MD OBampGYNInfertility fellowship 1 Prevalence Infertility affects 1015 of reproductiveage couples in the US Definition 1 year of unprotected intercourse without conception Primary infertility No prior pregnancies ID: 746464
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Infertility
E.Naghshineh M.DOB&GYN,Infertility fellowship
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Prevalence: Infertility affects 10-15% of reproductive-age couples in the U.S
.Definition:1 year of unprotected intercourse without conception
Primary infertility – No prior pregnancies
Secondary infertility – Prior pregnancy
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Fecundability : the chance of conception in one menstrual cycle
15-20% of healthy young couples will conceive in a single cycleWait a year to begin the infertility evaluation for young couples with no history suggestive of reproductive disordersEarlier workup in couples with a positive history of for a fertility lowering disease or advancing maternal age
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Medical historyPhysical examination (abdominal & pelvic exam)
Family history (fragile X syndrome, down)Ovulatory dysfunction tubal risk factors
Uterine & cervical abnormalities
peritoneal factorsmale factor
Evaluation
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Both members of the couple to be interviewed at the first visitEvaluate
ovulatory dysfunction: endocrine review, thyroid, androgen excess, marked weight fluctuations, galactorrheaTubal damage:
Hx of STDs, PID, pelvic surgery, ruptured appendix, septic abortion, endometriosis, EPuterine leiomyoma, uterine & cervical surgery
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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……
Causes of infertility
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Abnormal body habitus
Lack of testicular descentPenile abnormalitiesDiminished size or abnormal consistency of the testesPresence of the varicocele
Male
ph.exam
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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)
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Three tests in basic evaluatins:
1.semen analysis2.ovulation documentation3.Uterine/tubal evaluation
Evaluation: testing
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Semen analysis
≤
2 ml
Ejaculation
volume
7.2-7.8
PH
20
mil/ml
≤
Sperm density
40 mil
≤
Total
sperm count
50%
≤
Motility
25%
≤
3 and 4+ forward progression
30%
normal forms
<
Morphology
No significant
sperm agglutination
No significant
pyospermiaNo hyper viscosity
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A repeat semen analysis is typically obtained to confirm an abnormal semen analysis90 to 108 days
1 month is acceptable
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3 methods for Confirmed ovulation: -BBT chart
-LH ovulation kit -midluteal serum progesterone >3ng/ml -serial ultrasound
-cervical mucus examination
-endometrial biopsy
Confirmed ovulation
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Age >30 years : - day 3 FSH level
- CC chalenge test - AFC count
Ovarian reserve tests
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HSGSIS (only uterus)
Office hysteroscopy (only uterus)Laparoscopy & hysteroscopy Evaluation of uterus & fallopian tubes
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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 biopsyLeukocyte in semen: bacterial cultures & antibiotic treatment
Male factor
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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)
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Sperm donorIUI, IVF, ICSI
Surgery for obstructive azoospermiaSurgical ligation of varicoceleMedical therapy: only for hypothalamic
hypogonadism
MESA, PESA, TESETreatment
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Hypothalamic: weight loss, excessive exercise,
kallmann syndrome, hypothalamic lesionsPituitary: HPL, thyroid disease, Cushing disease, sheehan
syndrome
Ovarian: PCOS, POFAdrenal Lab tests: FSH,PRL,TSH T, 17(OH)P in
hirsutism or acne
Ovulatory
dysfunction
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Hypothalamic: -Due to weight loss or excessive exercise:
change in life style -Hypogonadotropic hypogonadism:
gonadotropins administrationsHPL: Dopamine-agonist therapy (bromocriptine
, cabergolin)
Treatment
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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
)
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POF: -HRT: prevent osteoporosis, minimize
hypoesterogenic symptoms -Donor oocytes
-Adoption
-Remain child free
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HSGLaparoscopic surgery
most common finding: EndometriosisIVFEvaluation of cervical mucus(PCT)?
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Uterine/tubal factorSlide23
16% intra cavitory lesions (endometrial polyps or sub mucosal
myoma)Asherman syndromeUterine septum------------Hysteroscopy
Intramural or
subserosal myoma ? (>4cm:
deacrease pregnancy rate)
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Treatment of uterine diseaseSlide24
Depends on the severity of diseaseHysteroscopically
RadiographicallyMicro surgical reanastomosisLaparoscopic removal of adhesions
IVF: much superior treatment
Removal or occlusion of damaged fallopian tubes and hydrosalpinx prior to IVF
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of tubal disease
TreatmentSlide25
15-25%1.No therapy: -50% conceive in 2 years
-70-80% conceive in 5 years 2.woman>30: treatment -CC+IUI -
Gn+IUI
-IVF
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Unexplained infertilitySlide26
women with endometriosis:liked unexplained infertility
GnRH agonist (3-6 m) prior to proceeding IVF26