Infertility, Version 1 Slide 4. Types of Infertility There are two types of infertility: primary and secondary. If a couple has never produced a pregnancy, it is defined as primary infertility. However, if the woman has previously been pregnant, regardless of the outcome (which may have been a premature or full-term delivery, spontaneous abortion, induced abortion or ectopic pregnancy), and is now unable to conceive, it is considered secondary infertility.
Infertility, Version 1 Slide 21. Fertility Evaluation Procedure Before the medical data are collected, the couple should be informed about the different causes of infertility, the tests and procedures required to make a diagnosis and the various therapeutic possibilities. After interviewing the couple together, the man and woman should be interviewed separately to obtain confidential information.
Infertility, Version 1 Slide 22. Fertility Evaluation: General and Sexual History A detailed history includes: General history This includes occupation and background, use of tobacco, alcohol and drugs, earlier diseases, history of abdominal surgery and earlier infections. Sexual history – One of the purposes of obtaining a sexual history is to determine whether the partners have any sexual disturbance or dysfunction. Erectile dysfunction, vaginismus (painful involuntary spasm of vagina preventing intercourse) and dyspareunia (pain during sexual intercourse) can explain involuntary childlessness in some couples. A history of sexually transmitted infections could be another cause of infertility in either partner.
Infertility, Version 1 Slide 23. Fertility Evaluation: Obstetric and Gynecological History The obstetric and gynecological history should include: Reproductive history (children, mode of delivery, prematurity, stillbirth, extrauterine pregnancy, spontaneous and induced abortion, fertility and infertility in earlier relationships). Gynecological history, including operations and medical treatment. Age at menarche. Menstrual periods: duration and intervals. Previous contraceptive use. Previous testing and treatment for infertility.
Infertility, Version 1 Slide 24. Fertility Evaluation: General and Gynecological Examination For women, a visual evaluation of hair distribution and of body and breast development can indicate endocrinopathy or various development deficiencies. A complete pelvic exam should reveal any uterine hypoplasia, fibroids, adnexal tumors or cervical lesions and should indicate whether dyspareunia may be a problem. For men, a visual inspection of sexual characteristics can identify such endocrinopathies as hypogonadism (a condition resulting in atrophy or deficient development of secondary sexual characteristics) or Klinefelter’s syndrome (a genetic anomaly often associated with infertility). A penile exam should detect atrophy, tumors, epididymal cysts, cryptorchidism (undescended testicles), vas thickening or absence of the vas deferens, hydrocele (fluid accumulation in the testis or along the spermatic cord) or varicocele.
Infertility, Version 1 Slide 28. Fertility Evaluation of the Male Partner: Semen Analysis Semen analysis is an essential part of the evaluation. The man is advised not to ejaculate for 2 to 3 days before giving the semen sample for evaluation. Because the sperm have a short life span outside the human body, the semen specimen must be evaluated within a short time frame. The semen is studied for a number of factors. An adequate semen analysis includes the following: Volume (1.5 cc to 5.0 cc). Number of sperm present (> 20 million/ml). Their ability to move (> 60%) and forward progression (more than 2 on a 1-to-4 scale). Morphology (> 60% normal forms). Absence of any infection.
Infertility, Version 1 Slide 29. Fertility Evaluation of the Male Partner: Other Tests Other tests for men include: Urine analysis to rule out an infection. Endocrine tests to check concentrations of the hormones testosterone, FSH and LH. Anti-sperm antibodies. The presence of anti-sperm antibodies have been found in infertile men, and suppression of these antibodies with corticosteroid treatment has improved the semen quality and increased the rate of conception. Sperm penetration assay. This test measures the ability of the sperm to penetrate a specially prepared egg from an animal, usually a hamster. Postcoital test. Used by some clinicians to evaluate the motility of the sperm and its ability to travel through the cervical mucus. The validity of this test is low.
Diagram shows the appropriate steps in an imaging evaluation for fallopian tube abnormalities.
