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How to approach a case of infertility for undergraduate


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Undergraduate course lectures in Gynecology prepared by dr manal behery,Faculty of medicine,Zagazig University

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How to approach a case of infertility for undergraduate

  1. 1. How to approacha case of infertilityDr Manal BeheryAssistant professorZagazig University2013
  2. 2. Definitions• Infertility = Inability of a couple practicingfrequent intercourse and not usingcontraception to conceive a childUnder 35 year :No conception after oneyear of unprotected intercourseOver 35 year :No conception after 6months of unprotected intercourse
  3. 3. Types of InfertilityPrimary infertility− Couple Has Never ProducedA pregnancySecondary infertility− Woman has previously been pregnant,regardless of the outcome, and now isunable to conceive
  4. 4. Causes of infertility• Tubal pathology 35%• Male factor 35%• Ovulatory dysfunction 15%• Unexplained 10%• Cervical/other 5%
  5. 5. Causes oftubal/ Pelvic pathology• Congenital anomalies• Tubal occlusion• May occur as sequelae of– PID– endometriosis– abdominal/pelvic surgery– peritonitis
  6. 6. Causes oftubal/ Pelvic pathology• Congenital anomalies• Tubal occlusion• May occur as sequelae of– PID– endometriosis– abdominal/pelvic surgery– peritonitis
  7. 7. Causes of Ovulatory Dysfunction– polycystic ovary syndrome– hypothalamic anovulation– hyperprolactinemia– premature and age-related ovarian failure– luteal phase defect (theoretical)
  8. 8. 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
  10. 10. 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
  11. 11. CouncellingEvaluating both partners isessentialCouple should be informed about:− different causes of infertility− tests and procedures required to makea diagnosis− various therapeutic possibilitiesCouple’s interview is conducted togetheras well as separatelyto obtain confidential informationRichardLord
  12. 12. Possible causes of infertility
  13. 13. Start with History. . .General and Sexual HistoryObstetric and Gynecological HistoryWhat Clues Can You Find on History?
  14. 14. 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
  15. 15. Obstetric and Gynecological HistoryReproductive historyGynecological historyAge at menarcheMenstrual periods: duration and intervalsPrevious contraceptive usePrevious testing and treatment for infertility
  16. 16. 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
  17. 17. 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
  18. 18. Semen analysis
  19. 19. 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
  20. 20. 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)
  21. 21. IUI VS ICSI
  22. 22. 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
  23. 23. 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.
  24. 24. Ovulation
  25. 25. Basal body temprature
  26. 26. Ovulation Predictor Kits
  27. 27. Salivary Estrogen: TCIOvulation Tester- 92% accurate
  28. 28. Add Saliva Sample
  29. 29. Non-Ovulatory Saliva Pattern
  30. 30. High Estrogen/ OvulatorySaliva Pattern
  31. 31. Approach to Ovulation Disorders• Evaluate- HypothyroidismProlactin DisorderHyperandrogenism- PCOSWeight loss/ weight gain• Induce OvulationClomid (clomiphene citrate)
  32. 32. 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
  33. 33. Hysterosalpingogram
  34. 34. HSG: Unilateral Blocked Tube
  35. 35. HSG: bilateral tubal block
  36. 36. HSG: Hydrosalpinx
  37. 37. Diagram shows the appropriate steps in an imaging evaluation for fallopian tubeabnormalities.©2009 by
  38. 38. Other TestsLaparoscopy− to evaluate for pelvic disease,− such as endometriosis− check patency of fallopian tubesHysteroscopy− to evaluate condition of uterine− cavity (polyps, fibroids)
  39. 39. Sorry, no data for...• Post coital test• endometrial biopsy• immune testing for antispermantibodies• routine cervical cultures
  40. 40. Traditional Infertility Evaluation1) Semen Analysis2) Hysterosalpingogram (HSG)3) Documentation of Ovulation4) Post-coital Exam5) Diagnostic Laparoscopy
  41. 41. Current Infertility Evalution1) Semen Analysis2) Hysterosalpingogram (HSG)3) Documentation of Ovulation4) Ovarian Reserve Testing
  42. 42. 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
  43. 43. Treatment Possibilities:Female InfertilityOvulation disordersOvulation disorders Ovulation-inducing drugsOvulation-inducing drugsHyperprolactinemiaHyperprolactinemia Prolactin-suppressingdrugsProlactin-suppressingdrugsUterine and tubalabnormalitiesUterine and tubalabnormalities Surgical proceduresSurgical proceduresCervical mucus problemsCervical mucus problems Intrauterine inseminationIntrauterine inseminationEndometriosisEndometriosis Suppressing hormonesor surgical procedureSuppressing hormonesor surgical procedure
  44. 44. 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?
  45. 45. 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?
  46. 46. 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?
  47. 47. 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?
  48. 48. 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?
  49. 49. 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?
  50. 50. 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?
  51. 51. 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.
  52. 52. ➤ 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.
  53. 53. • 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
  54. 54. • 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
  55. 55. • 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
  56. 56. • 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
  57. 57. Case 4A 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.
  58. 58. 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
  59. 59. 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
  60. 60. 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.
  61. 61. 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.
  62. 62. 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.
  63. 63. Partner• Semen analysis revealed 2 cc of semen, 4 million permL, 30% normal forms and 20% motility.
  64. 64. 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.•
  65. 65. 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
  66. 66. thank you