Infertility Patients Counseling & Evaluation

1. Infertility Patients Counseling & Evaluation (Beyond the Basics) By Dr. Tawfiq H. Gaafar F.R.C.O.G., Consultant Obstetrician and Gynecologist & Infertility & IVF Specialist,

2. Objectives • To present the recent concepts in the management of infertility • To draw clinically relevant conclusions based on: -META-ANALYSIS -RANDOMISED CONTROLLED TRIALS -GUIDELINES AND PROTOCOLS • To discuss the best possible clinical management options .

3. Causes of Infertility

4. BACKGROUND INFORMATION • Infertility is rarely absolute so the term sub-fertility may be more appropriate • Sub fertility is defined as the inability to conceive within 12 months of trying or age definition. • The single most important determinant of a couple’s fertility is the age of the female partner: • <25 years CCR is 60% at 6 months and 85% at one year. • >35 years CCR is 60% at one year and 85% at two years.

5. BACKGROUND INFORMATION • At puberty there are 300,000 primordial follicles • Dominant follicle produces oestradiol which leads to LH surge • Ovulation occurs 24-36 hours later • The fertilization life span of the ovum is 24-36 hours • The receptivity of the endometrium is days 16-19 of a 28 day cycle

6. BACKGROUND INFORMATION • The other factors influencing the likelihood of a spontaneous pregnancy are: -Duration of subfertility -Occurrence of a previous pregnancy • The effect of age on male fertility, however is less clear. • Any change in the prevalence of subfertility in recent years is a difficult question to answer but the male fertility is declining.

7. The Case: • A Stressed couple entering your clinic seeking the opportunity to get their dream of a childe after several failure trials: • Information gathering and analysis. • ·Implications and decision-making counseling. • ·Support counseling. • Therapeutic counseling.

8. General recommendations • Privacy and sufficient clinical time • Counseling is very important and essential,(avoid anxiety) • Routine examination is not necessary unless indicated by the history • Each stage in the investigation and treatment of infertility should be fully explained to the couple. • Environmental factors can affect fertility and therefore an occupational history should be taken. • The management should be individual ,according to particular clinical situation. • Patients should be fully involved in decisions regarding their treatment

9. CURRENT GUIDELINES • The current clinical approach to the investigations and the management of infertility is backed by the evidence-based guidelines issued by: • Royal College of Obstetricians and Gynaecologists(RCOG) • American Society of Reproductive Medicine (ASRM) • European Society of Human Reproduction and Embryology (ESHRE)

10. Start with History. . .Male & Female Investigation are done simultaneouslyWhat Clues Can You Find on History? • Male Factor • Tubal Factor • Ovulation

11. INVESTIGATIONS EVALUATION OF INFERTILITY IN MEN: The evaluation of male infertility may point to an underlying cause, which can guide treatment. A healthcare provider usually begins with A medical history, Physical examination, and a Semen test. Other tests may be needed.

12. 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

13. INVESTIGATIONS EVALUATION OF INFERTILITY IN MEN: History: The Most Important, childhood growth and development; sexual development during puberty; sexual history; illnesses and infections; surgeries; medications; exposure to certain environmental agents (alcohol, radiation, steroids, chemotherapy, and toxic chemicals); and any previous fertility testing Physical examination: height and weight, assessment of body fat inspection of the skin and hair pattern, and visual examination of the genitals, testosterone features, • Other conditions that might affect fertility include: -Varicocele, a varicose vein of the testicle. -Absent vas deferens or thickening of the epididymis.

14. INVESTIGATIONS EVALUATION OF INFERTILITY IN MEN: Semen Analysis: A semen analysis (sperm count) is a central part of the evaluation of male infertility WHO Criteria • volume:  2.0 ml • pH:  7.2 • sperm concentration:  20 million per ml • total sperm number:  40 million per ejaculate • motility:  50% • vitality : 75% or more live • white blood cells: fewer than 1 million per ml • normal morphology: 30% or 15% (based on strict morphological criteria)

15. INVESTIGATIONS EVALUATION OF INFERTILITY IN MEN: Blood Tests:total testosterone, (LH), (FSH), and prolactin. Genetic tests :If genetic or chromosomal abnormalities are suspected. ( Y Chromosome ). Other tests:  -If a blockage in the reproductive tract (epididymis or vas deferens) is suspected, a transrectal ultrasound test may be ordered. -If retrograde ejaculation (movement of semen into the bladder) is suspected, a post-ejaculation urine sample is needed. -Testicular biopsy.

16. INVESTIGATIONS EVALUATION OF INFERTILITY IN Female: Although a variety of tests are available for evaluating female infertility, it may not be necessary to have all of these testsYou usually begin with A medical history, a Thorough physical examination, and Some preliminary tests.