Infertility, Version 1 Slide 27. Evaluation of the Female Partner: Other Tests Other tests to evaluate a woman’s fertility include: Hysterosalpinogram (HSG). This test is performed early in the menstrual cycle after bleeding has stopped but prior to ovulation. Radiopaque dye is instilled into the uterine cavity through the cervix and x-rays are taken. The dye outlines the cavity of the uterus and spills out of the fallopian tubes. This indicates whether the fallopian tubes are open or blocked. If they are blocked, it indicates the site of the block. It also shows if there are any abnormalities in the uterine cavity, such as polyps or submucous fibroids; or abnormalities of the tubes, such as evidence of salpingitis. Laparoscopy. This allows the physician to evaluate the woman for any pelvic disease, particularly endometriosis, which may interfere with conception. The patency of the fallopian tubes can also be checked. Hysteroscopy. The uterine cavity is distended with a gas or liquid, and the hysteroscope is introduced into the uterine cavity which can then be carefully inspected. Polyps and submucous fibroids can be removed during this procedure.
Infertility, Version 1 Slide 30. Treatment Possibilities: Female Infertility Depending on the cause of infertility, there are different possibilities for treatment. Ovulation disorders can be treated with ovulation-inducing drugs. In women whose ovulation is suppressed by hyperprolactinemia (high blood levels of the pituitary hormone prolactin), ovulation may be induced with prolactin-suppressing drugs. Some uterine and tubal abnormalities, such as adhesions, uterine septum, or fibromyoma, may be corrected by surgical procedures. Cervical mucus problems impairing conception may be treated with intrauterine insemination (IUI) or uterine instillation of specially prepared sperm. Endometriosis can be treated with hormones that suppress the displaced endometrial tissue or the tissue can be removed by a surgical procedure.
How to approach a case of infertility for undergraduate
How to approacha case of infertilityDr Manal BeheryAssistant professorZagazig University2013
Definitions• Infertility = Inability of a couple practicingfrequent intercourse and not usingcontraception to conceive a childUnder 35 year :No conception after oneyear of unprotected intercourseOver 35 year :No conception after 6months of unprotected intercourse
Types of InfertilityPrimary infertility− Couple Has Never ProducedA pregnancySecondary infertility− Woman has previously been pregnant,regardless of the outcome, and now isunable to conceive
Causes of infertility• Tubal pathology 35%• Male factor 35%• Ovulatory dysfunction 15%• Unexplained 10%• Cervical/other 5%
Causes oftubal/ Pelvic pathology• Congenital anomalies• Tubal occlusion• May occur as sequelae of– PID– endometriosis– abdominal/pelvic surgery– peritonitis
Causes oftubal/ Pelvic pathology• Congenital anomalies• Tubal occlusion• May occur as sequelae of– PID– endometriosis– abdominal/pelvic surgery– peritonitis
Causes of Ovulatory Dysfunction– polycystic ovary syndrome– hypothalamic anovulation– hyperprolactinemia– premature and age-related ovarian failure– luteal phase defect (theoretical)
Causes of male infertility:– reversible conditions (varicocele, obstructiveazoospermia)– not reversible, but viable sperm available(ejaculatory dysfunction, inoperative obstructiveazoospermia)– not reversible, no viable sperm (hypogonadism)– genetic abnormalities– testicular or pituitary cancer
Counsel patient!• In normal young couples:– 25% conceive after one month– 70% conceive after six months– 90% conceive by one year• Only an additional 5%• will conceive in an additional 6-12 months
CouncellingEvaluating both partners isessentialCouple should be informed about:− different causes of infertility− tests and procedures required to makea diagnosis− various therapeutic possibilitiesCouple’s interview is conducted togetheras well as separatelyto obtain confidential informationRichardLord
Start with History. . .General and Sexual HistoryObstetric and Gynecological HistoryWhat Clues Can You Find on History?
