1 / 31

Infertility: the role of the family doctor

Infertility: the role of the family doctor. Carroll Haymon, M.D. January 7, 2002. Definitions . Infertility = Inability of a couple practicing frequent intercourse and not using contraception to fail to conceive a child within one year.

afra
Download Presentation

Infertility: the role of the family doctor

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Infertility: the role of the family doctor Carroll Haymon, M.D. January 7, 2002

  2. Definitions • Infertility = Inability of a couple practicing frequent intercourse and not using contraception to fail to conceive a child within one year. • Infertility affects 15-20% of couples, or 11 million reproductive age people in the U.S.

  3. Causes of infertility • Tubal pathology 35% • Male factor 35% • Ovulatory dysfunction 15% • Unexplained 10% • Cervical/other 5%

  4. Counsel patience! • In normal young couples: • 25% conceive after one month • 70% conceive after six months • 90% conceive by one year • Only an additional 5% will conceive in an additional 6-12 months

  5. Fecundity and Age • In a federal survey: • Impaired fertility in women < 25y is 11.7% • Impaired fertility in women > 35y is 42.1% • In another study: • 74% of women < 31y conceived in one year. • 54% of women >35y conceived in one year. • Our challenge: presenting data in a supportive, non-judgmental manner

  6. Congenital anomalies Tubal occlusion Evaluated by: hysterosalpingogram laparoscopy hysteroscopy May occur as sequelae of PID endometriosis abdominal/pelvic surgery peritonitis Tubal/ Pelvic pathology

  7. Male factor • Male partner should be evaluated simultaneously with female • Causes of male infertility: • reversible conditions (varicocele, obstructive azoospermia) • not reversible, but viable sperm available (ejaculatorydysfunction, inoperative obstructive azoospermia) • not reversible, no viable sperm (hypogonadism) • genetic abnormalities • testicular or pituitary cancer

  8. Ovulatory dysfunction • Causes 15% of infertility • Diagnosed by menstrual irregularities, basal body temperature charting, ovulation prediction kits, serum progesterone levels.

  9. Ovulatory Dysfunction - 2 • Causes of ovulatory dysfunction: • polycystic ovary syndrome • hypothalamic anovulation • hyperprolactinemia • premature and age-related ovarian failure • luteal phase defect (theoretical)

  10. Polycystic Ovarian Syndrome • Oligomenorrhea/amenorrhea and hyperandrogenism • Prevalence: 5%. Among women with O.D., 70% have PCOS. • Clinical evidence: hirsutism, acne, obesity • Lab evidence: elevated testosterone, elevated DHEA-S. • “Polycystic ovaries” supportive, not diagnostic

  11. PCOS: Treatment Approach • Weight loss if BMI>30 • Clomiphene to induce ovulation • If DHEA-S >2, clomiphene + glucocorticoid (dexamethasone) • If clomiphene alone unsuccessful, try metformin + clomiphene. • Source: ACOG Bulletin, #34, “Management of Infertility caused by Ovulatory Dysfunction” Feb 2002.

  12. Hypothalamic Anovulation • Low levels of GnRH, low of normal levels of FSH/ LH, low levels of endogenous estrogen. • Associated factors: low BMI (< 20), high-intensity exercise, extreme diets, stress. • Treatment: lifestyle modification.

  13. Hyperprolactinemia • Causes: pituitary adenoma, psych meds. • Test for: pregnancy, thyroid disease. • Imaging: MRI for macro vs microadenoma • Treament: Bromocriptine (dopamine agonist). After correction, 80% of women will ovulate, 80% will get pregnant. • Discontinue treatment once pregnancy established.

