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Laparoscopy 3

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  • 1. Infertility David Toub, M.D. Medical Director Newton Interactive
  • 2. Definitions
    • Infertility
      • Inability to conceive after one year of unprotected intercourse (6 months for women over 35?)
    • Fertility
      • Ability to conceive
    • Fecundity
      • Ability to carry to delivery
  • 3. Statistics
    • 80% of couples will conceive within 1 year of unprotected intercourse
    • ~86% will conceive within 2 years
    • ~14-20% of US couples are infertile by definition (~3 million couples)
    • Origin:
      • Female factor ~40%
      • Male factor ~30%
      • Combined ~30%
  • 4. Etiologies
    • Sperm disorders 30.6%
    • Anovulation/oligoovulation 30%
    • Tubal disease 16%
    • Unexplained 13.4%
    • Cx factors 5.2%
    • Peritoneal factors 4.8%
  • 5. Associated Factors
    • PID
    • Endometriosis
    • Ovarian aging
    • Spermatic varicocoele
    • Toxins
    • Previous abdominal surgery (adhesions)
    • Cervical/uterine abnormalities
    • Cervical/uterine surgery
    • Fibroids
  • 6. Emotional and Educational Needs
    • Disease of couples, not individuals
    • Feelings of guilt
    • Where to go for information?
    • Options
    • Feelings of frustration and anger
    • Support groups (e.g. Resolve)
  • 7. Overview of Evaluation
    • Female
      • Ovary
      • Tube
      • Corpus
      • Cervix
      • Peritoneum
    • Male
      • Sperm count and function
      • Ejaculate characteristics, immunology
      • Anatomic anomalies
  • 8. The Most Important Factor in the Evaluation of the Infertile Couple Is:
  • 9. HISTORY
  • 10. History-General
    • Both couples should be present
    • Age
    • Previous pregnancies by each partner
    • Length of time without pregnancy
    • Sexual history
      • Frequency and timing of intercourse
      • Use of lubricants
      • Impotence, anorgasmia, dyspareunia
      • Contraceptive history
  • 11. History-Male
    • History of pelvic infection
    • Radiation, toxic exposures (include drugs)
    • Mumps
    • Testicular surgery/injury
    • Excessive heat exposure (spermicidal)
  • 12. History-Female
    • Previous female pelvic surgery
    • PID
    • Appendicitis
    • IUD use
    • Ectopic pregnancy history
    • DES (?relation to infertility)
    • Endometriosis
  • 13. History-Female
    • Irregular menses, amenorrhea, detailed menstrual history
    • Vasomotor symptoms
    • Stress
    • Weight changes
    • Exercise
    • Cervical and uterine surgery
  • 14. When Not to Pursue an Infertility Evaluation
    • Patient not sexually-active
    • Patient not in long-term relationship?
    • Patient declines treatment at this time
    • Couple does not meet the definition of an infertile couple
  • 15. Physical Exam-Male
    • Size of testicles
    • Testicular descent
    • Varicocoele
    • Outflow abnormalities (hypospadias, etc)
  • 16. Physical Exam-Female
    • Pelvic masses
    • Uterosacral nodularity
    • Abdominopelvic tenderness
    • Uterine enlargement
    • Thyroid exam
    • Uterine mobility
    • Cervical abnormalities
  • 17. Overall Guidelines for Work-up
    • Timeliness of testing-w/u can usually be accomplished in 1-2 cycles
    • Timing of tests
    • Don’t over test
    • Cut to the chase, i.e. proceed with laparoscopy if adhesive disease is likely
  • 18. Work-up by Organ Unit
  • 19. Ovary
  • 20. Ovarian Function
    • Document ovulation:
      • BBT
      • Luteal phase progesterone
      • LH surge
      • EMBx
    • If POF suspected, perform FSH
    • TSH, PRL, adrenal functions if indicated
    • The only convincing proof of ovulation is pregnancy
  • 21. Ovarian Function
    • Three main types of dysfunction
      • Hypogonadotrophic, hypoestrogenic (central)
      • Normogonadotrophic, normoestrogenic (e.g. PCOS)
      • Hypergonadotrophic, hypoestrogenic (POF)
  • 22. BBT
    • Cheap and easy, but…
      • Inconsistent results
      • Provides evidence after the fact (like the old story about the barn door and the horse)
      • May delay timely diagnosis and treatment
      • 98% of women will ovulate within 3 days of the nadir
      • Biphasic profiles can also be seen with LUF syndrome
  • 23. Luteal Phase Progesterone
    • Pulsatile release, thus single level may not be useful unless elevated
    • Performed 7 days after presumptive ovulation
    • Done properly, >15 ng/ml consistent with ovulation
  • 24. Urinary LH Kits
    • Very sensitive and accurate
    • Positive test precedes ovulation by ~24 hours, so useful for timing intercourse
    • Downside: price, obsession with timing of intercourse
  • 25. Endometrial Biopsy
    • Invasive, but the only reliable way to diagnose LPD
    • ??Is LPD a genuine disorder???
