The McCoughey Septuplets

Infertility 101

DefinitionsDefinitions

Under 35 yoUnder 35 yo No conception after one No conception after one year of unprotected year of unprotected

intercourseintercourse

Over 35 yoOver 35 yo No conception after 6 No conception after 6 months of unprotected months of unprotected

intercourseintercourse

Your Infertility Patient. . .

34 yo woman presents to your 34 yo woman presents to your

clinic to discuss her concerns clinic to discuss her concerns

about infertilityabout infertility

Psychosocial Issues

ExpectationsExpectations Stress on RelationshipsStress on Relationships Stress on FinancesStress on Finances Alternatives- Adoption or ChildlessAlternatives- Adoption or Childless Counseling, Support GroupsCounseling, Support Groups

Etiologies

Male FactorMale Factor 40%40% Tubal FactorTubal Factor 40%40% Ovulation ProblemOvulation Problem 10%10% UnexplainedUnexplained 10%10%

Start with History. . .What Clues Can You Find on History?

Male FactorMale Factor

Tubal FactorTubal Factor

OvulationOvulation

Semen Analysis

Normal values:Normal values:

Volume Volume 2-5cc2-5cc

CountCount >20 million>20 million

MotilityMotility >50%>50%

MorphologyMorphology >50% normal >50% normal

(strict criteria >15%)(strict criteria >15%)

Male Factor Infertility

Evaluation:Evaluation:Repeat semen analysisRepeat semen analysisPhysical exam- varicocele, testicular sizePhysical exam- varicocele, testicular sizeLab testing- testosterone, FSH, LHLab testing- testosterone, FSH, LHGenetics for special casesGenetics for special cases

IUI (intrauterine insemination)IUI (intrauterine insemination)ICSI (intracytoplasmic sperm injection)ICSI (intracytoplasmic sperm injection)Donor spermDonor sperm

Etiologies

Male FactorMale Factor 40%40%

Tubal FactorTubal Factor 40%40% Ovulation ProblemOvulation Problem 10%10% UnexplainedUnexplained 10%10%

Hysterosalpingogram

HSG: Unilateral Blocked Tube

HSG: Tubal Infertility

HSG: Hydrosalpinx

HSG of DES daughter

Etiologies

Male FactorMale Factor 40%40% Tubal FactorTubal Factor 40%40%

Ovulation ProblemOvulation Problem 10%10% UnexplainedUnexplained 10%10%

Ovulation Physiology

The LH (lutenizing hormone) surge occurs The LH (lutenizing hormone) surge occurs 34-36 hours prior to follicle rupture34-36 hours prior to follicle rupture

Progesterone is increasingly produced after Progesterone is increasingly produced after the LH surgethe LH surge

Secretory changes to the endometrium Secretory changes to the endometrium occur secondary to the increased occur secondary to the increased progesterone levels progesterone levels

Ovulation Predictor Kits

Salivary Estrogen: TCI Ovulation Tester- 92% accurate

Add Saliva Sample

Non-Ovulatory Saliva Pattern

High Estrogen/ Ovulatory Saliva Pattern

Approach to Ovulation Disorders

Evaluate- Evaluate- HypothyroidismHypothyroidismProlactin DisorderProlactin Disorder

Hyperandrogenism- Hyperandrogenism- PCOSPCOS Weight loss/ Weight loss/ weight gainweight gain

Induce OvulationInduce OvulationClomid (clomiphene Clomid (clomiphene

citrate)citrate)

Traditional Infertility Evaluation

1)1) Semen AnalysisSemen Analysis

2)2) Hysterosalpingogram (HSG)Hysterosalpingogram (HSG)

3)3) Documentation of OvulationDocumentation of Ovulation

4)4) Post-coital ExamPost-coital Exam

5)5) Diagnostic LaparoscopyDiagnostic Laparoscopy

Current Infertility Evalution

1)1) Semen AnalysisSemen Analysis2)2) Hysterosalpingogram (HSG) Hysterosalpingogram (HSG) 3)3) Documentation of OvulationDocumentation of Ovulation

4)4) Ovarian Reserve TestingOvarian Reserve Testing

Ovarian Reserve Testing

Day #3 FSH Day #3 FSH (<10 mIU/ml)(<10 mIU/ml) and estradiol and estradiol (<80 pg/ml)(<80 pg/ml)

-Correlates with the functional status of the -Correlates with the functional status of the ovaries and the quality of the oocytesovaries and the quality of the oocytes

- FSH >15 only 5% success with IVF- FSH >15 only 5% success with IVF

- High estradiol level increases risk of - High estradiol level increases risk of cancelling IVF cyclecancelling IVF cycle

Unexplained Infertility

12-15% of couples12-15% of couples 3% chance of achieving a pregnancy3% chance of achieving a pregnancy Treatment:Treatment:

Superovulate with IUI Superovulate with IUI (intrauterine insemination)- (intrauterine insemination)-

ClomidClomid 12% success12% successPergonalPergonal 16%16%

IVFIVF

Infertility?