infertility
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Infertility. UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series. Objectives for Infertility . Define infertility Describe the causes of male and female infertility Describe the evaluation and initial management of an infertile couple - PowerPoint PPT PresentationTRANSCRIPT
InfertilityUNC School of Medicine
Obstetrics and Gynecology ClerkshipCase Based Seminar Series
Objectives for Infertility Define infertility
Describe the causes of male and female infertility
Describe the evaluation and initial management of an infertile couple
List the psychosocial issues associated with infertility
Failure of a couple to conceive after 1 year of regular intercourse without use of contraception Primary infertility – No prior pregnancies Secondary infertility – Prior pregnancy
Definition
Infertility affects 10-15% of reproductive-age couples in the U.S.
Approx. 85% of couples achieve pregnancy within 1 year Conception rate (fecundability)
25% conceive within 1 mo. 60% conceive within 6 mo.’s 75% conceive within 9 mo.’s 90% conceive within 18 mo.’s
Prevalence
Successful conception requires a specific series of events:1. Ovulation of competent oocyte2. Production of competent sperm3. Juxtaposition of sperm and oocyte in a patent reproductive tract4. Fertilization5. Generation of a viable embryo6. Transport of the embryo to the uterine cavity7. Implantation of the embryo into the endometrium
Etiology
Major causes of of infertility: Female factor – 60%
Ovulatory dysfunction Abnormalities of female reproductive tract Peritoneal factors Reproductive aging
Male factor – 20% Abnormal semen quality Abnormalities of male reproductive tract
Idiopathic – 15%
Infertility in ~ 20-40% of couples has multiple causes
Etiology
Female Duration of infertility and prior evaluation or therapy Menstrual cycle (length and characteristics)
Symptoms associated with ovulation (e.g. breast tenderness, bloating, mood changes)
Full OBHx and GynHx Prior pregnancies, surgeries, or STD’s
Sexual history (frequency of intercourse) Chronic medical illness Family history (infertility, birth defects, genetic disorders) Social history (smoking, EtOH, drugs)
Infertility: History
Male Prior children Genital tract infections Genital surgery or trauma Chronic medical illness Medications (e.g. Furantoins, CCB) EtOH, drugs, or smoking Sexual history (frequency of intercourse)
Infertility: History
Female Height, weight , BMI Pelvic exam
Masses Tenderness (Adnexa, Cul-de-sac) Structural abnormalities (Vagina, Cervix, or Uterus)
Male (Urologist referral) Evidence of androgen deficiency Structural defects (e.g. varicocele, hernia)
Infertility: Physical Exam
Male factor: Evaluation
Initial evaluation Further evaluationMale Factor Semen analysis
Urologic evaluationFSH, LH, and testosterone levelGenetic evaluationEpididymal sperm aspiration (PESA, MESA)Testicular biopsy
Element Reference value
Ejaculate volume 1.5-5.0 mL
pH > 7.2
Sperm concentration > 20 million/mL
Motility > 50%
Morphology > 30% normal forms
Male factor: Evaluation
Semen analysis Following 2-4 day period of abstinence Repeated x1 for accuracy
Male factor: Evaluation
Urologic evaluation Physical Exam
Varicocele Congenital absence of vas deferens (CAVD)
Transrectal ultrasound Vasography, Seminal vesiculography Epididymal sperm aspiration (PESA or MESA)
Male factor: Evaluation
Endocrine evaluation Indication: Oligospermia (< 10million/mL) or sexual dysfunction (decreased
libido, impotence) FSH, LH, testosterone
Genetic evaluation Indication: Azoospermia (no sperm) CFTR mutation Karyotype (Klinefelter’s, Y chromosome deletion)
Testicular biopsy Indication: Nonobstructive azoospermia
Palpable vasa Normal testis volume Normal FSH/LH
Female factor: Evaluation
Factor Initial evaluation Further evaluationOvulation History and physical exam
Basal body temp chartingOvulation predictor kit
Mid-luteal phase progesterone levelEndocrine testingEndometrial biopsy
Reproductive tract (uterus or fallopian tubes)
Hysterosalpingogram (HSG)Ultrasound
