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hysteroscopy

hysterosalpinogram
-procedure to see inside uterus using a tube inserted into vagina and through cervix

-procedure involving installation of radioopaque substance into uterine cavity and up though ovarian tubes 
Bilateral Tubal Ligation
A BTL is a permanent form of contraception that requires a surgical procedure. The ovarian tubes are located through a small sub-umbilical incision or by a minilaparotomy. The tubes are then clipped, ligated, electrocoagulated, banded, or plugged. Complications include: coagulation burns of the bowel, perforation of the bowel, pain, infection, hemorrhage, and adverse anesthesia effects. Successful reversal of a BTL is dependent upon the type of procedure performed.
btl.jpg
 
minilaparotomy
surgical section of abdominal wall
vasectomy
-clearing time
-restoration ranges  
A vasectomy is a relatively minor procedure resulting in effective male sterilization. This procedure, normally performed in an office setting, involves surgically severing the vas deferens in both sides of the scrotum. It requires approximately 4-6 weeks and 6-36 ejaculations to clear the remaining sperm from the vas deferens. The man is advised to use another form of birth control during this time period and to bring in 2 or 3 semen samples for a sperm count. The man is rechecked at 6 to 12 months to endure that fertility has not been restored by recanalization. Side effects associated with vasectomies may include: pain, infection, hematoma, sperm granulomas, and spontaneous reanastomosis. Vasectomies can sometimes be reverse by using microsurgery techniques. Restoration of fertility, as measured by subsequent pregnancies, ranges from 38%-89% (Hatcher, et al., 2007).
medical abortion
Medical Abortion is now available in the U.S. and provides women with an alternative to surgical abortion. Mifepristone (Mifeprex), originally called RU486,may be used to induce abortion medically for up to 9 weeks following the last menstrual period (LMP) (up to 63 days post-LMP). Mifepristone blocks the effects of progesterone and alters the endometrium. After the date of gestation is confirmed, the woman takes a dose of mifepristone. Then, 1-3 days later, she returns to her healthcare provider and takes a dose of misoprostol, a prostaglandin, that induces contractions and expels the embryo/fetus. Approximately 14 days after receiving the misoprostol, the woman returns to her healthcare provider to confirm that the abortion was complete. A serious adverse effect of this method of abortion is infection. Therefore, any woman who has taken the mifepristone regimen within the last 24 hours and then develops stomach pain, weakness, nausea, vomiting, or diarrhea, with or without fever should seek immediate medical attention
surgical abortion
-when can it be performed
Surgical Abortion may be performed in the first trimester and is usually accomplished through the use of dilatation and curettage (D&C), minisuction, or vacuum curettage. The major risks associated with surgical abortion include uterine perforation, laceration of the cervix, systemic reaction to the anesthetic used, hemorrhage, and infection. Second trimester abortion may be done through the use of dilatation and extraction (D&E), hypertonic saline, and systemic or intrauterine prostaglandins that induce labor. Surgical abortion is generally easier to perform and safer in the first trimester than in the second. It is important to note that time limits for legal second trimester abortions are limited by state regulations.
primary infertility
secondary infertility
Primary infertilitydescribes a couple that has never achieved pregnancy while secondary infertility is the inability to conceive after a previous pregnancy.
ASRM infertility definition
-also for 35+ yr old 
The American  Society for Reproductive Medicine defines infertility as the inability to conceive after 1 year of unprotected, regular, intercourse, or the inability to carry a pregnancy to the point of viability in a woman under the age of 35 years. In woman over 35, this timeline is reduced to 6 months
what percent of us couples experience infertility?
11%
infert diag and treatment may cause

  • Stress, anxiety, and depression may be experienced by both members of the couple as well as guilt and blame.

  • Sexual activity may become strained due to infertility testing and treatments.

social isolation as result of infertility

  • Couples may withdraw from social interactions because it is too painful to interact with other couples who have children.

  • Some couples may choose not to share with others the fact that they are experiencing infertility, thus they may not have individuals that can support them through diagnosis and treatment.

infertility self esteem

  • Self-esteem


    • Self-esteem may be severely effected by infertility.

    • Both the man and the woman may feel as though they are "defective."


infertility counseling
-should start before or after treatment
-discussions should include

  • Couples experiencing infertility may benefit from counseling.

  • Ideally, counseling should begin before infertility treatment is initiated.

