Sat 1420-infertility- -garibaldi

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Sat 1420-infertility- -garibaldi

  1. 1. 26/05/2014 1 Investigation of Infertility – An Initial Approach Jason A Hitkari, MD, FRCSC Medical Director, Olive Fertility Centre Vancouver Clinical Associate Professor, UBC Faculty/Presenter Disclosure • Faculty: Jason Hitkari • Relationships with commercial interests: – Grants/Research Support: Ferring Canada, Serono Canada, Merck Canada – Speakers Bureau/Honoraria: UBC, Canadian Fertility and Andrology Society – Consulting Fees: N/A – Other: Medical Director of Olive Fertility Centre CFPC CoI Templates: Slide 1
  2. 2. 26/05/2014 2 Disclosure of Commercial Support • This program has received financial support from no one. • This program has received in-kind support from no one. • Potential for conflict(s) of interest: – I have not received any financial benefit from doing this session. CFPC CoI Templates: Slide 2 Mitigating Potential Bias • There is an inherent bias in being a Medical Director of Olive Fertility Centre and speaking about fertility • In the pharmaceuticals discussed, I have no direct financial interest • In the testing discussed, I have no direct financial interest CFPC CoI Templates: Slide 3
  3. 3. 26/05/2014 3 Objectives • To review the impact age has on fertility • To discuss the initial work up but with specific focus on aspects relevant to practice • To review new options for patients (egg freezing) Work Up Of Infertility FEMALE MALE Ovarian Reserve Testing – Day 3 FSH and estradiol Semen analysis Hysterosalpingogram (or hysterosonogram) TSH and Prolactin Prenatal screening blood work Pelvic ultrasound Luteal phase progesterone
  4. 4. 26/05/2014 4 Concerns on History… • Patient not cycling regularly • Pelvic infection/surgery • Significant dysmenorrhea • Erectile dysfunction • Genital injury (male) Average age at first birth From: Organization for Economic Co-operation and Development (OECD)
  5. 5. 26/05/2014 5 From: Organization for Economic Co-operation and Development (OECD) Change in the mean age of women at the birth of the first child
  6. 6. 26/05/2014 6 Cumulative Fertility and Maternal Age Age Group % Conceiving Within 1 Year 20-24 86 25-29 78 30-34 63 35-39 52 Impact of Female Age on Fertility Canadian Fertility And Andrology Society Refer/Investigate After Trying 12 mos. 9 mos. 6 mos.
  7. 7. 26/05/2014 7 Abortion Risk by Maternal Age Maternal age (yrs) 15-24 25-29 30-34 35-39 40-44 >45 Abortion rate 9.5% 10.0% 11.7% 17.7% 33.8% 52.2% CARTR 2011 Pregnancy by Female Age
  8. 8. 26/05/2014 8 PGS Data (2012, based on 4600 embryos) MATERNAL AGE-RELATED ANEUPLOIDY RATES WHEN ALL CHROMOSOMES ARE EVALUATED IN DAY 5 HUMAN IVF EMBRYOS B Pettersen1, K Merrion1, J Keller1, G Gemelos1, M Rabinowitz1 Table 1: Day 5 Aneuploid Rates Maternal Age # of blastomeres Tested (# Cycles) Aneuploid Results <30 years 16 (3) 31.2% + 11.6 % 30-34 years 250 (35) 35.6% + 3.0% 35-39 years 424 (76) 50.0% + 2.4 % 40+ years 171 (43) 68.4% + 3.5% OVERALL 861 (157) 49.1% + 1.7 % NSGC-2011
  9. 9. 26/05/2014 9 Clinical Vignette “42 year old woman with two children conceived with IVF. She then underwent two IVF cycles without success and then underwent comprehensive chromosome testing”
  10. 10. 26/05/2014 10 Assessing Ovarian Reserve is Critical Lower ovarian reserve Higher aneuploidy rates Lower chance of conception Less time Panic!
  11. 11. 26/05/2014 11 How Do You Assess Ovarian Reserve? • Day 3 FSH and estradiol Problems with FSH 1. Fluctuates from month-to-month 2. Is dependent upon day of the month 3. Can be falsely alarming 4. Can be falsely reassuring (20% of the time in infertile patients!)* * Leader et al, Fertil Steril, 2012