Step1 history:General and Sexual HistoryGeneral history− occupation and background− use of tobacco, alcohol and drugs− history of abdominal surgery and earlierdiseases/infectionsSexual history− sexual disturbances or dysfunction such asvaginismus, dyspareunia or erectile dysfunction− sexually transmitted infections
Obstetric and Gynecological HistoryReproductive historyGynecological historyAge at menarcheMenstrual periods: duration and intervalsPrevious contraceptive usePrevious testing and treatment for infertility
Step2 : General andGynecological ExaminationVisual evaluation andpelvic exam for womento rule out:Visual evaluation andpelvic exam for womento rule out:Visual evaluation andpenile exam for mento rule out:Visual evaluation andpenile exam for mento rule out:EndocrinopathyEndocrinopathyCongenital anomaliesCongenital anomaliesUterine hypoplasiaUterine hypoplasiaCervical lesionsCervical lesionsDyspareuniaDyspareuniaHypogonadismHypogonadismTumorsTumorsEpididymal cystsEpididymal cystsCryptorchidismCryptorchidismHydroceleHydroceleVaricoceleVaricocele
Male Partner: Semen AnalysisSemen is studied for a number of factors including:Volume (1.5 cc to 5.0 cc)Number of sperm present(> 20 million/ml)Sperm motility (> 60%) and forward progression(more than 2 on scale 1 to 4)Morphology (> 60% normal forms)Presence of any infection
Other TestsUrine analysis: to rule out infectionEndocrine tests: to measureconcentrations of hormones testosterone, FSHand LHAnti-sperm antibodiesSperm penetration assay: to establish ability ofsperm to penetrate eggPostcoital test (low validity):to establish ability of spermto penetrate cervical mucus
Male partner: Evaluation:1) Repeat semen analysis2) Physical exam- varicocele, testicular size3) Lab testing- testosterone, FSH, LH4) Genetics for special casesIUI(intrauterine insemination)ICSI(intracytoplasmic sperm injection)
Don’t wait a year if:– irregular menses;intermenstrual bleeding– h/o PID– h/o appendicitis withrupture– h/o abdominal surgery– dyspareunia– age > 35– male factors
On your 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 & estradiol on cycle day 3 if >35y.– Cervical cultures prn.
Three months later• Hysterosalpingogram– evaluates tubal patency and uterine cavity shape– noninvasive but involves a tenaculum– performed by radiology with gynecology supervision– diagnostic and therapeutic
Other TestsLaparoscopy− to evaluate for pelvic disease,− such as endometriosis− check patency of fallopian tubesHysteroscopy− to evaluate condition of uterine− cavity (polyps, fibroids)
Sorry, no data for...• Post coital test• endometrial biopsy• immune testing for antispermantibodies• routine cervical cultures
Traditional Infertility Evaluation1) Semen Analysis2) Hysterosalpingogram (HSG)3) Documentation of Ovulation4) Post-coital Exam5) Diagnostic Laparoscopy
Current Infertility Evalution1) Semen Analysis2) Hysterosalpingogram (HSG)3) Documentation of Ovulation4) Ovarian Reserve Testing
Ovarian Reserve TestingDay #3 FSH (<10 mIU/ml) and estradiol (<80 pg/ml)-Correlates with the functional status of the ovaries andthe quality of the oocytes- FSH >15 only 5% success with IVF- High estradiol level increases risk of cancelling IVFcycle
Case 1• A 24 year old couple comes to see you. They have beentrying to get pregnant for 8 months.– What questions do you ask?
Case 1• The woman tells you she has never been pregnant. Shehas a regular 28 day cycle and bleeds for 4 days eachmonth. Her medical history is unremarkable except she“got really sick” when she was 16 and had “nasty stuffcoming from down there”– what do you do next?
Case 2• A 35 year old woman and her 31 year old male partnercome to see you. They have been trying to get pregnantfor 6 months.– What do you ask?
Case 2• She says her periods have been irregular since she wentoff the pill a year ago. She has never been pregnant. Hehas fathered a child by another woman several yearsago.– What do you look for on exam?– What lab tests do you order today?– Do you give them homework?
Case 2• They come back 3 months later with BBT charts showingno discernable pattern. Lab tests, including semenanalysis, were all normal.– What is the diagnosis?– What do you do next?
Case 2• You begin discussion of clomiphene. They want to knowthe side effects, and if this means they’ll have sextupletsand get a free house like the folks on TV.– What do you tell them?– How do you administer the clomiphene?
Case 2• They come back in one month. She feels “like a totalbitch - excuse me, doctor” on the clomiphene. She is notpregnant. BBT charting shows a mid-cycle temperaturerise.– What happens next?
Case 3 A 31-year-old G1 P1 woman presents with ahistory of infertility of 2-year duration. Manarche at 12 years and occurs at28-dayintervals. A biphasic basal body temperature chart isrecorded. She denies sexually transmitted diseases, hysterosalpingogram shows patent tubes and anormal uterine cavity. Her husband is 34 years old and his semenanalysis is normal.
➤ What is the most likely etiology ofthe infertility?• ➤ Most likely etiology: Endometriosis(peritoneal factor).• What further support the diagnosis ?• if the patient complained of the threeDs of endometriosis (dysmenorrhea,dyspareunia, anddyschezia), then theexaminer would be pointed toward theperitoneal factor.
