MANAGEMENT OF THE INFERTILE COUPLE IN A

PRIMARY CARE SETTINGPART ONE

MILIE NWOYE MD

SHAPE ARMY MEDICAL CLINIC

FEBRUARY 20TH 2014

OUTLINE

• GENERAL GYNECOLOGY

• Gynecologic cancer screening

• Pre-conception counselling

• Tests for ovarian reserve

• THE INFERTILE COUPLE

• Definition

• Evaluating the infertile couple

• Managing the infertile couple (PART 1)

CERVICAL CANCER SCREENING

• Screening starts at age 21 regardless of sex initiation

• Ages 21-29: Pap test only every 3 years

• Ages 30-65: Pap test every 3 years OR Pap and high risk HPV testing every 5 years

• Women without a cervix: No Pap test required except less than 20 year history of high

grade abnormality OR history of DES in-utero exposure

Population Recommended Screening

Method

Comment

Women younger than 21 years No screening

Women aged 21–29 years Cytology alone every 3 years

Women aged 30–65 years Human papillomavirus and cytology

co-testing (preferred) every 5 years

Cytology alone (acceptable) every 3

years

Screening by HPV testing alone is

not recommended

Women older than 65 years No screening is necessary after

adequate negative prior screening

results

Women with a history of CIN 2, CIN

3 or adenocarcinoma in situ should

continue routine age-based

screening for at least 20 years

Women who underwent total

hysterectomy

No screening is necessary Applies to women without a cervix

and without a history of CIN 2, CIN

3, adenocarcinoma in situ, or cancer

in the past 20 years

Practice bulletin, ACOG, November 2012

BREAST CANCER SCREENING

• Mammography has a false negative rate of 20%*

• Age <40: Self breast awareness

• Age >40: Self breast awareness, annual clinical breast exam and mammogram (except

women with first degree relatives with premenopausal breast cancer OR women with

BRCA mutation)

ACOG guidelines

*National Cancer Institute

Mammography

Clinical Breast

Examination

Breast Self-

Examination

Instruction

Breast Self-

Awareness

American College

of Obstetricians

and Gynecologists

Age 40 years and

older annually

Age 20-39 years

every 1-3 years

Consider for high-

risk patients

Recommended

Age 40 years and

older annually

Practice Bulletin, ACOG, August 2011

ENDOMETRIAL CANCER SCREENING

• Most common gynecologic cancer

• No screening tool.

• Red flags: postmenopausal bleeding

• Diagnosis:

• Endometrial biopsy or D&C

• Transvaginal ultrasound

Risk Factor Relative Risk

Longterm high dose

HRT

10-20

Tamoxifen 3-7

PCOS or estrogen

producing tumor

>5

Obesity 2-5

Nulliparity 3

ACOG practice bulletin, August 2005

OVARIAN CANCER SCREENING

• Lifetime risk of 1/70

• No evidence that screening leads to earlier

detection or improved survival

• Diagnostic tests: CA 125 and transvaginal

ultrasound

ACOG, July 2007

PRE-CONCEPTION SCREENING

• Folic acid 0.4mg (or 4mg with a history of open neural tube defects)

• Risk factor-based genetic screening/ counselling

• Optimize medical conditions (HTN, DM)

• Domestic violence screening

• Avoid alcohol, tobacco, radiation, and illegal drugs

• Weight reduction

• Vaccinations (Rubella, influenza)

ACOG Committee opinion, 9/2005

TESTING FOR OVARIAN RESERVE

•

ASRM, 2005

Speroff, 2005

THE INFERTILE COUPLEDEFINITION

For women ≤ 35: No conception after 1 year of unprotected intercourse

For women >35: No conception after 6 months of unprotected intercourse

Only 43% seek medical care

Age and infertility. Science 1986;233:1389-94

Age (years) Infertility rates (%)

15-24 4

25-34 13

35-44 30

CAUSES OF INFERTILITY- COUPLES

35%

35%

15%

10%

5%

Tubal and pelvic pathlogy

Male factor

Ovulatory dysfunction

Unexplained

Unusual problems

Speroff, 2005

CAUSES OF FEMALE INFERTILITY

40%

40%

10%

10%

Ovulatory dysfunction

Tubal and pelvic disease

Unexplained

Unusual problems

Speroff, 2005

STANDARD FERTILITY WORK-UP

• Assessment of male factor infertility: semen analysis

• Assessment of ovulation: history, BBT, day 21 progesterone

• Assessment of uterus/endometrium and ovaries: transvaginal ultrasound

• Assessment of tubal patency: hysterosalpingogram or laparoscopy

• Assessment of endometriosis: laparoscopy

ASRM Fact sheet 2005

INFERTILITY MANAGEMENT

• Timed intercourse

• Ovulation induction

• Intrauterine insemination (+/- ovulation induction)

• In-vitro fertilization (IVF)

• Intracytoplasmic sperm injection (ICSI)