Management of Infertility

1. Management of Infertility Modified by Israa

2. Introduction • Primary infertility: The inability to conceive after 1 year of unprotected intercourse for a woman younger than 35, or after 6 months of unprotected intercourse for a woman 35 or older. • Secondary infertility: The inability of a woman to conceive who previously was able to do so. • Infertility is more common in older women. However, increased age reduces the efficacy of treatment.

3. Prevalence and Overview of Treatments Approximately half of all women who receive fertility care achieve conception leading to a live birth.

4. Requirements for Conception • Production of healthy egg and sperm • Unblocked tubes that allow sperm to reach the egg • The sperms ability to penetrate and fertilize the egg • Implantation of the embryo into the uterus • Finally a healthy pregnancy

5. Causes of Infertility • Discovering which cause of infertility affects a particular couple is the basis of fertility care. • Causes are shared, almost equally, by men and women. • Mixed-factor infertility involves multiple causes, with some belonging to the man and some to the woman.

6. Causes of Infertility • Anovulation (10-20%) • Anatomic defects of the female genital tract (30%) • Abnormal spermatogenesis (40%) • Unexplained (10%-20%)

7. Evaluation of the Woman • Primary evaluation components: • Male factor • Ovarian factor • Cervical factor • Tubal factor • Uterine factor

8. Evaluation of the Male • Male factor contributes to infertility in 50 percent of infertile couples • Evaluation begins at the initial consultation with the couple.

9. Fertility Treatment: Goals • To ensure patient safety • To help a couple experience a healthy pregnancy and birth or an alternative way to build a family • To use as little of a couple’s resources as necessary

10. Fertility Treatment: Options • Correct ovulatory dysfunction • Correct tubal or uterine abnormalities • Overcome subfertile sperm parameters • ART

11. Ovulation Induction: Clomiphene Citrate (Clomid, Serophene) • The “first line” of fertility therapy • Used to treat mildly disordered ovulation and luteal-phase insufficiency • Establish tubal patency and sperm adequacy before use.

12. Ovulation Induction: Clomiphene Citrate • In appropriately selected patients, 80 percent ovulate and 40 percent conceive with clomiphene. • Multiples rate is about 10 percent. • After 6 months, women should move on to more aggressive therapy.

13. Ovulation Induction: Injectable Gonadotropins • Used: • When women exhibit resistance to clomiphene • When multiple oocytes are desirable to ovulate • With IVF and creation of donor oocytes and embryos • With ovulation induction (OI) • Multiple rates as high as 40 percent.

14. Ovulation Induction: Pulsatile Gonadotropin-Releasing Hormone • Anovulation may be due to the failure of the hypothalamus to provide sufficient stimulation to the pituitary gland. • Gonadotropin-releasing hormone (GnRH) can be directly administered via a small medication pump to induce ovulation. • The ideal patient is the hypogonadotropic woman.

15. Ovulation Induction: Pulsatile GnRH • Overall ovulation rates are between 50 percent and 80 percent. The chance of pregnancy is 10 percent to 30 percent per ovulatory cycle, depending on the couple’s other fertility factors. • The risk of multiples is low.

16. Artificial Insemination • Used to treat: • Male-factor infertility • Retrograde ejaculation • Neurologic impotence • Sexual dysfunction • Sperm used for insemination may be the male partner’s or donated.

17. Artificial Insemination • Methods of insemination • Intracervical insemination (ICI) • Intrauterine insemination (IUI) • Success rates vary from 6 percent to 24 percent per cycle

18. Assisted Reproduction • Assisted hatching of the embryo Images provided by author. Reprinted with permission. (Figure 8)

19. Assisted Reproduction • IVF : Placing the gametes and subsequent embryo into the uterus • ICSI: Intracytoplasmic semen injection, then placing the subsequent embryo in to the uterus • ZIFT (zygote intrafallopian transfer): Placing the gametes and subsequent embryo into the fallopian tubes • GIFT (gamete intrafallopian transfer): Placing the unfertilized oocyte and sperm into the fallopian tube

20. Assisted Reproduction • Stimulation type, dosage and duration depends on patient characteristics, diagnoses and the fertility center. • Monitoring is usually by serial TVUS, usually over four to five visits. • Cleavage of the embryos and other subjective indicators of embryo health help the clinician decide timing and number of embryos to transfer. • The usual timing of transfer of embryos is on day 3, 4 or 5 after retrieval.

21. Assisted Reproduction • Multicellular embryos

22. Assisted Reproduction: Cryopreservation • Freezing, thawing and using: • Sperm • Embryos • Oocytes

23. Assisted Reproduction: Cryopreservation • Expanded blastocysts Images provided by author. Reprinted with permission. (Figure10)

24. Assisted Reproduction: Cryopreservation • Cryopreserved blastocysts

25. Pre-implantation Genetic Diagnosis • Used only with IVF • One or two cells removed from the embryo and analyzed for defects before transfer to the uterus

26. Pre-implantation Genetic Diagnosis • May be helpful for: • Women older than 35 years • Couples who have experienced recurrent pregnancy loss • Couples with one partner known to carry a balanced chromosomal translocation • Up to 85 percent accurate for detecting the most common chromosomal abnormalities

27. Third-party Reproduction • Donor gametes • Donor embryos • Surrogacy • Gestational carrier: Carries other people’s oocyte and sperm • Traditional surrogate: Inseminated with the male partner’s sperm

28. ART Risks and Complications • Ovarian hyperstimulation syndrome (OHHS) • Multiple gestation—More than 43 percent of the rise in multiple births in the U.S. is linked to ART