Male and Female Infertility

Goals

Enhance comfort level with workup

Basic Management Strategies

TRICARE www.rotunda.co.in

Definition 12 months of unprotected intercourse

Earlier for certain historical factors

Older than 35

Infertility Etiology

Female Factors

Male Factors

General Causes Unknown: 40-50%

1 Hypogonadism: 30-40%

Altered Sperm Transport: 10-20%

2 Hypogonadism: 1-2%

Meds 1 or 2

Hypogonadism

Common medications Ketoconazole Cimetidine Spironolactone

The Scenario

Tech: “Husband and wife can’t get pregnant.”

You: OB rotation was last infertility workup

What now?

Workup

History is KEY

Focused Physical Exam

Labs and Specialized Tests

Workup: History Coital Practices Gestational History PMHx/PSHx Meds Menstrual History Substances Recent High Fever

Our Couple: History

Female G1 P0010

No hx of STIs

Normal menses

Unprotected sex for 15 months

Male No previous partner

pregnancies

Gonorrhea hx

No meds

Occasional EtOH

Workup: Physical Exam

Male Infection Hernia Vas deferens Androgen deficiency Testicular mass Varicocele

Female Breast Formation

Galactorrhea

Genitalia

Hyperandrogenism?

Workup: Labs

Female Ovulation problems

Ovulatory Dysfunction

Ovarian Reserve

Male CBC FSH, Testosterone GC/Chlam, UA Renal and Liver

Function Semen analysis Postejaculatory

urinalysis

WHO Seminal Fluid Analysis (1999)

Volume: >2ml Sperm concentration: >20 million/ml Total Sperm Number: >40 million/ejaculate Sperm Motility:

>50% motile and/or >25% progressively motile

Sperm Morphology: >14% normal forms

Workup: Special Tests

Female Transvaginal

Ultrasonography (TVUS)

Hysterosalpingography (HSG)

Hysteroscopy

Laparoscopy

Male Scrotal

Ultrasonography

TransrectalUltrasonography(TRUS)

Our Couple: Exam, Labs & Tests

Normal male exam

Normal initial labs

Oligospermia on 2 separate semen analyses

TRUS and postejaculatory UA normal

Management: General Concepts

41 different methods

“Fertile window” intercourse

“E-type” vaginal discharge

Avoid lubricants and douches

Management: Female

Treat underlying cause

Hyperprolactinemia

PCOS

Gonadotropin therapy

Management: Female

Ovulatory dysfunction (Unknown etiology) Clomiphene 50mg PO daily x 5 days Start on days 3-5 Can increase to 100mg daily next cycle Results

80% will ovulate Hyperstimulation and Twinning Higher-order multiples rare

Management: Female Clomiphene Failure?

IVF

Injectable ovulation-inducing agents

Management: Female

Tubal/Pelvic/Uterine Issues Reparative Surgery (low success) IVF

Endometriosis Laparoscopic ablation Laparotomy Ovulation induction +/- IUI and IVF

Management: Male

Hyperprolactinemia

Surgical repair

Fertility Specialist

Stress and Infertility

69% Women and 21% Men have preexisting condition

Greater risk for psychological stress

No significant difference in psychopathology

Stress and Infertility

Men have increased stress over time, same as women

Watch for normal grief vs. psychopathology

Same rates of depression as other chronic disease

Stress and Infertility

Bottom line: Not a means to improve pregnancy rates.

Management: Our Couple

Male: Imipramine Mar 08

Pregnant in www.rotunda.co.in June 2008!

Separated from USAF in July 2008

Questions?