  14. What Can I Do? Infertility Evaluation for the Family Doctor

  15. History menarche, puberty menstrual hx preganancies, abortions, birth control dysparenunia, dysmenorrhea STD’s, abdominal surg, galactorrhea Weight loss/gain Stress, exercise, drugs, alcohol, psychological Physical weight/BMI thyroid skin (striae? Acanthosis nigracans?) pelvic (vaginal mucosa, masses, pain) rectal (uterosacral nodularity) History and Physical - Female

  16. History prior fertility medications h/o diabetes, mumps, undescended testes genital surgery, trauma, infections ED drug/alcohol use, stress underwear, hot tubs, frequent coitus Physical habitus, gynecomastia sexual development testicular volume (5x3 cm) epididymis, vas, prostate by palpation check for varicocele History and Physical - Male

  17. Trouble in Paradise • Don’t wait a year if: • irregular menses; intermenstrual bleeding • h/o PID • h/o appy with rupture • h/o abdominal surgery • dyspareunia • age > 35 • male factors

  18. On your first visit: • Semen analysis • Confirm ovulation • basal body temperature charting • ovulation predictor kits (detect LH surge) • consider serum progesterone on day 21 • Labs: • TSH and prolactin. DHEA-S if concern for PCOS. • FSH & estradiol on cycle day 3 if >35y. • Cervical cultures prn.

  19. Three months later • Hysterosalpingogram • evaluates tubal patency and uterine cavity shape • noninvasive but involves a tenaculum • performed by radiology with gynecology supervision • diagnostic and therapeutic

  20. Sorry, no data for... • Postcoital test • endometrial biopsy • immune testing for antisperm antibodies • routine cervical cultures

  21. Clomiphene citrate • Effective for anovulatory patients. • Also used in unexplained fertility, but no data to support. • Most effective for women with nomal FSH and estrogen, least effective in hypothalamic amenorrhea or elevated FSH. • Induces ovulation by unknown mechanism • Most pregnancies occur in first 3 cycles. 80% will ovulate, 40% will become pregnant in 3 cycles.

  22. Clomiphene - complications • 7% twin gestations, 0.3% triplet gestations • Miscarriage rate = 15% • Birth defect rate unchanged from controls • Side effects: hot flashes, adnexal tenderness, nausea, headache, blurry vision • Contraindications: pregnancy, ovarian cysts.

  23. Clomiphene - Administration • 50 mg po qd, cycle day 3 through 7. Induce bleeding first with progesterone if amenorrheic. • Intercourse QOD cycle days 12 - 17. • Track ovulation with BBT or ovulation detection kits. • Increase dose to 100 qd, then 150, if no ovulation occurs.

  24. Bibliography • Bradshaw, Karen. Evaluation and Management of the Infertile Couple. Ob/Gyn vol 5, chapter 50, 1998. • Penzias, Alan. Infertility:Contemporary office-based evaluation and treatment. Obstet& Gynecol Clinics, vol 27, no 3, Sept 2000. • ACOG Practice Bulletin. Management of Infertility Caused by Ovulatory Dysfunction. Number 34, February 2002. • Royal College of Obstetricians and Gynecologists, The Management of Infertility in Secondary Care: National Evidence-Based Clinical Guidelines. www.rcog.org.uk.

  25. Case 1 • A 24 year old couple comes to see you. They have been trying to get pregnant for 8 months. • What questions do you ask?

  26. Case 1 • The woman tells you she has never been pregnant. She has a regular 28 day cycle and bleeds for 4 days each month. Her medical history is unremarkable except she “got really sick” when she was 16 and had “nasty stuff coming from down there” • what do you do next?

  27. Case 2 • A 35 year old woman and her 31 year old male partner come to see you. They have been trying to get pregnant for 6 months. • What do you ask?

  28. Case 2 • She says her periods have been irregular since she went off the pill a year ago. She has never been pregnant. He has fathered a child by another woman several years ago. • What do you look for on exam? • What lab tests do you order today? • Do you give them homework?

  29. Case 2 • They come back 3 months later with BBT charts showing no discernable pattern. Lab tests, including semen analysis, were all normal. • What is the diagnosis? • What do you do next?

  30. Case 2 • You begin discussion of clomiphene. They want to know the side effects, and if this means they’ll have sextuplets and get a free house like the folks on TV. • What do you tell them? • How do you administer the clomiphene?

  31. Case 2 • They come back in one month. She feels “like a total bitch - excuse me, doctor” on the clomiphene. She is not pregnant. BBT charting shows a mid-cycle temperature rise. • What happens next?

More Related