Infertility

infertility & percentages

inability to conceive after 12 months of unprotected sex

40% related to male factors

40% related to female factors

etiologies

environmental

drugs (tobacco/weed)

idiopathic factors

older age

male factors

varicoceles (40%)

semen disorders

abnormal sperm

antisperm antibodies

cryptorchordism (undescended testes)

obstruction

infections

genetics

varicoceles

most common cause of infertility (40%)

enlargement of veins in the scrotum

varicoceles raise temperature of the testicle affecting development of the sperm

infertility work up for men

semen samples collected & studied

antisperm antibody test looks for antibodies that fight against sperm

if analysis is normal, evaluate female partner

infertility work up for females

thryoid testing

breast exam

pelvic exam

ultrasound

lab test for ovulatory function hormones

female factors

ovarian/ovulatory disfunction (40%)

tubal disease

cervical factors

endometriosis

IUD

ovulation disorders

very important (25% of ALL infertility issues)

when suspected, pt needs full endocrine workup

serial US of ovarian follicles is helpful

anovulation

when ovaries don’t release oocyte during menstrual cycle

18% of infertility cases

4 main reasons:

failure of hypothalamus/pituitary to produce hormones

failure of follicle to rupture → failure to ovulate

dysfunctional devlopement of dominant follicle

PCOS

hypothalamic/pituitary causes of anovulation

Kallmann Syndrome: hypo/pituitary can’t produce LH/FSH

treatment can include pharmaceutical drugs:

GnRH-a

hMG

HCG

LUF syndrome

another cause of anovulation

follicle enlarges but fails to rupture & release oocyte

overtime, unruptured follicle regresses at time normal corpus luteum would have

US used to identify follicle w/thickened walls & hazy/indistinct borders

dysfunctional follicular development

dominant follicle enlarges more than normal

stays enlarged then gradually regress w/o rupture

thickening of follicle wall does not occur

on US, thin echogenic wall

luteal phase deficiency

inadequate decidualization of endometrium secondary to failure of corpus luteum to produce enough progesterone

PCOS

common cause of infertility

single dominant follicle does not form

can be treated to induce ovulation but drugs increase risk of ovariant hyperstimulation syndrome

US- string of pearls around periphery

cervical factors

cervical mucus important for transportation of sperm

abnormalities of production can cause infertility

abnormal cervical mucus production- hormonal changes/medicine

cervical stenosis- congenital, infections, surgery

evaluating cervix

in nongravid, difficult to assess

HSG can be used to evaluate internal os diameter

diameter <1 may indicate cervical stenosis

uterine infertility factors

endometritis

asherman’s syndrome

submucosal fibroids/polyps

diff. b/w fibroids & polyps material

fibroids made of muscle cells & connective tissue

polyps made of endo tissue

synechiae on US

linear strands of tissue extending from one wall of uterine cavity to other

endo thickness ideal for achieving pregnancy

>6 mm

DES

synthetic form of estrogen in 40s-70s to prevent miscarriage, premature labor, & other complications

linked to rare cancer (clear cell adenocarcinoma) CCA which is cancer of vagina & cervix

tubal factors

fallopian tube factors 35% of female infertility cases

abnormal transport or obstruction to passages of the ovum cause infertility

pharmacologic methods of treatment

ovulation induction- increase fertilization chances

clomid- makes pit. think estrogen levels are low stimulating more FSH & LH to produce follicles

pergonal- mixture of FHS & LH

HCG- LH surge to induce ovulation

ovarian hyperstimulation syndrome (OHSS)

excessive stimulation of ovaries commonly in women taking infertility drugs

bilateral enlargement of ovaries

variable sized cysts

radial arrangement of cysts

ascites possible

different assisted reproductive technologies

artificial insemination

IVF

GIFT
ZIFT

artificial insemination

sperm introduced into uterus via catheter

option for enhancing fertility

IVF

In Vitro Fertilization

egg & sperm fertilized outside body

after 3-5 days, transferred back into body & fertilized egg known as blastocyst (last stage of oocyte/sperm development)

GIFT

gamete intrafallopian transfer

mixing sperm & egg immediately after retrieval & placing directly into fallopian tube allowing fertilization to occur in tube

ZIFT

zygote intrafallopian tube transfer

fertilizing egg outside the body & as soon as visibly documented, transfer s=zygote (1st stage) into fallopian tube

IVF statistics

patients under 35: works 55-62% of time

US role in infertility

baseline scan

follicular monitoring

assessment of endo development

assessment of tubal patency

guided follicular aspiration

dominant follicles growth

b/w days 5-7, follicles grow 2 mm per day

tubal patency

normal fall. tubes not seen on US

introducing sterile saline can show spillage into the peritoneal cavity (normal) showing that the fallopian tubes are patent

guided follicular aspiration

AKA transvaginal oocyte retrieval/aspiration

method of removing oocytes from ovary for IVF

IUD contraceptions

IUD (intrauterine contraceptive devices)

ParaGard- non-hormonal copper IUD

Mirena- hormonal IUD that thickens cervical mucus

on US, appears brightly echogenic foci contained in uterine cavity, posterior shadowing, ring-down/comet tail artifacts

oral contraceptive pills (OCPs)

stop ovulation

thicken cervical mucus

thin lining of uterus so fertilized egg can’t attach

dominant follicles generally don’t develop while on OCPs