Infertility (CMPP)

Infertility

the inability of a couple to conceive after 1 year of regular unprotected intercourse

Indicaitons for Infertility Evaluation

Under 35 and no fertilization after 12 months of intercourse

35 to 40 years and no fertilization after 6 months

Women over 49

Women with oligomenorrhea/amenorrhea'

Hx of Chemo or XRT

Hx of Endometriosis

Known or suspected uterine or tubal disease

Male partener = Grion or testicular surgery, mumps, chemo, XRT

Primary infertility

infertility in the absence of previous pregnancy

Secondary infertility

infertility after a previous pregnancy

When is the most fertile time in the cycle

3-4 days prior to ovulation and 2 days post-ovulation

What endocrine abnormalities can cause infertility

Hypothalamic-pituitary insufficiency

Hyperprolactinemia

PMOS

Luteal phase defects

Premature ovarian failure

What are important history questions to ask for inferiltily

Menstrual history

History of spontaneous abortions

Endometriosis

Galactorrhea

Weight changes

Hot flashes

How can we evaluate the evidence of ovulation in infertility cases

Tracking the menstrual cycle

Measuring the basal body temperatures,

Monitoring the cervical mucous

Measuring the mid-luteal progesterone

Measuring day 3 FSH and estradiol levels

Documenting any premenstrual or ovulatory symptoms

BBT Charting

Measure temperature at complete rest first thing in the morning, using a specialized thermometer

How should normal BBT charting look

biphasic pattern after ovulation

Lower temperature prior to ovulation, higher after ovulation

What causes the temperature elevation for ovulation?

Progesterone

When should BBT be highest

Ovulation

What is normal luteal progesterone level

4 ng/mL

What is the most accurate way to determine ovulation

Endometrial biopsy

LH surge kit

Measure urinary LH

As the LH surge begins, LH is excreted in the urine

Helps prediction ovulation, but cannot confirm ovulation

What is a strong indicator of normal ovulation

Hx of monthly menses

What test determines the progesterone effect on endometrium

endometrial biopsy to evaluate the glands and stroma of the endometrium

What labs should be ordered for cases of infertility

FSH

LH

Prolactin

TSH / T4

Thyroid Ab

How is infertility from ovulatory dysfunction

ovulation induction with fertility drugs (i.e., Clomid)

Abnormalities to what structures can cause infertility

Cervix

Uterus

Fallopian Tubes

Ovaries

Adjancent pelvic casue

Most comon caues of anatomic infertility

Tubal occlusion

Endometerious

Risk Factors for Uterine/Tubual Infertility

PID Hx

IUD Use

Endometriosis

Adenomyosis

Adnexal Surgey

What procedure can help dx anatomic infertilit

TVUS

Hysterosalpingogram (HSG)

Radio-opaque dye is injected into the cervix and uterus

Should fill both fallopian tubes and spill into the peritoneal cavity

What imaging is usually ordered for inferility

Hysterosalpingogram (HSG)

laparoscopy with chemotubation

When should HSG studies be done

Follicular

Risk Factors for Male Infertility

occupational or environmental exposure to chemical, radiation, or excessive heat

varicocele

mumps

hernia repair,

pituitary tumor,

anabolic steroid use,

impotence

What is the primary method to examine male infertility

Semen analysis

Pre-Procedure Info for Semen Analysis

abstain from ejaculation 2 to 7 days prior to the test

When does analysis need to occur with semen analysis?

performed less than 2 hours after specimen is collected

What are the characteristics evaluated on semen analysis

Sperm Count

Voulme

Motility

Morphology

pH

WBC

What tests are ordered on abnormal semen analysis

TSH / T4

Serum Testosterone

Prolactin

FSH

What lifestyle modifications can help with infertility

Both female and male cess smoking

Female - Abstain from ETOH, reduce caffeine, and get BMI = 20-25

Treatment for Hypothalamic-pituitary failure Infertility

hormonal injections

Treatment for Varicocele Infertility

ligation

Treatment for Low Semen Volume Infertility

Clomid to the male

AID = artificial insemination using donor sperm

AIH = artificial insemination, homologous

IUI (intrauterine insemination)

What is the most common advanced reproductive technology

IVF and ET

IVF/ET (in vitro fertilization and embryo transfer)

Uses hormones that stimulate the ovaries to produce multiple follicles

The eggs are collected and inseminated

Fertilized eggs develop into embryos

Embryos are then transferred to uterus

GIFT (gamete intrafallopian transfer)

Eggs are removed from ovaries

Combined with sperm

Unfertilized egg and sperm are placed into fallopian tube via laparoscopy

Success Rate of IVF

20%

Success Rate of GIFT

25%

Success Rate of ZIFT

30%

ZIFT (zygote intrafallopian transfer)

Eggs are removed from ovary

Fertilize eggs outside of body

Embryo placed in fallopian tube via laparoscopy