  • Should include discussions about:


    • How treatment may effect them as a couple, as an individual, and as a family

    • The various treatment options and potential ethical issues related to treatment

    • The effects, consequences, and resolution of treatment

    • When to discontinue treatment

    • Adoption


Examples of culture and infertility:


Arab

Orthodox Jewish
For example, in some Arab cultures, the woman may only be inseminated with the sperm of her own husband due to concerns about lineage. For some Orthodox Jews, insemination with donor sperm is forbidden because this may constitute adultery. However, performing in-vitro fertilization using donor sperm may be acceptable because this does not involve putting sperm into another's wife (
female and male factor percentages
Multiple known and unknown factors affect fertility. Female factor infertility is detected in about 40% of all cases, male factor infertility in about 40%, and in approximately 20% of cases, the cause is either combined or unknown.
what is the most common hormomal disorder among women of reproductive age?

describe it
Polycystic ovarian syndrome
PCOS

 PCOS is the most common hormonal disorder among women of reproductive age. The name of the condition comes from the appearance of the ovaries in most, but not all, women with the disorder. The ovaries may appear enlarged and contain numerous small cysts located along the outer edge (polycystic appearance). Infrequent or prolonged menstrual periods, excess hair growth, acne and obesity can all occur in women with PCOS. Menstrual abnormality may signal the condition in adolescence, or PCOS may become apparent later following weight gain or difficulty becoming pregnant. The exact cause of PCOS is unknown. Women with PCOS may have trouble becoming pregnant due to infrequent or lack of ovulation. Early diagnosis and treatment of PCOS can help reduce the risk of long-term complications, such as type 2 diabetes, heart disease and stroke
Infertility Risk Factors (Women)

  • Overweight or underweight because this may disrupt hormone function

  • Hormonal imbalances leading to irregular ovulation

  • endometriosis

  • history of PID

  • incompetent cervix

  • smoking and alcohol consumption

  • multiple miscarriages

  • psych stress

  • fibroids

  • tubal blockages (often scar tissue secondary to STIs)


  • Chronic diseases such as diabetes, thyroid disease, and asthma


    • Sexually transmitted infections (STI's)


      • Gonorrhea and clamydia can cause scarring of the reproductive organs


    • Age


      • Fertility begins to decline by age 35 and drops significantly by age 40. There is also an associated reduction in egg quality with age.



Male infertility risk factors

  • Exposure to toxic substances such as lead, mercury, x-rays

  • Cigarette or marijuana smoke

  • Heavy alcohol consumption

  • Use of prescription drugs for ulcers or psoriasis

  • Exposure of the genitals to high temperatures (hot tubs, saunas, tight fitting underwear)

  • Hernia repair

  • STI's

  • Frequent long distance cycling

  • Mumps after puberty

initial infert analysis for male should include...
The initial infertility evaluation for the male partner should include a reproductive history and semen analysis. From the male perspective, 3 things must happen for conception to occur:1) there must be an adequate number of sperm, 2) the sperm must be healthy and mature, and 3) the sperm must by able to penetrate the ovum. Semen analysis is the most important indicator of male fertility. To conduct this diagnostic test, the man is asked to produce a specimen by ejaculating into a specimen cup. For this test to be reliable, it is essential for the man to abstain from ejaculation for 24-48 hours prior to collection. After collection, the specimen must be delivered to the laboratory within 1-2 hours for analysis.
physical exam of male for infertility
The physical examination of the male partner should include:

  • Assessment for the presence of secondary sexual characteristics such as body hair and muscle development

  • Examination of the reproductive organs for abnormalities

  • Assessment for normal development of external genitalia (appropriate size of testicles)

  • Performance of a digital internal examination of the prostate to check for tenderness or swelling

female assessment of ovarian function

  • Menstrual history-regularity of menstrual cycle

  • Determination of ovulation using basal body temperature (BBT) and cervical mucus methods (refer back to the family planning module for a review of BBT)

  • Ovulation predictor kits used midcycle


    • Home ovulation kits test for the presence of luteinizing hormone (LH) in the urine and therefore may be used to predict ovulation. A significant color change from baseline noted on the test strip indicates the LH surge and presumably the most fertile day of the month.


  • Clomiphene citrate (Clomid) challenge test


    • The Clomid challenge test is used to assess a woman's ovarian reserve (capacity of her eggs to become fertilized). Follicle stimulating hormone (FSH) levels are drawn on day 3 of the woman's menstrual cycle and again on day 10 after the woman has taken 100 mg of Clomid on cycle days 5 through 9. If the FSH level is higher than 15, the test is considered abnormal and the likelihood of conception with the woman's own eggs is low.


