A 35-year-old woman presents to your office. She and her 32-year-old husband have been unsuccessful in their attempts to get pregnant for the last 6 years. He has fathered two children in a prior marriage and has a normal semen analysis. Her basal body temperature chart is biphasic. Her past history notes multiple episodes of chlamydia and gonorrhea. A hysterosalpingogram demonstrates blocked fallopian tubes bilaterally, and a laparoscope notes dense and profuse peritubal and pelvic adhesions, along with bilateral clubbed tubes.
The most appropriate fertility treatment would be:
Correct Answer D:
With extensive tubal disease on both the HSG and laparoscopy, operative assistance will be needed in order for an egg to reach the uterine cavity. Due to the tubal disease, GIFT is not possible. ICSI is the treatment of choice for azoospermia and severe oligospermia. The patient is ovulatory based on her basal body temperature chart, so ovulation induction alone is not necessary. IVF with transcervical transfer of the embryo is the optimal treatment for this couple. With blastocyst transfer, the current success rates are above 50%.
→ The two tests of tubal function both demonstrate that it is highly unlikely for the egg to successfully transport down the tube. Thus, IUI will be of no benefit, since the sperm and egg will not meet.
→ ICSI is used for oligospermic and even some azospermic males to achieve fertilization.
→ Again, ovulation induction alone will not be successful if the tubes are blocked bilaterally.
→ This technique can only be used if there is tubal patency. The egg and sperm mixture is placed in the distal fallopian tube via laparoscopy. The tubes here are blocked.
What is the most common cause of female infertility?
Correct Answer A: Etiology of Female Infertility:
PEARL: Ovulatory disorders are the most common cause of female infertility.
Which of the following medications is contraindicated in the last trimester of pregnancy?
Correct Answer A:
Sulfonamides (the "sulfa" drugs) are safe early in pregnancy, but their use in the last trimester might result in a jaundiced infant. The other medications listed are safe in pregnancy.
Which one of the following is safest for use in pregnancy?
Correct Answer C:
The FDA has established a fetal risk summary dividing drugs into categories. Category A drugs have been shown in controlled studies to pose no risk. At present there are no category A antibiotics. Most fall into categories B and C, with category B drugs thought to be relatively safe in pregnancy. When possible, a category B antibiotic should be chosen for treatment of a pregnant patient. Category C drugs have unknown fetal risk with no adequate human studies, and the possibility of risks and benefits must be considered before prescribing them for pregnant women. Category D drugs show some evidence for fetal risk; although there may be times when use of these drugs is necessary, they should not be used unless there is a very serious or life-threatening situation. Category X drugs have proven fetal risk and are contraindicated in pregnancy.
Of the drugs listed, only nitrofurantoin is in category B. The others are all category C drugs.
The FDA is currently in the process of revising their classification and labeling for drugs in pregnancy and lactation.
A young couple undergo a postcoital test as part of an infertility evaluation. Several hours after coitus, the cervical mucus is thick and tenacious. No sperm are seen in the mucus, although they are present in the vagina. Semen analysis is normal. Eight days later, the patient menstruates. Her basal body temperature (BBT) record for that cycle indicates ovulation and a normal luteal phase.
The most appropriate management of this patient is to:
The luteal phase of the menstrual cycle is about 14 days in most women. Differences in cycle length are due to differences in the proliferative phase length. The reason that the cervical mucus is progestational is that the test was done 6 days too late (A postcoital test is done at ovulation, which occurs 14 days prior to the NEXT menstrual period). The correct thing to do is to repeat the test 6 or 7 days earlier on the next cycle.
→ Since the test was done at the wrong time of the cycle, no assessment of male factor can be made at this time.
→ See answer to A.
→ Although estrogen may change the nature of the cervical mucus, the test was done at the wrong time in the cycle.
→ The basal body temperature chart indicates ovulation (biphasic); so there is no benefit at this time for clomiphene citrate therapy.
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