation 1.7.5 The normal menstrual cycle 1.7.6 35 yo over achiever 1.7.7 Male Infertility 1.7.8 Treatable Azoospermia 1.7.9 Menopause onset

Infertility

Causes and Diagnosis

Objectives

• To become acquanted with:
  • prevalence of infertility in the general population
  • the causes of female and male infertility
  • A systematic approach to the evaluation of the infertile couple

Definition

• Infertile is one year of unprotected sex without pregnancy.
• Women are most fertile 15-25 yo.
• The timing is important.
  • Not so exquisite that you must be down to the minute.
  • Those expensive kits aren't worth it.
• Sperm will stick around a fair bit.

Prevalence

• 20% of couples after 1 year of unprotected sex.
  • Has stayed the same over many decades.
• Now, however, people don't get married because they have birth control and then get married later and have more trouble as 30 yos getting pregnant.
  • 33% of the female partner is over the age of 35.
• No appreciable change since the 1950s but more treatment are available.

What does it take to get pregnant

• Three ways to show that a woman can ovulate:
  • look at the corpus luteum via lapro
  • wash the egg out of the reproductive tract (don't do that anymore)
  • she gets pregnant
• Sperm have to be able to get to the ovum.

• And the people have to have sex.

• Much of infertility is and is not practical.
  • Wedge shaped pillows do not help.
  • Timing and intention are important: Intercourse 2-5 / week should give reasonable chances for getting pregnant.

Components of Normal Fertility

• Woman must ovulate (follicle erupting, corpus luteum, oocyte released), fillopian tube must be intact, egg must be competent enough to pass egg into fallopian tube, sperm must meet the egg.
• Million of sperm at the cervix, only about 1000 at the distal fallopian tube.
  • So we often try interuterine insemination to increase the numbers.
• Implantation requires that the endometrium have a nice mucus layer.
  • Requires cycling of estradiol from the corpus luteum.
  • Thick mucus is a good sperm trap.
  • Recall, however, tha the vagina is a sperm killer because of the pH being low.
• Also requires proper coitus and high frequencey

Pathophys of Female Infertility

EStrogen Deficiency

• Without estrogen (from the ovary, the follicle), they don't ovulate.
• Check FSH levels:
  • Low: that's why they aren't ovulating
  • High: follicle is not responding

FSH

• This is themost reliable test to determine if the ovary is functioning.

Polycystic ovaries

• Hirsutism, diabetes, acanthosis nigricans, receading hair line.
• FSH levels are low, relative to the LH levels.
• Her granular cells are making testosterone.
• The follicles of PCOS are defuct.

Lean Anovulation

• Kenyan Runner propably has mean PCOS.
  • Measure both FSH and LH (2:1, 3:1, or 4:1)
• Functional chronic anovulation may occur in anorexic women or highly trained athletes.

The normal menstrual cycle

• Length of the post-ovulatory phase should average 14 days (at least 12).
• We don't want post-ovul to take place at the cost of the pre-ov phase.
• Short post-ov indicates a luteal phase defect.
• We use "ovulationn prediction kit" which measures urine LH.

35 yo over achiever

• This is the usual suspect now-a-days.
• Fertility declines after the age of 35.
• Eggs: 6 million in utero, 1 million at birth, ...

Male Infertility

• Azoosperm = no sperm at al.
• Oligo-asthenospermia = few sperm, don't work well.
  • Associated with increased scrotal heat.
  • Expsoure to meds / Radx.
  • Congenital
• Erectile and ejaculatory dsyfunction

Treatable Azoospermia

• Look for incomplete androgen sensitivity.
• If biopsy shows sperm we can extract and use it for insemination.
  • If not, get a donor.

Menopause onset

• Mother's age of menopause is a good predictor of when the pt will commence menopause.