  12. 12. 26/05/2014 12 ANTI-MULLERIAN HORMONE ASSAY
  13. 13. 26/05/2014 13
  14. 14. 26/05/2014 14
  15. 15. 26/05/2014 15 How to incorporate AMH into your practice. • Realize that it is our BEST marker of ovarian reserve • Consider it in patients who: – Have concerning FSH levels – Patients >40 – Everyone struggling with fertility? – Future role in PCOS diagnosis? Work Up Of Infertility FEMALE MALE Ovarian Reserve Testing – Day 3 FSH and estradiol Semen analysis Hysterosalpingogram (or hysterosonogram) TSH and Prolactin Prenatal screening blood work Pelvic ultrasound Luteal phase progesterone
  16. 16. 26/05/2014 16 Hysterosalpingogram • Still our “go to” test to evaluate both tubes and uterus • Sonohysterogram is an alternative • Not always accessible Work Up Of Infertility FEMALE MALE Ovarian Reserve Testing – Day 3 FSH and estradiol Semen analysis Hysterosalpingogram (or hysterosonogram) TSH and Prolactin Prenatal screening blood work Pelvic ultrasound Luteal phase progesterone
  17. 17. 26/05/2014 17 Work Up Of Infertility FEMALE MALE Ovarian Reserve Testing – Day 3 FSH and estradiol Semen analysis Hysterosalpingogram (or hysterosonogram) TSH and Prolactin Prenatal screening blood work Pelvic ultrasound Luteal phase progesterone Pelvic Ultrasound PROS CONS Will inform you about fibroids No information on fallopian tubes Will identify ovarian pathology (ex endometrioma) Limited information on intra-cavity bumps (ie polyps) Limited information on ovarian reserve
  18. 18. 26/05/2014 18 Work Up Of Infertility FEMALE MALE Ovarian Reserve Testing – Day 3 FSH and estradiol Semen analysis Hysterosalpingogram (or hysterosonogram) TSH and Prolactin Prenatal screening blood work Pelvic ultrasound Luteal phase progesterone Luteal Phase Progesterone • >95% of patients with a regular cycle are ovulating • Good for monitoring response to ovulation induction (ie PCOS) • Good if you are really uncertain if they are ovulating • Looking at the absolute value is limited so think of this result as binary – YES OR NO
  19. 19. 26/05/2014 19 Work Up Of Infertility FEMALE MALE Ovarian Reserve Testing – Day 3 FSH and estradiol Semen analysis Hysterosalpingogram (or hysterosonogram) TSH and Prolactin Prenatal screening blood work Pelvic ultrasound Luteal phase progesterone Semen Analysis Tips • Morphology is of limited value in predicting pregnancy rates • Repeat abnormal results • Persistently abnormal in repeat testing – consider referal
  20. 20. 26/05/2014 20 What Could Be Wrong?? Important to recognize the limitation of our testing. Unexplained Infertility Age Per month/year 1 First year Per month/ year 2 < 35 15-20% 60-85% 4% 35-39 10-15% 4% 40 6% ? > 43 <1% ? Canadian Fertility And Andrology Society
  21. 21. 26/05/2014 21 Odds And Ends…. EMPIRIC CLOMID “in couples whose infertility remains unexplained…empiric treatment with clomiphene citrate combined with intercourse is no better than expectant management” ASRM, Committee Opinion, 2013 Other Fertility Situations • Same-sex couples • Single women • Egg donation • Gestational Carriers • PGD • Oocyte Freezing
  22. 22. 26/05/2014 22 Egg Freezing • Works “relatively” well Impaired Ovarian Reserve Egg Freezing • Consider in patients < 35 • Consider discussing with single patients • AMH is a critical part of assessment
  23. 23. 26/05/2014 23 SUMMARY • Aneuploidy! • We need an accurate assessment of ovarian reserve in ALL patients – Anti-mullerian Hormone • Patients with longstanding histories of unexplained infertility generally need more intervention jhitkari@olivefertility.com

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