Infertility
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infertility laura detti

infertility laura detti

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  • Fecundability: Probability that ONE CYCLE results in pregnancy = 20-25% in normal couples

Infertility Infertility Presentation Transcript

  • Basic infertility workup Laura Detti, MD Reproductive Endocrinology and Infertility University of Tennessee Health Science Center October 1, 2009
  • Normal reproductive efficiency
    • Time required for conception in fertile couples
    • Time % pregnant
    • 3 months 57%
    • 6 months 72%
    • 1 year 85%
    • 2 years 93%
  • Physiology of reproductive aging in women
    • Variation of oocyte number during a woman’s life
    • Period Number
    • 16-20 weeks fetus 6-7 million
    • Birth 1-2 million
    • Puberty 300-500,000
    • 37-38 years 25,000
    • Menopause 1,000
  • Definition
    • One year of unprotected intercourse without conception
    • After 35 yrs of age:
    • Six months of unprotected intercourse without conception
    • Affects 10-15% of couples in the US
  • Causes of infertility
    • Cervical
    • Uterine/endometrial
    • Tubal
    • (30-40%)
    • Peritoneal
    • Ovulatory (15%)
    • Male Factor (40%)
    • Combined M-F (20%)
  • Human reproductive process
    • Sperm has to ascend through Cx, Ut, Tubes and has to have the capacity to fertilize the oocyte (male factor)
    • Cx must filter and nurture sperm into Ut and Tubes (cervical factor)
    • Ovulation of a mature oocyte must occur (ovarian factor)
    • Tubes must capture ovulated oocyte and transport sperm and embryo (tubal/peritoneal factor)
    • Ut must be receptive to embryo implantation and support pregnancy (uterine factor)
  • Cervical factor
    • Anatomical changes (DES exposure)
    • Infections (TB)
    • Changes in mucus characteristics
  • Evaluation of cervical factor
    • Cultures
    • Post-coital test
  • Uterine/endometrial factor
    • • Anatomical changes (congenital malformations, fibroids, adhesions)
    • • Functional abnormalities (endometritis,
    • receptivity)
  • Evaluation of Uterine/endometrial factor
    • TV Ultrasound and Sonohysterography
    • Hysterosalpingography
    • Hysteroscopy
    • Endometrial biopsy
  • Tubal/peritoneal factor
    • • Anatomical changes (congenital malformations, BTL, adhesions, endometriosis)
  • Evaluation of tubal/peritoneal factor
    • Hysterosalpingography
    • Laparoscopy with chromopertubation
    • Sonohysterography
  • Ovarian factor
    • Ovulatory dysfunction:
    • • Oligo/Anovulation
    • • Luteal phase deficiency
  • Evaluation of ovulatory dysfunction
    • Menstrual history
    • Basal body temperature
    • Serum progesterone
    • Urinary LH excretion (ov. predictor kits)
    • Basal FSH/Clomiphene challenge test
    • Oligo-amenorrhea testing
  • Male Factor
    • Medical History
    • Semen analysis:
    • Volume 1.5-5.0 ml
    • Concentration > 20 Mil/ml
    • Motility > 40%
    • Morphology > 14%
    • pH > 7.2
    • Round cells < 1 Mil/ml
  • Male Factor
    • Low volume and other parameters:
    • Retrograde ejaculation
    • Duct obstruction
    • Hypogonadism
    • CBAVD
    • Evaluation of male factor infertility:
      • FSH, LH, PRL, Testosterone
      • Karyotype
      • Y chromosome microdeletions
  • Male Factor
    • Low volume and other parameters:
    • Retrograde ejaculation
    • Duct obstruction
    • Hypogonadism
    • CBAVD
    • Treatment of male factor infertility:
      • Endocrine treatment
      • IUI, TDI
      • ART
  • Treatment of infertility
    • Correction of anatomical defects
    • Rx of infections
    • Restoration of a regular ovulatory pattern
    • Ovulation induction:
    • Clomiphene Citrate, Aromatase Inhibitors, Gonadotropins
  • Assisted Reproduction Techniques
    • IUI = intra-uterine sperm injection
    • IVF-ET = in vitro fertilization and embryo transfer
    • ICSI = intra-cytoplasmic sperm injection
  • ART overview
    • Preliminary Testing
    • Multiple Follicular Recruitment
    • Oocyte Retrieval
    • Oocyte Identification, Grading and Preparation for Insemination or ICSI
    • Sperm Preparation
    • Insemination or ICSI
    • Embryo Culture
    • Embryo Transfer or Cryopreservation
    • Luteal Support
    • Early Pregnancy Support
  • Multiple Follicular Recruitment
  • Multiple Follicular Recruitment
  •  
    • IVF-ET / ICSI
  • Micromanipulation in ART ● Intracytoplasmic Sperm Injection ● Blastomere Biopsy for Preimplantation Genetic Diagnosis ● Assisted Hatching
  • Embryo Transfer, Luteal Support and Pregnancy Support
    • Embryo transfer 3 – 6 days after oocyte retrieval (2 – 5 days after fertilization)
    • Luteal support
      • hCG
      • Progesterone
    • Pregnancy diagnosis by serially rising hCG levels starting 12 days after transfer
    • Continue supplemental progesterone until viability diagnosed and placental progesterone production established
  •