Group 4

Kristen Dominik, Kelly Lawn, Kelly Magoffin,Leigh Smyczek, Jennifer Townsell

KR has been trying unsuccessfully for 1.5 years to become pregnant.

She has a very irregular menstral cycle.

She’s been using an ovulation monitor for 6 months with no positive readings.

She is feeling depressed.

KR’s Questions:

Should I meet with a fertility specialist?

What are the advantages?

What tests will be run?

Metformin helped my friend conceive, what should I know about that?

35 year old woman(gravida 0, para 0)

• Saliva Test1. Place a drop of saliva on the surface of the lens 2. Allow the sample to dry for at least five minutes and replace the lens into the

body of the microscope. 3. Look into the lens and push the light button to observe the test results. (focus

on image)4. If you see a "ferning" or crystal pattern in your saliva, you know you are fertile

- the perfect time to conceive!

• Urine Test (Clearblue monitors)1. Assemble the test and hold in your urine stream for 5-7 seconds. 2. The test ready symbol will start flashing after 20-40 seconds to show the test

is working. 3. The display will show your result within 3 minutes.4. If the Luteinizing Hormone (LH) Surge symbol is displayed, then you have

detected your LH surge!5. You should ovulate within the next 24-36 hours.

•For a 28 day cycle, you should test on day 9 of your cycle, ovulation should occur between days 10 and 17.•If your cycle is 21 days or less (irregular period), you should start testing on day 5 of your cycle. If your cycle is longer than 40 days, you should start testing 17 days before you expect your next period.

Can Result From… Improper use of test Irregular periods Improper timing of sexual activity in conjunction

with LH surge Women over 35 ovulate less, but still have

menstrual periods (anovulation) Infertility

Most women will seek the help of a specialist after unsuccessfully trying to become pregnant for one year. However, women over the age of 35, those

having irregular periods, or with medical problems should visit sooner.

KR should see a fertility specialist

Advantages:

• Fertility specialists have extensive training in obstetrics, gynecology, endocrinology and infertility.

• Tests can be run for female infertility as well as semen analysis. It is important to test both partners as male factors account for 50% of all infertility cases.

• The specialist will perform advanced tests to determine the fertility of the patient.

First Visit: The fertility specialist will measure the patient’s follicle stimulating hormone (FSH) and luteinizing hormone (LH) to determine baseline levels. This is done on the third day of the patient’s cycle.

Second Visit: The second visit occurs on the day of the LH surge, which is before ovulation in most cases. The reproductive specialist will likely perform the following tests..

• Cervical Mucus Test – this is a post-coital test to determine the sperm’s ability to penetrate and survive in the cervical mucus.

•Ultrasound Test – used to assess the thickness of the lining of the uterus (endometrium), monitor follicle development, and check the condition of the uterus and ovaries.

• Hormone Testing – evaluates levels of hormones contributing to the reproductive process such as LH, FSH, estradiol, progesterone, prolactin and more.

• Hysterosalpingogram (HSG) – an x-ray of the uterus and fallopian tubes to identify any blockages.

• Hysteroscopy – used to examine the inside of the uterus and is helpful in diagnosing abnormal uterine conditions such as internal fibroids, scarring, polyps, and congenital malformations.

• Laparoscopy - outpatient procedure to view the fallopian tubes, ovary and uterus which can diagnose causes of infertility such as endometriosis or tubal blockage.

• Endometrial Biopsy- removing a small amount of tissue from the endometrium prior to menstruation to determine if there is a hormonal imbalance.

Upon normal results from the previous tests, the fertility specialist may pursue the following..

