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Infertility

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Infertility

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    1. Infertility UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series

    2. Objectives for Infertility Define infertility Describe the causes of male and female infertility Describe the evaluation and initial management of an infertile couple List the psychosocial issues associated with infertility

    3. Failure of a couple to conceive after 1 year of regular intercourse without use of contraception Primary infertility – No prior pregnancies Secondary infertility – Prior pregnancy Definition

    4. Infertility affects 10-15% of reproductive-age couples in the U.S. Approx. 85% of couples achieve pregnancy within 1 year Conception rate (fecundability) 25% conceive within 1 mo. 60% conceive within 6 mo.’s 75% conceive within 9 mo.’s 90% conceive within 18 mo.’s Prevalence

    5. Successful conception requires a specific series of events: Ovulation of competent oocyte Production of competent sperm Juxtaposition of sperm and oocyte in a patent reproductive tract Fertilization Generation of a viable embryo Transport of the embryo to the uterine cavity Implantation of the embryo into the endometrium Etiology

    6. Major causes of of infertility: Female factor – 60% Ovulatory dysfunction Abnormalities of female reproductive tract Peritoneal factors Reproductive aging Male factor – 20% Abnormal semen quality Abnormalities of male reproductive tract Idiopathic – 15% Infertility in ~ 20-40% of couples has multiple causes Etiology

    7. Female Duration of infertility and prior evaluation or therapy Menstrual cycle (length and characteristics) Symptoms associated with ovulation (e.g. breast tenderness, bloating, mood changes) Full OBHx and GynHx Prior pregnancies, surgeries, or STD’s Sexual history (frequency of intercourse) Chronic medical illness Family history (infertility, birth defects, genetic disorders) Social history (smoking, EtOH, drugs) Infertility: History

    8. Male Prior children Genital tract infections Genital surgery or trauma Chronic medical illness Medications (e.g. Furantoins, CCB) EtOH, drugs, or smoking Sexual history (frequency of intercourse) Infertility: History

    9. Female Height, weight , BMI Pelvic exam Masses Tenderness (Adnexa, Cul-de-sac) Structural abnormalities (Vagina, Cervix, or Uterus) Male (Urologist referral) Evidence of androgen deficiency Structural defects (e.g. varicocele, hernia) Infertility: Physical Exam

    10. Male factor: Evaluation

    11. Male factor: Evaluation

    12. Male factor: Evaluation

    13. Male factor: Evaluation

    14. Female factor: Evaluation Chlamydia Gonorrhea TSH prolactinChlamydia Gonorrhea TSH prolactin

    15. Female factor: Menstrual Cycle

    16. Ovulation Initial evaluation: Basal body temp – rise for > 10 days indicates ovulation Ovulation predictor kit – detects LH surge in urine Further evaluation: Mid-luteal phase progesterone level - level > 3 ng/mL provides qualitative evidence of recent ovulation Endocrine testing (TSH, prolactin, FSH, LH, Estradiol, DHEA-S) Endometrial biopsy Not routinely performed Female factor: Evaluation

    17. Female factor: Evaluation

    18. Female factor: Evaluation

    19. Female factor: Evaluation

    20. Female factor: Evaluation Infertility 45 ~100% 35 ~15%Infertility 45 ~100% 35 ~15%

    21. Female factor: Evaluation

    22. Idiopathic Infertility

    23. Infertility: Management

    24. Infertility: Management

    25. Infertility: Management

    26. Infertility: Management (IVF)

    27. The psychological stress associated with infertility must be recognized and patients should be counseled appropriately. Psychological

    28. Bottom Line Concepts Infertility is defined as one year of unprotected coitus without conception. Infertility may be primary or secondary. Multiple causes must be considered for infertility diagnosis and treatment. Male and female reproductive tract anatomy and physiology should be reviewed in order to generate a full differential diagnosis. Components of an initial infertility workup include a thorough history and physical examination. Laboratory investigations include a semen analysis, documentation of ovulation, and hysterosalpingogram. Dysfunction of the hypothalamic-pituitary-ovarian (HPO) axis and medical illness, including thyroid disease and pituitary tumors, can cause ovulatory disturbances. Success rates with IVF depend on the etiology of infertility and the age of the female partner.

    29. References and Resources APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 48 (p102-103). Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 38 (p337-346). Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 34 (p371-378).

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