Question

ility Case study

L. B. and her husband, J.B., come to the clinic, saying they want to become pregnant. LB. is 29 years old and a self-employedphotographer. J.B. is 31 years old and a dispatcher with a local oil and gas company. They have been married for 4 years and have been trying to become pregnant for just over 2 years. LB.has not been pregnant previously; J.B. says he has never gotten a girl pregnant “that he knows of.

1. Is this couple infertile? Defend your response.

2. What type of infertility does the couple have, primary or secondary?

3. What are the common causes of male infertility?

4. What are the common causes of female infertility?

5. Describe the reproductive and sexual history you need to obtain from the couple?

6. In addition to performing a general physical examination, what lab tests do you expect the provider to order?

General Assessment

L.B. J.B.

29 years old 31 years old

BMI 26.1 BMI 27.1

Reproductive structure normal Reproductive structure normal

Slightly irregular menses 28-35 day cycle No problems with erections &

Nonsmoker, nondrinker ejaculation

Nonsmoker; drink 1-2 alcoholic

beverages per week

Continuation

Both report their spouse has been their only sexual partner for the past 6 years. They engage in intercourse an average of 2 to 3 times per week and deny any sexual problems. L.B. had been using contraceptive pills for about 4 years prior to their attempting to conceive. She says her menses were regular before using the oral contraceptives, but once she stopped using them, regular menses did not resume. Both deny any history of urinary tract and sexually transmitted infections. Their general physical assessments are unremarkable except their BMI’s. Neither engage in any regular physical activity exercise. The provider orders an ultrasound for L.B. and lab testing for both. LB. is to begin performing basal body temperature (BBT) charting in conjunction with using an ovulation kit.

7. J.B. needs a semen analysis. What instructions will you give him about specimen collection?

Select all that apply

a. Keep the container in an insulated bag with ice.

b. Bring the specimen to the office within 8 hours.

c. Place the specimen in a clean container for transport.

d. He can collect the specimen in a sterile, nonlubricated condom

e. He should not have sex or ejaculate for 2 to 5 days before the procedure.

8. What information is obtained from a semen analysis?

9. The provider orders follicle stimulating hormone (FSH), estradiol, and progesterone levels for L.B.; & luteinizing hormone (LH) level for J.B.; and TSH levels for both. When will you schedule these tests?

10. What is the purpose of BBT charting?

11. What teaching will you provide L.B. on how to perform BBT charting?

12. Outline the teaching you will provide L.B. on how to use an ovulation kit.

13. Because lifestyle and sexual practices can affect fertility, what do you encourage the couple to do to enhance their ability to conceive?

select all that apply

a. Relax in a hot tub daily before going to bed.

  b. Avoid the use of artificial lubricants during sex.

  c. Have them drink alcohol before sex to help relax.

d. Eat a healthy diet with plenty of fruits and vegetables.

  e. Have them drink alcohol before sex to help relax.

  f. Engage in moderate exercise for 30 minutes, 3 to 4 times per week.

14. As you finish the appointment L. B. begins to cry and says, “I can’t believe this is happening to us when all of my friends are just popping out babies. “How do you respond”.

Progression

Chart View

Lab Results

L.B.   J.B.

Progesterone low   TestosteroneNormal

Estradiol normal   LH normal

FSH normal     TSH norm

TSH normal     Seminal parameters normal

Pelvic ultrasound normal

J.B.'s semen analysis reveals no apparent problem. L.B. appears to be ovulating normally. BBT charting captures a change in temperature, and ovulation testing reveals an LH surge. The provider suspects L.B. may have a luteal phase defect because her progesterone levels are low after ovulation. The providerdecides to order an hysterosalpingogram (HSG) for LB.

15. How will you describe a HSG to the couple?

16. You tell L.B. that it is important for her to call the office when her menstrual cycle starts

so the HSG can be scheduled between days 7 and 10 of her cycle. It is important they abstain from sex between the first day of her cycle until after the test. L.B. asks why. What do you tell her?

The HSG was normal, with no blockage to the fallopian tubes. The provider speaks with the couple about starting L.B. on clomiphene (Clomid) and progesterone vaginal suppositories, starting 2 days after ovulation.

17. What is the expected outcome associated with each of these medications?

18. You determine that L. B. understands your teaching about clomiphene therapy.

(Select all that apply;)

a. “I do not need to use the LH testing kits anymore.”

b. “There is a higher risk of my having twins, or more.”

c. “I will take this medicine orally for 5 days each month.”

d. “I may experience some flushing and breast tenderness.”

e. “My husband will need to learn to give me daily injections.”

Answer 1

1.

The infertility is failure to conceive with in one or more years of regular unprotected intercourse. Here, the couple have been married for 4 years and have been trying to become pregnant for two years. So, the couple is infertile.

2.

The couple have primary infertility. Because, Mrs. LB has not been pregnant. The primary infertility denotes, couple who have never been able to conceive and the secondary infertility indicates , difficulty in conceiving after already having conceived. So, the couple having primary infertility.

3.

Common causes of male infertility are :-

* HYPOTHALAMIC AND PITUITARY DISORDERS ( 1-2%)

- Idiopathic isolated gonadotropin deficiency

- Kallmann syndrome

- Single gene mutation

- Hypothalamic and pitutary tumors

- Infiltrative disease

- Hyperprolactinemia

- Drugs

- Chronic systemic illnesses and malnutrition

- Infections

- Obesity

* PRIMARY GONADAL DISORDER (30-40%)

- Klinefelter syndrome

- Y chromosome deletions

- Cryptorchidism

- Varicoceles

- Infections

- Drugs

- Radiation

- Environmental gonadotoxins

- Chronic illnesses

* DISORDERS OF SPERM TRANSPORT (10-20%)

- Epididymal obstruction or dysfunction

- Infection causing obstruction to vas defence

- Vasectomy

- Ejaculatory dysfunction

- Young syndrome

* IDIOPATHIC ( 40-50% )

4. Common causes of female infertility are :-

* OVARIAN FACTORS : Anovulation or oligoovulation

- Turner's syndrome

- Hypothyroidism

- Ovarian tumors

- X ray / radioactive exposure

- General I'll health

- Poor diet

- BMI < 20/>24

- Use of easily digested carbohydrates ( white bread (

- PCOS ( Polycystic Ovarian syndrome)

- Stress

- High Insulin or glucose levels

* TUBAL FACTORS

- Chronic salpingitis

- History of tubal ligation

- Pelvic inflammatory disease ( PID)

* UTERINE FACTORS

- Fibroids

- Congenital deformation

- Low estrogen / progesterone from ovary

- Endometriosis in ovaries or fallopian tubes

* CERVICAL FACTORS

- Coitus after 12-72 hours after ovulation

- Infections

- Stenotic cervical os

- Obstruction of os

- Repeated cervical surgeries

- Anti-sperm antibiotics

* VAGINAL FACTORS

- Infections

- Sperm immobilizing or agglutinating antibiotics

5.

Reproductive and sexual history need from the couple are:-

- Frequency of intercourse

- Difficulties in intercourse

- H/o unprotected intercourse

- Coital frequency and sexual dysfunction

- History of exposure to STD

- H/o pelvic inflammation

- Hypo/ oligo / amenorrhea

- Any contraceptive practices

- Sexual problems such as dyspareunia, loss of libido etc.

6.

The lab test are :-

* Semen analysis

* Follicular stimulating hormone ( FSH) Testing

* Estradiol

* Leutinizing hormone ( LH) level

* Anti-mullerian hormone ( AMH)

* Serum progesterone

* Prolactin

* Androgen

Thankyou ?