Mechanism of Action Selective Estrogen Receptor Modulator (SERM)

Inhibits normal negative feedback of circulating estradiol on the hypothalamus, preventing estrogen from lowering the output of gonadotropin releasing hormone (GnRH)

Weak Estrogen Agonist

Dosage Initially: 50mg by mouth everyday for 5 days, beginning on 3rd, 4th,

or 5th day of menstrual cycle If ovulation does NOT occur: 100mg by mouth everyday for 5 days

Start as early as 30 days after initial dosage Patient may receive up to 3 treatment cycles

Clomiphene is often a first line treatment to induce regular ovulation

– Provides an assessment of the patient’s ovarian reserve

– Procedure:– FSH and estradiol levels are measured on day 3– Patient takes clomiphene 100mg on days 5-9– FSH level is measured again on day 10

– Considered abnormal if:• either the day 3 or 10 FSH values are elevated or • day 3 estradiol is greater than 80 pg/ml

– If these results are abnormal, then the patient will have a decreased response to injectable FSH in assisted reproductive technology cycles• These patients have low pregnancy success rates and have an

increased chance of miscarriage

The use of injectable fertility drugs to stimulate ovulation will be considered after treatment with clomiphene has failed

Gonadotropins hormones produced by the brain to stimulate the ovaries to produce hormones and prepare eggs for release. -Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH)

Follicle Stimulating Hormone (FSH), such as Follistim, Fertinex, Bravelle, and Gonal-F Directly stimulates the recruitment and development of follicles

Human Menopausal Gonadotropin (hMG), such as Pergonal, Repronex, and Metrodin. This drug combines both FSH and LH.

Gonadotropin Releasing Hormone (GnRH), such as Factrel and Lutrepulse. Stimulates the release of FSH and LH from the pituitary gland. These hormones are rarely prescribed in the U.S.

Gonadotropin Releasing Hormone Agonist (GnRH agonist), such as Lupron, Zoladex, and Synarel Inhibits premature LH surges in women undergoing controlled ovarian stimulation

Gonadotropin Releasing Hormone Antagonist (GnRH antagonist), such as Antagon and Cetrotide Prevents premature ovulation

Human Chorionic Gonadotropin (hCG), such as Pregnyl, Novarel, Ovidrel, and Profasi. This drug is usually used along with other fertility drugs to trigger the ovaries to release the mature egg or eggs.

Metformin alone and later in combination with clomiphene citrate has been proposed as a sequential treatment program before the use of gonadotropin therapy for ovulation induction in infertile women with polycystic ovary syndrome (PCOS).

Current conservative practice: Discontinue metformin once pregnancy has been established.

Two retrospective analyses of metformin treatment continued through the first trimester suggested reduced rates of pregnancy loss, but data from a more recent prospective study did not support this effect. If the effect is on implantation, continuation of therapy into pregnancy would be

advised; however, an effect on the developmental potential of the embryo would support the advice to withdraw treatment at establishment of pregnancy.

Metformin is a Class-B drug.

Dose: 500mg TID or 850mg BID with meals

Side Effects: The most common are gastrointestinal side effects such as diarrhea, abdominal discomfort, nausea, and vomiting. These effects are dose-related.

Contraindications: Patients with renal, hepatic or cardiovascular problems, and sepsis.

Chronically abnormal ovarian function and hyperandrogenism

Affects 5–10% of women of reproductive age

Patient presents with: Infertility Irregular menstrual cycles Hirsutism

Further testing to exclude endocrine disorders and The

Presence of polycystic ovaries, as shown by ultrasonography, (not included in the definition but this feature is mandatory in many centers).

ð Fertility Center of Illinois http://www.fcionline.com/treatment-of-infertility/metformin-pcos.html

l Clinical Pharmacology

o Wilcox, Allen J. “The timing of the ‘fertile window’ in the menstrual cycle: day specific estimates from a prospective study.” British Medical Journal. 321 (2000):1259-1262.

9 Clearblueeasy.com

m Drugstore.com

m Harborne, Lyndal. “Descriptive review of the evidence for the use of metformin in polycystic ovary syndrome.” The Lancet. 361 (2003): 1894-1901. www.thelancet.comhttp://dspace.dial.pipex.com/town/estate/aquc35/book/pcosmet.pdf

m Emedicine.com: Infertility

n The American Fertility Association www.theafa.org

t American Pregnancy Association www.americanpregnancy.org