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
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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% 3
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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)
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7. Overview of Evaluation
• Female
– Ovary
– Tube
– Corpus
– Cervix
– Peritoneum
• Male
– Sperm count and function
– Ejaculate characteristics, immunology
– Anatomic anomalies
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8. The Most Important Factor in
the Evaluation of the Infertile
Couple Is:
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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
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12. History-Female
• Previous female pelvic surgery
• PID
• Appendicitis
• IUD use
• Ectopic pregnancy history
• DES (?relation to infertility)
• Endometriosis
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13. History-Female
• Irregular menses, amenorrhea, detailed
menstrual history
• Vasomotor symptoms
• Stress
• Weight changes
• Exercise
• Cervical and uterine surgery
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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
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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
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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 20
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21. Ovarian Function
• Three main types of dysfunction
– Hypogonadotrophic, hypoestrogenic (central)
– Normogonadotrophic, normoestrogenic (e.g.
PCOS)
– Hypergonadotrophic, hypoestrogenic (POF)
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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
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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
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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
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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 25
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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) 27
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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 H2O-based
– May be associated with fertility rates 28
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29. Hysterosalpingography (HSG)
• Can be uncomfortable
• Pregnancy test is advisable
• Can detect intrauterine and tubal disorders
but not always definitive
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30. When to do HSG
• Not during menstruation
• Not after day 12
• Best is day 7-10
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31. 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
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32. Falloposcopy
• Hysteroscopic procedure with cannulation
of the Fallopian tubes
• Can be useful for diagnosis of intraluminal
pathology
• Promising technique but not yet widespread
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37. Cervical Function
• Tests:
– Culture for suspected pathogens
– Postcoital test (PK tests)
• Scheduled around 1-2d before ovulation (increased
estrogen effect)
• 48 hours of male abstinence before test
• No lubricants
• Evaluate 8-12h after coitus (overnight is ok!)
• Remove mucus from cervix (forceps, syringe)
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39. 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
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44. Male Factors-Semen Analysis
• Collected after 480 of abstinence
• Evaluated within one hour of ejaculation
• If abnormal parameters, repeat twice, 2
weeks apart
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45. Normal Semen Analysis
Quality Normal Value
Volume >1 cc
Concentration >20 x 106
/cc
Initial Forward
Motility
>50%
Normal Morphology >60%
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46. 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
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48. 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
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49. Ovarian Disorders
• Central amenorrhea
– CC first, then hMG
– Pulsatile GnRH
• LPD
– Progesterone suppositories during luteal phase
– CC ± hCG
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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
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51. hMG (Pergonal)
• LH +FSH (also FSH alone = Metrodin)
• For patients with hypogonadotrophic
hypoestrogenism or normal FSH and E2
levels
• Close monitoring essential, including
estradiol levels
• 60-80% pregnancy rates overall, lower for
PCOS patients
• 10-15% multifetal pregnancy rate 51
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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
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54. Corpus
• Asherman syndrome
– Hysteroscopic lysis of adhesions (scissor)
– Postop Abx, E2
• Fibroids (rarely need treatment)
– Myomectomy(hysteroscopic, laparoscopic,
open)
– ??UAE
• Uterine anomalies (rarely need treatment)
– metroplasty 54
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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
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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 56
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57. Male Factor
• Hypogonadotrophism
– hMG
– GnRH
– CC, hCG results poor
• Varicocoele
– Ligation? (no definitive data yet)
• Retrograde ejaculation
– Ephedrine, imipramine
– AIH with recovered sperm 57
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58. Male Factor
• Idiopathic oligospermia
– No effective treatment
– ?IVF
– donor insemination
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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
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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 60
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