  • Endometrial biopsy to document luteal phase


    • An endometrial biopsy is an assessment of ovulation that indicates whether progesterone secretion is adequate. A strip of endometrial tissue is removed just before menstruation. If analysis of the endometrial tissue is normal, it implies that ovulation has occurred. An abnormal result may indicate a luteal phase defect.


endometrial biopsy to document luteal phase

  • Endometrial biopsy to document luteal phase


    • An endometrial biopsy is an assessment of ovulation that indicates whether progesterone secretion is adequate. A strip of endometrial tissue is removed just before menstruation. If analysis of the endometrial tissue is normal, it implies that ovulation has occurred. An abnormal result may indicate a luteal phase defect.


clomiphene citrate (clomid) challenge test
  • Clomiphene citrate (Clomid) challenge test
    • The Clomid challenge test is used to assess a woman's ovarian reserve (capacity of her eggs to become fertilized). Follicle stimulating hormone (FSH) levels are drawn on day 3 of the woman's menstrual cycle and again on day 10 after the woman has taken 100 mg of Clomid on cycle days 5 through 9. If the FSH level is higher than 15, the test is considered abnormal and the likelihood of conception with the woman's own eggs is low.
ovulation predictor kits used midcycle

  • Ovulation predictor kits used midcycle


    • Home ovulation kits test for the presence of luteinizing hormone (LH) in the urine and therefore may be used to predict ovulation. A significant color change from baseline noted on the test strip indicates the LH surge and presumably the most fertile day of the month.


postcoital testing
  • Postcoital testing
    • Postcoital testing is performed to assess the response of cervical mucus to sperm. Cervical mucus is examined 2-8 hours following intercourse during the expected time of ovulation, and the number of live, motile sperm are assessed.
hysterosalpinogram

  • Hysterosalpinogram (HSG)


    • Involves the instillation of a radiopaque substance through the cervix into the uterine cavity to visualize internal structures and determine tubal patency. This procedure may also have a therapeutic effect caused by the flushing out of debris, breaking of adhesions, or induction of peristalsis within the tubes.


transvaginal ultrasound
Transvaginal Ultrasound-imaging of internal reproductive organs for abnormalities
hysteroscopy

  • Hysteroscopy


    • Insertion of a fiber optic instrument into the uterus for further evaluation of polyps, fibroids, or structural variations


laparoscopy

  • Laparoscopy


    • Enables direct visualization of the pelvic organs and is not routinely done if earlier HSG findings are normal. Laparoscopy is usually performed as an outpatient procedure under general anesthesia.



 
gonadotropins
Therapy using human menopausal gonadotropins (hMG's), which include menotropins (Repronex and Menopur) and urofollitropin (Bravele), is indicated as a first line of therapy for anovulatory infertile women with low to normal levels of gonadotropins (FSH and LH). It is a second line drug for women who have failed to ovulate or conceive while using clomiphene citrate. It may also be used during controlled ovarian stimulation for women undergoing assisted reproductive technologies (discussed later in this module). Therapy with gonadotropin requires close observation due to the increased risk for ovarian hyperstimulation syndrome and the potential for multiple fetuses.
clomphene citrate (clomid or serophene)
-used in women who..
-induces ovulation in... %
-% become pregnant
-% with multi gestation
Clomiphene Citrate (Clomid or Serophene)-if the woman has normal ovaries, a normal prolactin level, and an intact pituitary gland, clomiphene citrateis often used. This medication will induce ovulation in 70% of women by actions at both the hypothalamic and ovarian levels; 30%-40% of these women will become pregnant. clomiphene citrate works by stimulating the hypothalamus to secrete more gonadotropin-releasing hormone (GnRH). Approximately 10% of women using clomiphene citrate will develop multiple-gestation pregnancies-almost exclusively twins and rarely higher order multiples.
bromocriptine
-acts on...

-allowing...  

