“my biological clock is running out, doctor” max brinsmead mb bs phd april 2014
TRANSCRIPT
“My biological clock is running out, doctor”
Max Brinsmead MB BS PhD
April 2014
Hannah 38 and Barry 36
Have been living together for 6 years without contraception but Hannah has never conceived. She now seeks your advice because: “My biological clock is running out, doctor”
WHAT ARE THE POSSIBLE CAUSES?
Hannah & Barry Differential Diagnosis
Female FactorsAnovulationGenital tract pathology – tubes & cervix Implantation failure
Male FactorsFailure of sperm generationGenital tract pathology – epididymis, vas
and ejaculatory ductSperm delivery problems
Hannah & Barry with 6 years of infertility
Seek your advice because Hannah believes that time is running out
WHAT ADDITIONAL INFORMATION DO YOU REQUIRE?
History required of Hannah & Barry with 6 years of infertility
Previous conceptions, either partner
General health, drugs, smoking, exercise etc
Past health and any operations
Previous STDs
Menstrual history
Coital history
Hannah & Barry with 6 years of infertility
Previous conceptions?General health, drugs, smoking, exercise etcPast health and any operationsPrevious STDsMenstrual historyCoital history
Hannah TOP at age 18. Barry’s previous wife no conception in 4 yearsBarry smokes 10-15/dayBarry had a “hernia operation” in infancyHannah suffers recurrent thrush. Was treated for CIN at age 28Periods every 26-29 days. Mild dysmenorrhoeaCoitus 2-3 x per week, no problems
Hannah & Barry with 6 years of infertility
Do you examine either partner?
What tests would you request?
Any other advice?
Possible Tests for Hannah & Barry
Semen analysisHormone test for ovulationSTD screenAntenatal screen especially Rubella & VaricellaBasal body temperature chart (BBT)Gene testing for cystic fibrosis, maybeRecommend smoking cessation (Barry) and Folic acid for Hannah(Hysterosalpingogram) (Laparoscopy, hysteroscopy and dye studies)
Test Results for Hannah & Barry
Semen analysis
Routine AN tests
BBT
Volume 1 ml (NR>2) Count <1 million/ml (NR>20) Motility 30% (NR>50) Normal 0% (NR>15)
AN tests NAD but non immune to Varicella
BBT biphasic but coitus not as frequent as claimed
Hannah, 38 & Barry, 36 with 6 years of infertility have a severe male problem
What do you do now?
Examine either or both?
Repeat the semen analysis
Do more tests on Hannah?
Do more tests on Barry?
Hannah & Barry further evaluation
Examine Barry
Repeat the semen analysisBlood tests for BBlood tests for HUltrasound female pelvis
R. testis 15 ml. L testis small & soft. Epidiymis & vas deferens NADMuch the same, but volume 2 ml
FSH, Testoserone, PRL, antisperm antibodiesDay 2 FSH, LH & E2 Day 21 ProgesteroneNormal endometrium, myometrium & ovaries
Hannah, 38 & Barry, 36 with 6 years of infertility have a severe male problem
What do you do now?
Barry wants to know if there is anything that he can do about his sperm count
Is Hannah’s biological clock running out?
Hannah & Barry are advised to seek assisted conception with an IVF Clinic
What sorts of assisted conception are there?
What do they need to know?
Assisted conception options for Hannah & Barry
AIH +/- ovarian stimulationDIGIFTIVF
ICSI
Ovarian stimulation with Clomid or FSH then intrauterine insemination with washed & concentrated husband’s spermInsemination with donor spermOvarian stimulation, egg collection then fallopian tube transfer of eggs and spermOvarian stimulation, egg collection, in vitro fertilisation then uterine transfer of embryo(s).Ovarian stimulation, egg collection, sperm microinjection in vitro then uterine transfer of embryo(s).
Hannah & Barry need to understand:
What is done
What are the risks
Side effects of drugs
Pituitary suppression with GnRHa, FSH stimulation of ovaries, vaginal egg collection with ultrasound, IVF or ICSI, culture to blastocysts then uterine transfer. Extra embryos can be frozen for later attempts.1-5% risk of OHSS, 1% risk of egg collection mishap. No risk of ovarian Ca, premature menopause etc.
Few side effects of these physiological hormones used in pharmacological doses
Hannah & Barry need to understand:
Success rates
Possible cycle outcomes
Possible pregnancy outcomes
Cost
30 – 40% chance of pregnancy per embryo transfer. Depends on female age.Cycle cancellation 10%, failed egg collection 1%, failed fertilisation 5-10%
Miscarriage, ectopic (2-fold increased risk), 3% risk of chromosomal abnormality with ICSI but not IVF
Medicare eligible but most IVF programs have out of pocket costs
Endometriosis is:
Ectopic endometrium i.e. “internal menstruation”
Requires laparoscopy +/- biopsy for diagnosis
Activity is more important than appearance
Symptoms do not always correlate with grading
Symptoms of Endometriosis
The Classic Triad…
DysmenorrhoeaDyspareunia Infertility
Symptoms of Endometriosis
But consider also…
Pre menstrual stainingPain with defaecation during menstruation Intermenstrual painDisordered cyclesFamily history
Diagnosis of Endometriosis
A Careful History (The most important)
Rule out other Causes of Symptoms (The next most important)
Examination (not much help)
Ultrasound (of little value)
MRI (useful for rectovaginal deposits)
Laparoscopy (The gold standard)
Serum CA125 (Lacks sensitivity)
Iridology (a good guess!)
Differential Diagnosis:
Primary Dysmenorrhoea
Irritable Bowel Syndrome
Ovulation Pain
Pelvic Inflammatory Disease
Psychosexual Problems
Aetiology
Two Main Theories: Retrograde menstruation Peritoneal metaplasia
Predisposing Factors Familial predisposition Disordered immunity Environmental toxins Recurrent ovulation Infertile partner Obstructed menstrual flow
Principles of Management:
When the Problem is Pain – Use Medical Rx
When the Problem is Infertility – Use Surgical Rx
When there is no Problem – Use no Rx
Medical Therapy OptionsProgestins COC (best in continuous form) Provera or Norethisterone The Mirena IUS
• Danazol & Gestrinone
• GnRH agonists +/- Add Back Therapy
• A question of side effects