infertility + recurrent preg loss

Question 1

history for infertility

Answer 1

• length of time
• prior reproduction
• menstrual cycle
• symptoms of PID or endometriosis
• coital timing, freq
• prev pelvic or abdo surg
• urologic disorders of male
• impotency
• medication hx, vasc dis hx

Question 2

infertility evaluation

Answer 2

ovulatory + luteal function:

• day 3 FSH <10
• luteal serum prog (day 21) / cycle monitoring
• AMH
• antral follicle count
• ovarian volume
• urinary LH kit
• clomiphene challenge test: give on CD3-7, check FSH on CD10

other HPO axis

• PCOS symptoms
• weight high or low
• hypothalamic
• prolactin
• thyroid: TSH, fT3, t4

other- DM test

Cervical factor - post coital test

uterine or tubal factor - hysterosaplingogram or sonohystogram, laparoscopy

endometriosis/scarring - laparoscopy

male factor

• semen analysis
• if oligosperm: androgens, LH, FSH, TSH

Question 3

coital technique

Answer 3

• 2-3 times per week
• mid cycle
• avoid lubricants and post-coital douches (oil or water based ok)

Question 4

basic treatments

Answer 4

• counselling
• medications: clomiphene citrate, letrozole, thyroid meds, bromocriptine for excess prolactin
• surgery: laparoscopy, hysteroscopy
• IUI

Question 5

advanced fertility therapies

Answer 5

• IVF
• IVF with intracytoplasmic sperm injection
• donation or surrogacy
• pre-implantation genetic screening

Question 6

IVF technique

Answer 6

• stimulate eggs /w FSH +/- LH
• when follicles large enough, hCG induce ovulation, retrieval 35hrs later
• egg incubated with sperm or mature oocyte used for ICSI
• PGS possible prior to transfer

Question 7

PGS risks

Answer 7

• more monozygotic twins

- embryo destruction

Question 8

recurrent early preg loss definitions

Answer 8

• 3 losses prior to 20 weeks
• usually investigate after 2
• early: <12 weeks
• late: 12-20wks
• primary
• secondary; prev living child

Question 9

recurrence rate after 3 misscariages

Answer 9

• 50% if no live born child

if have child, 70-75% do conceive again

Question 10

etiology of recurrent preg loss

Answer 10

• anatomical: ashermans, cervical incompetence (DES), mullerian anomalies, leiomyoma
• genetic
• immunologic - autoimmune antibodies
• infections
• thrombophilia
• environmental
• endocrine - poor DM, thyroid, luteal phase defect, PCOS?
• AMA / low reserve? - tx /w clomid + supplemental hCG + progesterone

Question 11

work up for recurrent loss

Answer 11

• karyotype
• DM + thyroid test, prolactin
• luteal phase test: midluteal progesterone
• PCOS work up if symptoms
• ovarian reserve tests
• thrombophilias (prot C, S deficiency, others)
• lupus anti-coagulant + aPTT
• anti-cardiolipin antibodies
• antiphospholipid antibodies (infarction, less annexin V)
• endo biopsy + culture for TORCH, listeria, chlamydia, mycoplasm + cervical culture
• anatomical assessment
• assess exposures (meds, etc)

Question 12

treatment for RPL

Answer 12

if infection give abx

if thrombophilia give LMWH

if no thrombosis + mod or high antibody titre:

• ASA
• heparin - but bleed risk
• heparin + ASA - most effective
• prednisone + ASA
• IvIG - experimental