-should be discontinued if...
high prolactin levels may impair the glandular production of FSH and LH or block their action on the ovaries. If an anovulatory woman has hyperprolactinemia, this type of infertility may be treated with bromocriptine (Parlodel). This drug acts directly on the prolactin-secreting cells in the anterior pituitary-inhibiting the secretion of prolactin thus preventing the suppression of the pulsatile secretion of FSH and LH. This in turn allows normal menstrual cycles and induces ovulation. Parlodel should be discontinued if pregnancy is suspected or around the time of anticipated ovulation because of it's potential teratogenic effects. Other side effects include: nausea, diarrhea, dizziness, headache, and fatigue.
aromatase inhibitors
Aromatase inhibitors such as letrozole (Fermara) and anastrozole (Arimidex) are medications that reduce estrogen levels and may successfully induce ovulation. Pregnancy rates with this drug are comparable to those observed with the use of clomiphene citrate; however, recent data has raised concerns that the use of letrozole may be associated with congenital defects.
progesterone
Treatment of luteal phase defects may include the use of progesterone to augment luteal phase progesterone levels.Use of ovulation inducing drugs such as clomiphene citrate and menotropins may be associated with a decline in luteal phase production of progesterone and estrogen necessary to maintain a pregnancy. It is therefore common to combine these ovulation induction agents with progesterone supplementation for luteal phase support to increase endometrial receptivity to embryonic implantation.
therapeutic insemination
Therapeutic Insemination (THI): has replaced the previously accepted term artificial insemination. This procedure involves the deposit of sperm at the cervical os or into the uterus (intrauterine insemination, IUI) by mechanical means and is timed with ovulation. Insemination may be done with sperm from the woman's partner or a donor. THI may be indicated when the male partner has a low sperm count, decreased sperm motility, or a high percentage of abnormal sperm. It may also be indicated for men who have an anatomical abnormality such as a hypospadias or an ejaculatory dysfunction. For some types of female factor infertility and unexplained infertility, THI may be beneficial. Because seminal fluid contains prostaglandins that can cause nausea, severe cramping, abdominal pain, and diarrhea if inserted directly into the uterus, the sperm must first be prepared through a washing procedure that separates it from the seminal fluid.
IVF
-when used, what is used to stim final egg maturation
-when is egg retrieval?
-when are embryos usually inserted? how many at a time?

- most women have good chance of achieving preg w/ average of _____ IVF cycles
 IVF is selectively used when infertility is caused by tubal factors (such as scar tissue or other blockages), mucous abnormalities, male infertility, unexplained infertility, and cervical factors (such as scarring). Prior to an IVF procedure, fertility drugs are used to induce ovulation, This process is closely monitored using ultrasound and hormone levels. When the ovarian follicles appear mature, human chorionic gonadotropin (hCG) is given to stimulate final egg maturation and control the induction of ovulation. Egg retrieval is typically performed about 35 hours later-before ovulation actually occurs. Retrieval is performed transvaginally with ultrasound guidance. The eggs are then fertilized in the laboratory using the sperm of a donor or the woman's partner. After normal embryo development has begun, the embryos are inserted into the woman's uterus-usually 1-2 days after fertilization. To increase the potential for success, often 3 or 4 embryos are transferred at a time. This also increases the risk for a mulifetal gestation and potential complications for the woman and her fetuses.
If the procedure has been successful, the embryo will continue to develop and pregnancy will proceed naturally. IVF is typically performed on an outpatient basis and the woman is advised to engage in minimal activity for 12-24 hours following the procedure and progesterone supplementation is initiated to promote embryo implantation and support early pregnancy. Successful IVF is dependent upon many factors but particularly the woman's age. Most women have a good chance of achieving pregnancy with an average of 3 IVF cycles. Unfortunately, many couples find that the emotional and financial expense of trying beyond 3 cycles is too great. Cost per treatment varies significantly depending on the region of the country but the average is approximately $12,000 per cycle.

  • Gamete Intrafallopian Transfer (GIFT)



GIFT involves the retrieval of eggs through laparoscopy and immediate placement of the eggs in a catheter with washed, motile sperm. The gametes are then placed in the fimbriated end of the fallopian tube. Fertilization occurs in the fallopian tube naturally rather than in the laboratory; therefore, this procedure is accepted by the Roman Catholic church. The fertilized egg then travels down the fallopian tube and implants in the uterus.
Zygote Intrafallopian Transfer (ZIFT)
ZIFT is a procedure that has evolved from the GIFT procedure. Eggs are retrieved and incubated with the sperm. However, the eggs are transferred back to the woman much earlier than with IVF and they're transferred back to the fallopian tube. Tubal embryo transfer (TET) is done at the embryo stage thus allowing documentation that fertilization has actually occurred prior to transfer.
*While procedure such as GIFT, ZIFT, and TET offer some benefits, they are more invasive and expensive than IVF and therefore may have limited acceptability.
pre-inplantation genetic diagnosis
Recent advances in "micro-manipulation" allow a single cell to be removed from the embryo for genetic study. Couples who are at risk for having an infant with an identifiable single gene or chromosomal abnormality may choose to undergo this type of pre-implantation genetic testing called blastomere analysis or more recently referred to as pre-implantation genetic testing (PGD). A single cell is removed from a 6-8 cell embryo by a process referred to as blastomere biopsy. The genetic content of the cell is examined using florescence in situ (FISH). Results of the genetic testing are available in 4-24 hours, so only genetically unaffected embryos are transferred. The rapid results of the genetic testing allow transfer of embryos within the required biological window of time for transfer.
A significant benefit of this procedure is that it allows the detection of genetic disorders prior to implantation of the embryo and may prevent a couple from later having to make the difficult decision to continue or terminate the pregnancy if the fetus is affected. However, the procedure also raises significant ethical issues such as:

  • Embryo gender selection

  • Selection for other non-medical reasons and concerns over the potential for "designer babies"

  • Identification of late onset diseases such as Huntington's Disease

  • Availability and access to centers that offer these technologies. Should society provide this service for couples who are at risk and unable to pay?