    • Pregnancy loss rate <1%
    • Perform around 2 days before expected menstruation (= day 28 by definition)
    • Lag of >2 days is consistent with LPD
    • Must be done in two different cycles to confirm diagnosis of LPD
  • 26. Fallopian Tubes
  • 27. Tubal Function
    • Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition
    • Kartagener’s syndrome can be associated with decreased tubal motility
    • Tests
      • HSG
      • Laparoscopy
      • Falloposcopy (not widely available)
  • 28. Hysterosalpingography (HSG)
    • Radiologic procedure requiring contrast
    • Performed optimally in early proliferative phase (avoids pregnancy)
    • Low risk of PID except if previous history of PID (give prophylactic doxycycline or consider laparoscopy)
    • Oil-based contrast
      • Higher risk of anaphylaxis than H 2 O-based
      • May be associated with fertility rates
  • 29. Hysterosalpingography (HSG)
    • Can be uncomfortable
    • Pregnancy test is advisable
    • Can detect intrauterine and tubal disorders but not always definitive
  • 30. Laparoscopy
    • Invasive; requires OR or office setting
    • Can offer diagnosis and treatment in one sitting
    • Not necessary in all patients
    • Uses (examples):
      • Lysis of adhesions
      • Diagnosis and excision of endometriosis
      • Myomectomy
      • Tubal reconstructive surgery
  • 31. Falloposcopy
    • Hysteroscopic procedure with cannulation of the Fallopian tubes
    • Can be useful for diagnosis of intraluminal pathology
    • Promising technique but not yet widespread
  • 32. Uterine Corpus
  • 33. Corpus
    • Asherman Syndrome
      • Diagnosis by HSG or hysteroscopy
      • Usually s/p D+C, myomectomy, other intrauterine surgery
      • Associated with hypo/amenorrhea, recurrent miscarriage
    • Fibroids, Uterine Anomalies
      • Rarely associated with infertility
      • Work-up:
        • Ultrasound
        • Hysteroscopy
        • Laparoscopy
  • 34. Cervix
  • 35. Cervical Function
    • Infection
      • Ureaplasma suspected
    • Stenosis
      • S/P LEEP, Cryosurgery, Cone biopsy (probably overstated)
    • Immunologic Factors
      • Sperm-mucus interaction
  • 36. Cervical Function
    • Tests:
      • Culture for suspected pathogens
      • Postcoital test (PK tests)
        • Scheduled around 1-2d before ovulation (increased estrogen effect)
        • 48 0 of male abstinence before test
        • No lubricants
        • Evaluate 8-12h after coitus (overnight is ok!)
