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Obg01 Infertility

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  • 1. Infertility Edward A. Rose, M.D., M.S.A. North Oakland Medical Centers Pontiac, MI
  • 2. Description of Case
    • 29 y o G 0 concerned about not getting pregnant
    • Unprotected sex X 1 ½ years
    • PMHx negative
    • No other complaints
  • 3. Further History?
    • Frequency of intercourse, use of lubricants (e.g., K-Y gel) that could be spermicidal, use of vaginal douches after intercourse, or presence of any sexual dysfunction such as anorgasmia or dyspareunia
    • Menstrual history, frequency, and patterns since menarche; weight changes, hirsutism, frontal balding, acne
  • 4. History (continued)
    • Male partners: previous spermogram results, history of impotence, premature ejaculation, change in libido, history of testicular trauma, previous relationships, history of any previous pregnancy, existence of offspring from previous partners
    • History of sexually transmitted diseases; surgical contraception (e.g. vasectomy, tubal ligation); lifestyle; consumption of alcohol, tobacco, and recreational drugs; occupation; physical activities
  • 5. History (continued)
    • Either partner currently under medical treatment, the reason, and whether they have a history of allergies
    • Complete review of systems may be helpful to identify any endocrinological or immunological problem
  • 6. Your Patient
    • History of weight gain, acne, facial hair, irregular menses
    • ROS + for an elevated glucose and elevated BP a few months ago
    • Exam shows android body habitus, weight 205#, acne on face and back, some facial hair
    • Diagnosis, first years?
  • 7. Definition
    • Inability to conceive after one year of intercourse without contraception
    • Counsel patience!
  • 8. Causes of Infertility
  • 9. Male Factor
    • Male partner should be evaluated simultaneously with female partner
    • Causes of male infertility:
      • Reversible conditions (varicocele, obstructive azoospermia)
      • Not reversible, but viable sperm available (ejaculatory dysfunction, inoperative obstructive azoospermia)
      • Not reversible, no viable sperm (hypogonadism)
      • Genetic abnormalities
      • Testicular or pituitary cancer
  • 10. Ovulatory Dysfunction
    • Causes 18% of infertility
    • Diagnosed by
      • Menstrual irregularities
      • Basal body temperatures
      • Ovulation prediction kits
      • Serum progesterone levels (18-24 days after onset of menses; level > 3 ng/ml is diagnostic of ovulation)
  • 11. BBT Kit
  • 12. Completed Sample BBT Chart
  • 13. Evaluation of Ovarian Reserve
    • Assessed in women > 35 or younger women with risk factors for premature ovarian failure
    • Day 3 FSH and CCCT (clomiphene citrate challenge test)
      • Administer 100 mg clomiphene on cycle days 5-9
      • Measure FSH on days 3 and 10; maybe estradiol on day 3 (conflicting data)
      • Normal test not useful, but abnormal test virtually assures that pregnancy will not occur even with treatment
    • Ultrasound may also be used
  • 14. Causes of Ovulatory Dysfunction
    • Polycystic ovary syndrome
    • Hypothalamic anovulation
    • Hyperprolactinemia
    • Premature and age-related ovarian failure
    • Luteal phase defect
      • Abnormalities of corpus luteum resulting in inadequate production of progesterone
      • Based on finding of 2 consecutive endometrial biopsy specimens showing histology > 2 days out-of-phase with actual biopsy date
      • Relevance is controversial
  • 15. Polycystic Ovarian Syndrome
    • Oligomenorrhea/amenorrhea and hyperandrogenism
    • Prevalence: 5%
    • Among women with ovulatory dysfunction, 70% have PCOS
    • Clinical evidence: hirsutism, acne, obesity
    • Lab evidence: elevated testosterone, elevated DHEA-S
    • “ Polycystic ovaries” supportive, not diagnostic
  • 16. PCOS Treatment Approach
    • Weight loss if BMI > 30
    • Clomiphene to induce ovulation
    • If DHEA-S > 2, clomiphene + glucocorticoid (dexamethasone)
    • If clomiphene alone unsuccessful, try metformin + clomiphene
  • 17. Hypothalamic Anovulation
    • Low levels of GnRH, low or normal levels of FSH/LH, low levels of endogenous estrogen
    • Associated factors: low BMI (< 20), high-intensity exercise, extreme diets, stress
    • Treatment: lifestyle modification
  • 18. Hyperprolactinemia
    • Causes: pituitary adenoma, psych meds
    • Test for pregnancy, thyroid disease
    • Imaging: MRI for macro vs. microadenoma
    • Treatment: Bromocriptine (dopamine agonist)
    • After treatment, 80% of women will ovulate, 80% will get pregnant
    • Discontinue treatment once pregnancy established
  • 19. What Can I Do?