  • Potential effects on the offspring if a cell is removed during this critical embryonic period

preterm birth
after 20th week, before 38th
conception
-blastocyst implants ______ days after conception 
-major organ systems begin to form _____ days after conception
Conception occurs when a sperm (containing 22 autosomes and one sex chromosome- X or Y) fertilizes an ovum (which contains 22 autosomes and one sex chromosome- X), restoring the diploid number to 46 chromosomes. The zygote undergoes repetitive division to form the blastocyst, which implants 6-10 days after conception. The next expected menstrual cycle is missed 1-2 weeks later. Many women do not realize they are pregnant when major organ systems begin to form 17 days after conception, just a few days after the menstrual period is missed.
-implantation occurs ________ days after conception
-teratogens may or may not affect fetus during first 2 weeks?
-as third week of life begins, embryo's cells begin to form ____________ and are vulnerable to teratogens
-major organs are completed at _____ weeks 
-at beginning of 9th week, embryo is called a ________ and exposure to teratogens throughout this stage may cause_______
 
Implantation occurs 6-10 days after conception. During the first 2 weeks post conception, exposure to teratogens may not affect the fetus, or may cause spontaneous abortion. However, as the third week of life begins, the implanted embryo's rapidly dividing cells begin to form the major organs and external structures. These cells are vulnerable to structural malformations if exposed to environmental teratogens. This formative period for major organs and external structures continues until completed at eight weeks, although the CNS remains vulnerable to injury throughout pregnancy. At the beginning of the ninth week, the embryo is called a fetus due to its' human appearance.  Exposure to teratogens throughout the fetal stage may cause functional or growth disturbances, such as mental retardation or autism.
preconception care is...

its purpose is...
Preconception care is defined as: Maternal health promotion to maximize likelihood of a desired, healthy pregnancy & healthy infant; her partner should also be included. The purpose of preconception care is to improve pregnancy outcomes, because many poor outcomes are preventable & begin early in pregnancy, before a woman initiates prenatal care.
prenatal care begins...
Prenatal care (prior to birth) traditionally begins 8-12 weeks after conception
% of pregnancies unplanned, also for adolescents/young adults
The March of Dimes reports at least 50% of US pregnancies are unplanned; but for adolescents and young adults, up to 70% of pregnancies are unintended.
folic acid supp
-reduces...
-amount
-amount if prev preg with NTD or if 1degree relative w/ NTD
-sources

  • Reduces risk of neural tube defect (NTD) and preterm delivery

  • 400 -800 mcg daily (0.4- 0.8 mg daily) if no history of NTD

  • 4 mg daily if previous pregnancy with NTD or if she or a first degree relative had NTD   

  • Folic acid sources: enriched cereals, breads & pasta, avocado, asparagus, orange juice, broccoli, spinach, black beans,romaine lettuce, & peanuts However, nutritional sources are inadequate to achieve the recommended levels, even with fortified foods.

immunization preconception

  • Varicella

  • Tetanus

  • Polio

  • HBV

  • Influenza

  • MMR

preconception history, done to ID risk factors

  • Complete History & Physical of woman

  • Medical history

  • Physical exam

  • Lab tests

  • Teratogen exposure

  • Psychosocial issues

  • Nutrition

  • History of  Partner & Family

genetic screening is performed prior to conception to discover risk to pregnancy for women with...

  • Advanced maternal age (> 35 years)

  • Metabolic disorders such as Diabetes Mellitus or phenylketonuria (PKU)

  • Previous stillborn or recurrent pregnancy loss or stillbirth

  • Personal, family, or partner history of genetic or congenital abnormalities

  • Thalassemia (if Italian, Greek, Mediterranean or Asian)

  • Neural Tube Defect (NTD)

  • Cardiac defect

  • Down Syndrome

  • Tay-Sachs (Jewish, Cajun, or French-Canadian)

  • Sickle Cell Disease or trait (African)

  • Hemophilia

  • Muscular Dystrophy

  • Cystic Fibrosis

  • Huntington Chorea

  • Mental Retardation

  • Autism

what is single best genetic screen available for preconception care
A 3 generation family medical history with ethnicity, for the woman and her partner, is the single best genetic screen applicable to preconception care.
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