Infertility E Naghshineh M D OBGYN Infertility fellowship

Infertility E. Naghshineh M. D OB&GYN, Infertility fellowship 1

Infertility affects 10 -15% of reproductive-age couples in the U. S. � Prevalence: � Definition: 1 year of unprotected intercourse without conception § Primary infertility – No prior pregnancies § Secondary infertility – Prior pregnancy 2

� Fecundability : the chance of conception in one menstrual cycle � 15 -20% of healthy young couples will conceive in a single cycle � Wait a year to begin the infertility evaluation for young couples with no history suggestive of reproductive disorders � Earlier workup in couples with a positive history of for a fertility lowering disease or advancing maternal age 3

Evaluation � Medical history � Physical examination (abdominal & pelvic exam) � Family history (fragile X syndrome, down) � Ovulatory dysfunction � tubal risk factors � Uterine & cervical abnormalities � peritoneal factors � male factor 4

� Both members of the couple to be interviewed at the first visit � Evaluate ovulatory dysfunction: endocrine review, thyroid, androgen excess, marked weight fluctuations, galactorrhea � Tubal damage: Hx of STDs, PID, pelvic surgery, ruptured appendix, septic abortion, endometriosis, EP � uterine leiomyoma, uterine & cervical surgery 5

Causes of infertility � Male factor: 30 -40% -STD & other GU infections -chemo or radiation therapy -mumps during adolescence -testicular surgery or injury -decreased ejaculatory function -chronic occupational exposure ( heat, gametotoxic chemicals) -drugs…… 6

Male ph. exam � Abnormal body habitus � Lack of testicular descent � Penile abnormalities � Diminished size or abnormal consistency of the testes � Presence of the varicocele 7

� Social & life style Hx: -smoking (oocyte toxicity, premature menopause, decreased sperm motility and number) -alcohol abuse -illicit drug -excessive exercise & anorexia -exposure to teratogens (lead) 8

Evaluation: testing Three tests in basic evaluatins: � 1. semen analysis � 2. ovulation documentation � 3. Uterine/tubal evaluation 9

Semen analysis Ejaculation volume ≥ 2 ml PH 7. 2 -7. 8 Sperm density ≥ 20 mil/ml Total sperm count ≥ 40 mil Motility ≥ 50% 3 and 4+ forward progression ≥ 25% Morphology >30% normal forms No significant sperm agglutination No significant pyospermia No hyper viscosity 10

�A repeat semen analysis is typically obtained to confirm an abnormal semen analysis � 90 to 108 days � 1 month is acceptable 11

Confirmed ovulation � 3 methods for Confirmed ovulation: -BBT chart -LH ovulation kit -midluteal serum progesterone >3 ng/ml -serial ultrasound -cervical mucus examination -endometrial biopsy 12

Ovarian reserve tests � Age >30 years : - day 3 FSH level - CC chalenge test - AFC count 13

Evaluation of uterus & fallopian tubes � HSG � SIS (only uterus) � Office hysteroscopy (only uterus) � Laparoscopy & hysteroscopy 14

Male factor � Surgical ligation of varicocele: increase sperm motility, density, morphology and the pregnancy rate � Hormonal testing: T, FSH, LH, PRL -in sperm count <10 mil/ml -low male libido � Fructose level � Testicular biopsy � Leukocyte in semen: bacterial cultures & antibiotic treatment 15

� Most men have idiopathic oligoasthenospermia � Retrograde ejaculation: DM, Neurologic disorders, after pelvic surgery � Congenital bilateral absence of vas defrens: CF � Non-obstractive oligo and azoospermia: genetic screening (karyotype and PCR analysis of the Y chromosome) 16

Treatment � Sperm donor � IUI, IVF, ICSI � Surgery for obstructive azoospermia � Surgical ligation of varicocele � Medical therapy: only for hypothalamic hypogonadism � MESA, PESA, TESE 17

Ovulatory dysfunction � Hypothalamic: weight loss, excessive exercise, kallmann syndrome, hypothalamic lesions � Pituitary: HPL, thyroid disease, Cushing disease, sheehan syndrome � Ovarian: PCOS, POF � Adrenal � Lab tests: FSH, PRL, TSH T, 17(OH)P in hirsutism or acne 18

Treatment � Hypothalamic: -Due to weight loss or excessive exercise: change in life style -Hypogonadotropic hypogonadism: gonadotropins administrations � HPL: Dopamine-agonist therapy (bromocriptine, cabergolin) 19

� PCOS: -losing 5 -10% of body weight - CC (85% ovulate) -surgical treatment (laparoscopic cautery, diathermy, laser) -human gonadotropins injection: (multiple gestation, OHSS) -Insulin-sensitizing agents (metformin) 20

� POF: -HRT: prevent osteoporosis, minimize hypoesterogenic symptoms -Donor oocytes -Adoption -Remain child free 21

Uterine/tubal factor � HSG � Laparoscopic surgery most common finding: Endometriosis � IVF � Evaluation of cervical mucus(PCT)? 22

Treatment of uterine disease � 16% intra cavitory lesions (endometrial polyps or sub mucosal myoma) � Asherman syndrome � Uterine septum ------Hysteroscopy � Intramural or subserosal myoma ? (>4 cm: deacrease pregnancy rate) 23

Treatment of tubal disease � Depends on the severity of disease � Hysteroscopically � Radiographically � Micro surgical reanastomosis � Laparoscopic removal of adhesions � IVF: much superior treatment � Removal or occlusion of damaged fallopian tubes and hydrosalpinx prior to IVF 24