  • 20. History and Physical - Female
    • History
      • Menarche, puberty
      • Menstrual history
      • Pregnancies, abortions, birth control
      • Dyspareunia, dysmenorrhea
      • STDs, abdominal surgery, galactorrhea
      • Weight loss/gain
      • Stress, exercise, drugs, alcohol, psychological
    • Physical
      • Weight/BMI
      • Thyroid
      • Skin (striae, acanthosis nigricans)
      • Pelvic (vaginal mucosa, masses, pain)
      • Rectal (uterosacral nodularity)
  • 21. History and Physical - Male
    • History
      • Prior fertility
      • Medications
      • History of diabetes, mumps, undescended testes
      • Genital surgery, trauma, infections
      • ED
      • Drug/alcohol use, stress
      • Underwear, hot tubs, frequent coitus
    • Physical
      • Habitus, gynecomastia
      • Sexual development
      • Testicular volume (5x3 cm)
      • Epididymis, vas, prostate by palpation
      • Check for varicocele
  • 22. How Long To Wait Before Work-up
    • For young patients, wait a year
    • Don’t wait a year if:
      • Irregular menses; intermenstrual bleeding
      • History of PID
      • History of appendicitis with rupture
      • History of abdominal surgery
      • Dyspareunia
      • Age > 35
      • Male factors
  • 23. On The First Visit
    • Semen analysis
    • Confirm ovulation
      • Basal body temperature charting
      • Ovulation predictor kits (detect LH surge)
      • Consider serum progesterone on day 21
    • Labs:
      • TSH and prolactin
      • DHEA-S if concern for PCOS
      • FSH and estradiol on cycle day 3 and 10 if >35y
      • Cervical cultures prn
  • 24. Three Months Later
    • Hysterosalpingogram
      • Evaluates tubal patency and uterine cavity shape
      • Noninvasive but involves a tenaculum
      • Not a painless test
      • Performed by radiology with gynecology supervision
      • Diagnostic and therapeutic
  • 25. Hysterosalpingogram
  • 26. Limited Clinical Utility
    • Postcoital test
      • Limited diagnostic potential, poor predictive value
    • Endometrial biopsy (luteal phase defect)
    • BBTs
      • Very inexpensive but interpretation difficult
      • Temperature changes too late to be useful for timing intercourse
    • Zona-free hamster oocyte penetration test
      • Not sure if hamster oocytes predict human oocytes
    • Immune testing for antiphospholipid, antisperm, antinuclear, antithyroid antibodies
    • Routine cervical cultures
      • Mycoplasma hominis or Ureaplasma urealyticum
    • Karyotype
  • 27. Clomiphene Citrate
    • Effective for anovulatory patients
      • Also used in unexplained fertility, but no data to support
      • Most effective for women with normal FSH and estrogen, least effective in hypothalamic amenorrhea or elevated FSH
    • Induces ovulation by unknown mechanism
    • Most pregnancies occur in first 3 cycles
    • 80% will ovulate, 40% will become pregnant in 3 cycles
  • 28. Clomiphene - Complications
    • 7% twin gestations, 0.3% triplet gestations
    • Miscarriage rate = 15%
    • Birth defect rate unchanged from controls
    • Side effects: hot flashes, adnexal tenderness, nausea, headache, blurry vision
    • Contraindications: pregnancy, ovarian cysts
  • 29. Clomiphene - Administration
    • 50 mg daily, cycle day 3 through 7
      • Induce bleeding first with progesterone if amenorrheic
    • Intercourse QOD cycle days 12 - 17
    • Track ovulation with BBT or ovulation detection kits
    • Increase dose to 100 mg daily, then 150, if no ovulation occurs
  • 30. Thank You!