infertility

inability to conceive after:

12 months of regular, unprotected intercourse

6 months if woman ≥35 years old

what is the clinical definition of infertility?

Ovulatory dysfuncitons: PCOS (most common overall female cause)

Hypothalamic amenorrhea

Hyperprolactinemia

Thyroid disorders

Premature ovarian insufficiency

most common female cause of infertility

PID (Chlamydia)

Endometriosis

Prior pelvic surgery

Ectopic pregnancy

tubal factors leading to infertility

Fibroids (submucosal)

Asherman syndrome

Congenital anomalies

Endometrial polyps

uterine factors of infertility

sperm abnormalities

Low count

Poor motility

Abnormal morphology

most common male cause infertility

congenital absence of vas deferens

common (occurs unilaterally in ~1% of male subjects); ~80% of cases of unilateral absence of the vas deferens are associated with cystic fibrosis, may also be associated with renal agenesis: cystic fibrosis is associated with mesonephreic duct anomalies

varicocele

enlarged, dilated veins near the testicle

1) semen analysis (least invasive)

2) assess ovulation

3) evaluate uterus

first step in evaluation of an infertile couple

>3 ng/mL confirms ovulation

this mid-luteal progesterone confirms ovulation

ovarian reserve

AMH tests for

hysterosalpingogram

test to evaluate for a tubal pregnancy

ectopic pregnancy

contrast spilling into peritoneum on hysterosalpingogram indicates

Letrozole (preferred over clomiphene)

Clomiphene citrate (older standard)

first line treatment for ovulatory dysfunction

Weight loss (even 5-10%)

Metformin (adjunct)

first line management of PCOS (ovulatory dysfunction)

IVF often preferred

management of infertility due to tubal disease

Ovulation induction + Intrauterine insemination

IVF if unsuccessful

stepwise management of unexplained fertility

intrauterine insemination

Washed sperm placed in uterus

Used for mild male factor or unexplained infertility

IVF

Egg retrieval

Fertilization in lab

Embryo transfer

introcytoplasmic sperm induction

Single sperm injected into egg

Severe male factor

varicocele

most common correctable male cause of infertility

HSG (hysterosalpingography)

_______ evaluates tubal patency

IVF

onlly _______ bypasses tubal disease

Letrozole (Femara)

first line for ovulation induction

Letrozole

aromatase inhibitor used to induce ovulation

Semen analysis

Confirm ovulation

Check tubal patency (HSG)

Evaluate uterus

Treat based on cause

quick algorithm of infertility eval

Clomiphene citrate

ovulation stimulant