Female Infertility

00:00 Female infertility is the next topic.

00:03 One should always suspect this when there is failure to become pregnant after one year of unprotected intercourse, in an average, on average twice weekly in women younger than 35 years of age and after six months in women over age 35.

00:20 The history and physical exam has a numerous clues that one should look for.

00:25 First of all, a menstrual history should be obtained to determine ovulatory status, the state of previous pregnancies, if they have occurred and have been successful should be determined.

00:37 Has the patient been on prior cancer therapy particularly agents that are toxic to the gonads and reproductive system and ovaries? Has the patient had prior substance abuse? Do they have any sexually transmitted infections or history of sexually transmitted infections? Have they had pelvic inflammatory disease? Have they also had any prior gynecologic procedures that may have led to abnormalities of the uterus or fallopian tubes.

01:06 And finally, the gynecological procedures provide important information about the anatomy of the patient in terms of where to go with the further work-up.

01:18 Assessment of symptoms include ruling out any thyroid dysfunction, ruling out any galactorrhea or abnormal milk production.

01:28 Assessing for hirsutism, determining whether there is the presence of pelvic pain and then any dysmenorrhea and/or dyspareunia, dyspareunia being painful intercourse.

01:40 There after, one should go on to do an assessment for any clinical signs.

01:45 Firstly, is there any evidence of hyperandrogenism, Is the patient hirsute? Do they have any features on the exam that suggest that they are androgenized? Also look for evidence of estrogen deficiency clinically, Do they have vaginal dryness, etc.

02:04 Hyperprolactinemia, the clinical findings usually present as galactorrhea which is excess milk production.

02:11 And then finally, do they have signs clinically of thyroid dysfunction.

02:17 Is there a goiter, for instance, in the the neck? Here is an algorithm that helps you assess the female reproductive axis and we'll go through this slowly.

02:28 First of all, we begin with pulses of gonadotropin releasing hormone that drive luteinizing hormone and FSH production.

02:37 Luteinizing hormone affects the theca cells to stimulate androgens, principally androstenedione.

02:44 Androstendione is metabolized to estradiol in the granulosa cells.

02:51 FSH acts on the granulosa cells to enhance follicle maturation.

02:56 And granulosa cells produce negative feedback regulation through inhibin to regulate FSH production.

03:04 Ovulatory status is then assessed using a midluteal phase progesterone level obtained 1 week before expected menses.

03:13 A progesterone level that is greater than 3 ng/mL is evidence of recent ovulation.

03:20 If anovulatory cycles are suspected, evaluation including a prolactin level, a TSH and FSH measurement with subsequent assessment for polycystic ovary syndrome is warranted.

03:33 The anatomical assessment follows.

03:35 A hysterosalpingogram is used to assess for tubal occlusion and to evaluate the uterine cavity.

03:42 This would be particularly important in the case of Asherman syndrome where the patient has undergone prior currettages of the uterus.

03:51 An exploratory laparoscopy may be used if endometriosis or pelvic adhesions are suspected.

03:58 In this manner, a laparoscope is induced, is inserted into the peritoneum to look for any areas of endometriosis that may be contributing to the infertility.

04:11 If no abnormalities are found, fertility treatments will be offered under the direction of a reproductive endocrinologist.

04:18 These treatments could include a variance stimulation with clomiphine or letrozole or intrauterine insemination.

04:25 Also, in-vitro fertilization can be offered to women age 40 years or older as the first line therapy.