        • Remove mucus from cervix (forceps, syringe)
  • 37. Cervical Function
    • PK, continued (normal values in yellow)
      • Quantity (very subjective)
      • Quality (spinnbarkeit) (>8 cm)
      • Clarity (clear)
      • Ferning (branched)
      • Viscosity (thin)
      • WBC’s (~0)
      • # progressively motile sperm/hpf (5-10/hpf)
      • Gross sperm morphology (WNL)
    Male factors
  • 38. Problems with the PK test
    • Subjective
    • Timing varies; may need to be repeated
    • In some studies, “infertile” couples with an abnormal PK conceived successfully during that same cycle
  • 39. Peritoneum
  • 40. Peritoneal Factors
    • Endometriosis
      • 2x relative risk of infertility
      • Diagnosis (and best treatment) by laparoscopy
      • Can be familial; can occur in adolescents
      • Etiology unknown but likely multiple ones
        • Retrograde menstruation
        • Immunologic factors
        • Genetics
        • Bad karma
      • Medical options remain suboptimal
  • 41. Male Factors
  • 42. Male Factors
    • Serum T, FSH, PRL levels
    • Semen analysis
    • Testicular biopsy
    • Sperm penetration assay (SPA)
  • 43. Male Factors-Semen Analysis
    • Collected after 48 0 of abstinence
    • Evaluated within one hour of ejaculation
    • If abnormal parameters, repeat twice, 2 weeks apart
  • 44. Normal Semen Analysis
  • 45. Sperm Penetration Assay
    • aka “zona-free hamster ova assay”
    • Dynamic test of fertilization capacity of sperm
    • Failure to penetrate at least 10% of zona-free ova consistent with male factor
    • False positives and negatives exist
  • 46. Treatment Options
  • 47. Ovarian Disorders
    • Anovulation
      • Clomiphene Citrate ± hCG
      • hMG
      • Induction + IUI (often done but unjustified)
    • PRL
      • Bromocriptine
      • TSS if macroadenoma
    • POF
      • ?high-dose hMG (not very effective)
  • 48. Ovarian Disorders
    • Central amenorrhea
      • CC first, then hMG
      • Pulsatile GnRH
    • LPD
      • Progesterone suppositories during luteal phase
      • CC ± hCG
  • 49. Ovarian Matrix
  • 50. Ovulation Induction
    • CC
      • 70% induction rate, ~40% pregnancy rate
      • Patients should typically be normoestrogenic
      • Induce menses and start on day 5
      • With dosages, antiestrogen effects dominate
      • Multifetal rates 5-10%
      • Monitor effects with PK, pelvic exam
  • 51. hMG (Pergonal)
    • LH +FSH (also FSH alone = Metrodin)
    • For patients with hypogonadotrophic hypoestrogenism or normal FSH and E 2 levels
    • Close monitoring essential, including estradiol levels
    • 60-80% pregnancy rates overall, lower for PCOS patients
    • 10-15% multifetal pregnancy rate
  • 52. Risks
    • CC
    • Vasomotor symptoms
    • H/A
    • Ovarian enlargement
    • Multiple gestation
    • NO risk of SAb or malformations
    • hMG
    • Multiple gestation
    • OHSS (~1%)
      • Can often be managed as outpatient
      • Diuresis
      • Severe cases fatal if untreated in ICU setting
  • 53. Fallopian Tubes
    • Tuboplasty
    • IVF
    • GIFT, ZIFT not options
  • 54. Corpus
    • Asherman syndrome
      • Hysteroscopic lysis of adhesions (scissor)
      • Postop Abx, E 2
    • Fibroids (rarely need treatment)
      • Myomectomy(hysteroscopic, laparoscopic, open)
      • ??UAE
    • Uterine anomalies (rarely need treatment)
      • metroplasty
  • 55. Cervix
    • Repeat PK test to rule out inaccurate timing of test
    • If cervicitis Abx
    • If scant mucus low-dose estrogen
    • Sperm motility issues (? Antisperm AB’s)
      • Steroids?
      • IUI
  • 56. Peritoneum (Endometriosis)
    • From a fertility standpoint, excision beats medical management
    • Lysis of adhesions
    • GnRH-a (not a cure and has side effects, expense)
    • Danazol (side effects, cost)
    • Continuous OCP’s (poor fertility rates)
    • Chances of pregnancy highest within 6 mos-1 year after treatment
  • 57. Male Factor
    • Hypogonadotrophism
      • hMG
      • GnRH
      • CC, hCG results poor
    • Varicocoele
      • Ligation? (no definitive data yet)
    • Retrograde ejaculation
      • Ephedrine, imipramine
      • AIH with recovered sperm
  • 58. Male Factor
    • Idiopathic oligospermia
      • No effective treatment
      • ?IVF
      • donor insemination
  • 59. Unexplained Infertility
    • 5-10% of couples
    • Consider PRL, laparoscopy, other hormonal tests, cultures, ASA testing, SPA if not done
    • Review previous tests for validity
    • Empiric treatment:
      • Ovulation induction
      • Abx
      • IUI
      • Consider IVF and its variants
    • Adoption
  • 60. Summary
    • Infertility is a common problem
    • Infertility is a disease of couples
    • Evaluation must be thorough, but individualized
    • Treatment is available, including IVF, but can be expensive, invasive, and of limited efficacy in some cases
    • Consultation with a BC/BE reproductive endocrinologist is advisable
  • 61. Thank you!