17. 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? Acanthosisnigracans?) pelvic (vaginal mucosa, masses, pain) rectal (uterosacralnodularity) History and Physical - Female

18. INVESTIGATIONS EVALUATION OF INFERTILITY IN Female: Medical History: The Most Important, childhood growth and development; sexual development during puberty; sexual history; illnesses and infections; surgeries; medications; exposure to certain environmental agents (alcohol, radiation, steroids, chemotherapy, and toxic chemicals); and any previous fertility testing Menstrual history : Amenorrhea, Oligomenorrhea ..etc

19. INVESTIGATIONS EVALUATION OF INFERTILITY IN Female: Physical Examination: a general examination, with special attention to any signs of hormone deficiency ,Basal Body Temperature, Pelvic examination. Blood Tests: FSH, LH, Prolactine, TSH, Estrogens, progesterone Tests to evaluate the uterus and fallopian tubes : Hysterosalpingogram, Hysteroscopy, Pelvic ultrasound , Sonohysterogram, Laparoscopy. Genetic tests:in case of suspicion that genetic or chromosomal abnormalities are contributing to infertility

20. AMH: Ant Mullrian Hormone • The AMH is a hormone produced by the granulosa cells of the early developing antral follicles. • As a woman runs out of eggs, the number of small antral follicles decline in number and as a result the serum Anti-Mullerian hormone falls. This is why serum Anti-Mullerian hormone testing is a good estimate of residual egg number. (The Ovarian Reserve ) • When I should go for AMH ??

21. Hysterosalpingogram:

22. Laparscopy:

23. Laparscopy:

25. Hysteroscopy:

26. Hysteroscopy:

27. Where Should I Start? 1. Regular menstruation is strongly suggestive of ovulation, should be confirmed Serum progesterone in the mid-luteal phase level >10 ng/ml is diagnostic of ovulation. 2-No need for thyroid function or prolactin in women with a regular menstrual cycle, in the absence of galactorrhoea or symptoms of thyroid disease • Prolactin >1000 IU need further investigation ( brain CT/MRI to exclude pituitary adenoma , TFT) • If Progesteron<10 ng/ml (anovulation): Complete Other Endocrine Tests to determine the Cause if anovulation

28. 3-Early follicular phase estimation of FSH and LH is only performed if clinically indicated • LH > 10 IU may be due to PCOS need U/S to confirm • FSH >10 IU indicate poor ovarian reserve and less respond to treatment 4..Ovarian reserve tests added to the investigation of couple with infertility in : • Women with advanced age>35ys • Or history of previous ovarian surgery. • Day 3 FSH , Estradiol level AMH,U/S antral follicular count (AFC). • Or using clomiphene citrate challenge test (ccct)

29. 5.No ovulation induction with out tubal patency test , So the female partner should normally have a test of tubal patency during the initial investigation of infertility before starting treatmen: • A hysterosalpingogrammay be used as a screening test for tubal patency in low risk couples • When an evaluation of the pelvis is required, however, a diagnostic laparoscopy with dye transit is the procedure of choice. • Ultrasound scan and hydrotubation has not been widely adopted. • The images obtained by falloposcopy are not yet of sufficiently good quality to provide useful clinical information.

30. Pelvic Ultrasound

32. Precutions: - Before any uterine instrumentation, consideration should be given either to screening women for Chlamydia trachomatis, using an appropriately sensitive technique, or using appropriate antibiotic prophylaxis . • Endometrial biopsy to evaluate the luteal phase should not be performed as part of the routine investigation of the infertile couple • Sperm function tests are specialized tests and should not be used in the routine investigation of the infertile couple .

33. Precutions: • Routine testing for antisperm antibodies in semen is not recommended. • Hysteroscopy should not be considered as a routine investigation in the infertile couple as there is no evidence linking the treatment of uterine abnormalities with enhanced fertility. • An ultrasound examination of the endometrium is unnecessary in the initial investigation of infertility. However, ultrasound evaluation of the ovaries may be .

34. DIAGNOSIS OF PCOS! • The debate was resolved in Rotterdam in May 2003 At PCOS consensus workshop • It was agreed that two of the following three criteria were essential to establish diagnosis: • OVARIAN DYSFUNCTION. • CLINICAL OR BIOCHEMICAL EVIDENCE OF HYPERANDROGENISM. • POLYCYSTIC OVARIAN MORPHOLOGY ON ULTRASOUND

35. DIAGNOSIS OF PCOS! Ultrasound is the gold standard for the diagnosis of PCO. The diagnostic criteria is of 10 discrete follicles of <10mm usually peripherally arranged around an enlarged, hyperechogenic central stoma

36. WHICH INVESTIGATIONS? • Diagnostic tests for infertility were classified into following three categories by ESHRE Capri workshop in 2000 A-Tests which have an established correlation with pregnancy. B-Tests which are not consistently correlated with pregnancy. C-Tests which seem NOT to correlate with pregnancy.

37. Tests which have an established correlation with pregnancy • Semen analysis • Tubal patency test by HSG or Laparoscopy • Mid luteal serum progesterone for the diagnosis of ovulation

38. Tests which are not consistently correlated with pregnancy • Zona free hamster egg penetration tests • Post-coital test • Antisperm antibodies assays

39. Tests which seem NOT to correlate with pregnancy • Endometrial dating • Varicocoel assessment • Chlamydial testing MAY HAVE A ROLE IN SPECIAL SITUATIONS

40. 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?

41. 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?

42. 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?

43. 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?

44. Thank You