Saline-infusion sonographyHysteroscopyLaparoscopy
Peritoneal LaparoscopyReproductive aging FSH, estradiol, or AMH
Female factor: Menstrual Cycle
Ovulation Initial evaluation:
Basal body temp – rise for > 10 days indicates ovulation Ovulation predictor kit – detects LH surge in urine
Further evaluation: Mid-luteal phase progesterone level - level > 3 ng/mL provides
qualitative evidence of recent ovulation Endocrine testing (TSH, prolactin, FSH, LH, Estradiol, DHEA-S) Endometrial biopsy
Not routinely performed
Female factor: Evaluation
Reproductive tract Initial evaluation:
Hysterosalpingogram (HSG) Detect uterine anomalies (septate or bicornuate uterus, uterine
adhesions, uterine leiomyoma) Detect patency of fallopian tubes (occlusion, hydrosalpinx, salpingitis)
Ultrasound – alternative to HSG to evaluate uterus
Female factor: Evaluation
Reproductive tract Further evaluation:
Saline-infusion sonography (SIS) Hysteroscopy Laparoscopic chromotubation
Female factor: Evaluation
Peritoneal factors Laparoscopy
Endometriosis Pelvic/adnexal adhesions
Female factor: Evaluation
Reproductive aging Indications:
> 35 years of age 1st degree relative with early menopause Previous ovarian insult (surgery, chemotherapy, radiation) Smoking Poor response to ovarian stimulation Unexplained infertility Candidate for IVF
Female factor: Evaluation
Reproductive aging Cycle day 3 serum FSH and estradiol
Abnormal (“diminished ovarian reserve”) FSH > 10 IU/L Estradiol > 75-80 pg/mL
Clomiphene citrate challenge test Cycle day 10 serum FSH
Serum antimullerian hormone (AMH)
Female factor: Evaluation
Prevalence ~ 15% Factors that cannot be identified
Sperm transport defects Inability of sperm to fertilize egg Implantation defects
Idiopathic Infertility
Infertility: Management
Male Factor Avoidance of alcohol Scheduled intercourse Ligation of venous plexus for significant varicocele Intrauterine insemination (IUI) with washed sperm Intracytoplasmic sperm injection (ICSI) + IVF Donor sperm insemination
Anovulation Oral medications:
Clomiphene citrate Dopamine agonists (Bromocriptine) - hyperprolactinemia
Injectable medications: Gonadotropins (FSH/hMG, hCG)
Laparoscopic “ovarian drilling” Complications: Ovarian hyperstimulation, Multiple pregnancy
Infertility: Management
Reproductive tract abnormality Uterine: Myomectomy, Septoplasty, Adhesiolysis Tubal: Microsurgical tuboplasty, Neosalpigostomy Peritoneal: Laparascopic treatment of endometriosis, Adhesiolysis
Idiopathic infertility Ovarian stimulation + IUI
Clomiphene or gonadotropins (hMG, hCG) IVF
Infertility: Management
Used for: Severe male factor Tubal disease Couples who failed other treatments
Requires Controlled ovarian hyperstimulation Retrieval of oocytes In vitro fertilization and embryo transfer
Procedures IVF + embryo transfer (IVF-ET) Intracytoplasmic sperm injection + embryo transfer (ICSI-ET) Donor egg IVF + embryo transfer
Infertility: Management (IVF)
The psychological stress associated with infertility must be recognized and patients should be counseled appropriately.
Psychological
Bottom Line Concepts Infertility is defined as one year of unprotected coitus without
conception. Infertility may be primary or secondary. Multiple causes must be considered for infertility diagnosis and
treatment. Male and female reproductive tract anatomy and physiology should be
reviewed in order to generate a full differential diagnosis. Components of an initial infertility workup include a thorough history
and physical examination. Laboratory investigations include a semen analysis, documentation of ovulation, and hysterosalpingogram.
Dysfunction of the hypothalamic-pituitary-ovarian (HPO) axis and medical illness, including thyroid disease and pituitary tumors, can cause ovulatory disturbances.
Success rates with IVF depend on the etiology of infertility and the age of the female partner.
References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 48 (p102-103).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 38 (p337-346).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 34 (p371-378).