• A 22-year-old G0 P0 woman complains of irregularmenses every 30 to 65 days. The semen analysis isnormal. The hysterosalpingogram is normal. Whichof the following is the most likely treatment for thispatient?• A. Laparoscopy• B. Intrauterine insemination• C. In vitro fertilization• D. Clomiphene citrate
• A 26-year-old G0 P0 woman has regular mensesevery 28 days. The semen analysis is normal• . The patient had a postcoital test revealing motilesperm and stretchy watery cervical mucus. She hasbeen treated for chlamydial infection in the past.• Which of the following is the most likely etiologyof her infertility?• A. Peritoneal factor• B. Male factor• C. Cervical factor• D. Uterine and tubal factor• E. Ovulatory factor
• A 28-year-old G1 P1 woman complains ofpainful menses and pain with intercourse. Shehas menses every month and denies a historyof STD• Which of the following tests would mostlikely identify the etiology of the infertility?• A. Semen analysis• B. Laparoscopy• C. Basal body temperature chart• D. Hysterosalpingogram• E. Progesterone assay
• A 34-year-old infertile woman is noted tohave evidence of blocked fallopian tubes byHSG• Which of the following is the best nextstep for this patient?• A. FSH therapy• B. Clomiphene citrate therapy• C. Laparoscopy• D. Intrauterine insemination
Case 4A 37-year-old female and her 37-year-oldhusband present with the complaint of apossible fertility problem. The couple has beenmarried for 2 years.The patient has a 4-year-old daughter from aprevious relationship.The patient used birth control pills until one-and-a- half-years-ago. The couple has been trying to conceive sincethen and report a high degree of stress relatedto their lack of success.
Case cont’ The patient reports good health and noproblems in conceiving her previous pregnancyor in the vaginal delivery of her daughter. She reports that her periods were regular on thebirth control pill, but have been irregular sinceshe discontinued taking them. She reports having periods every 5-7 weeks. Past history is remarkable only for milddepression. Imipramine 150 mg qhs for the last8 months is her only medication
Case cont’ has no history of STDs, abnormal Paps, smoking,alcohol or other drugs. She has had no surgery. The patient’s partner also reports good health andreports no problems with erection, ejaculation orpain with intercourse. He has had no prior urogenital infections orexposure to STDs . He has had unprotected sex prior to his currentrelationship, but has not knowingly conceived. He has no medical problems or past surgery
Case cont’;He works as a long-distance truck driver and ison the road 2-3 weeks each month.He smokes a pack of cigarettes a day since age18 and drinks 2-3 cans of beer 3-4 times a weekwhen he’s not driving.He occasionally uses amphetamines to stayawake while driving at night. The couple hasvaginal intercourse 3-5 times per week when heis at home.
Physical exam The patient is 5’9” and weighs 130 pounds. Breast exam reveals no tenderness or masses,but bilateral galactorrhea on compression of theareola. Pelvic exam reveals normal genitalia, a well-estrogenized vaginal vault mucosa and cervicalmucus consistent with the proliferative phase. The uterus is anteflexed and normal in sizewithout masses or tenderness.
Patient Laboratory• Results Normal Values• TSH 2.1 mIU/ml 0.5-4.0 mIU/ml• Free T4 1.1 ng/dl 0.8-1.8 ng/dl• Prolactin 60 ng/ml <20 ng/ml• FSH 6 mIU/ml 5-25 mIU/ml• LH 4 mIU/ml 5-25 mIU/ml• Basal body temperature chart shows a monophasictemperature graph.
Partner• Semen analysis revealed 2 cc of semen, 4 million permL, 30% normal forms and 20% motility.
Management• The patient’s major infertility factor is anovulation;• the most likely cause is hyperprolactinemia fromimipramine.• The prolactin level is elevated, consistent with drug-induced hyperprolactinemia.• The patient was instructed, in conjunction with hertherapist, to taper off the imipramine.• Her follow-up basal body temperature chart wasbiphasic, consistent with ovulatory cycles.•
Management cont’ The patient’s partner, however, has a semenanalysis that is consistent with oligospermia.The couple was given their options of: 1) In Vitro fertilization with ISCI; 2) artificial insemination with partner’s sperm; 3) artificial insemination with donor sperm; or 4) adoption