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Obg01 Infertility


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Obg01 Infertility

  1. 1. Infertility Edward A. Rose, M.D., M.S.A. North Oakland Medical Centers Pontiac, MI
  2. 2. Description of Case <ul><li>29 y o G 0 concerned about not getting pregnant </li></ul><ul><li>Unprotected sex X 1 ½ years </li></ul><ul><li>PMHx negative </li></ul><ul><li>No other complaints </li></ul>
  3. 3. Further History? <ul><li>Frequency of intercourse, use of lubricants (e.g., K-Y gel) that could be spermicidal, use of vaginal douches after intercourse, or presence of any sexual dysfunction such as anorgasmia or dyspareunia </li></ul><ul><li>Menstrual history, frequency, and patterns since menarche; weight changes, hirsutism, frontal balding, acne </li></ul>
  4. 4. History (continued) <ul><li>Male partners: previous spermogram results, history of impotence, premature ejaculation, change in libido, history of testicular trauma, previous relationships, history of any previous pregnancy, existence of offspring from previous partners </li></ul><ul><li>History of sexually transmitted diseases; surgical contraception (e.g. vasectomy, tubal ligation); lifestyle; consumption of alcohol, tobacco, and recreational drugs; occupation; physical activities </li></ul>
  5. 5. History (continued) <ul><li>Either partner currently under medical treatment, the reason, and whether they have a history of allergies </li></ul><ul><li>Complete review of systems may be helpful to identify any endocrinological or immunological problem </li></ul>
  6. 6. Your Patient <ul><li>History of weight gain, acne, facial hair, irregular menses </li></ul><ul><li>ROS + for an elevated glucose and elevated BP a few months ago </li></ul><ul><li>Exam shows android body habitus, weight 205#, acne on face and back, some facial hair </li></ul><ul><li>Diagnosis, first years? </li></ul>
  7. 7. Definition <ul><li>Inability to conceive after one year of intercourse without contraception </li></ul><ul><li>Counsel patience! </li></ul>
  8. 8. Causes of Infertility
  9. 9. Male Factor <ul><li>Male partner should be evaluated simultaneously with female partner </li></ul><ul><li>Causes of male infertility: </li></ul><ul><ul><li>Reversible conditions (varicocele, obstructive azoospermia) </li></ul></ul><ul><ul><li>Not reversible, but viable sperm available (ejaculatory dysfunction, inoperative obstructive azoospermia) </li></ul></ul><ul><ul><li>Not reversible, no viable sperm (hypogonadism) </li></ul></ul><ul><ul><li>Genetic abnormalities </li></ul></ul><ul><ul><li>Testicular or pituitary cancer </li></ul></ul>
  10. 10. Ovulatory Dysfunction <ul><li>Causes 18% of infertility </li></ul><ul><li>Diagnosed by </li></ul><ul><ul><li>Menstrual irregularities </li></ul></ul><ul><ul><li>Basal body temperatures </li></ul></ul><ul><ul><li>Ovulation prediction kits </li></ul></ul><ul><ul><li>Serum progesterone levels (18-24 days after onset of menses; level > 3 ng/ml is diagnostic of ovulation) </li></ul></ul>
  11. 11. BBT Kit
  12. 12. Completed Sample BBT Chart
  13. 13. Evaluation of Ovarian Reserve <ul><li>Assessed in women > 35 or younger women with risk factors for premature ovarian failure </li></ul><ul><li>Day 3 FSH and CCCT (clomiphene citrate challenge test) </li></ul><ul><ul><li>Administer 100 mg clomiphene on cycle days 5-9 </li></ul></ul><ul><ul><li>Measure FSH on days 3 and 10; maybe estradiol on day 3 (conflicting data) </li></ul></ul><ul><ul><li>Normal test not useful, but abnormal test virtually assures that pregnancy will not occur even with treatment </li></ul></ul><ul><li>Ultrasound may also be used </li></ul>
  14. 14. Causes of Ovulatory Dysfunction <ul><li>Polycystic ovary syndrome </li></ul><ul><li>Hypothalamic anovulation </li></ul><ul><li>Hyperprolactinemia </li></ul><ul><li>Premature and age-related ovarian failure </li></ul><ul><li>Luteal phase defect </li></ul><ul><ul><li>Abnormalities of corpus luteum resulting in inadequate production of progesterone </li></ul></ul><ul><ul><li>Based on finding of 2 consecutive endometrial biopsy specimens showing histology > 2 days out-of-phase with actual biopsy date </li></ul></ul><ul><ul><li>Relevance is controversial </li></ul></ul>
  15. 15. Polycystic Ovarian Syndrome <ul><li>Oligomenorrhea/amenorrhea and hyperandrogenism </li></ul><ul><li>Prevalence: 5% </li></ul><ul><li>Among women with ovulatory dysfunction, 70% have PCOS </li></ul><ul><li>Clinical evidence: hirsutism, acne, obesity </li></ul><ul><li>Lab evidence: elevated testosterone, elevated DHEA-S </li></ul><ul><li>“ Polycystic ovaries” supportive, not diagnostic </li></ul>
  16. 16. PCOS Treatment Approach <ul><li>Weight loss if BMI > 30 </li></ul><ul><li>Clomiphene to induce ovulation </li></ul><ul><li>If DHEA-S > 2, clomiphene + glucocorticoid (dexamethasone) </li></ul><ul><li>If clomiphene alone unsuccessful, try metformin + clomiphene </li></ul>
  17. 17. Hypothalamic Anovulation <ul><li>Low levels of GnRH, low or normal levels of FSH/LH, low levels of endogenous estrogen </li></ul><ul><li>Associated factors: low BMI (< 20), high-intensity exercise, extreme diets, stress </li></ul><ul><li>Treatment: lifestyle modification </li></ul>
  18. 18. Hyperprolactinemia <ul><li>Causes: pituitary adenoma, psych meds </li></ul><ul><li>Test for pregnancy, thyroid disease </li></ul><ul><li>Imaging: MRI for macro vs. microadenoma </li></ul><ul><li>Treatment: Bromocriptine (dopamine agonist) </li></ul><ul><li>After treatment, 80% of women will ovulate, 80% will get pregnant </li></ul><ul><li>Discontinue treatment once pregnancy established </li></ul>
  19. 19. What Can I Do?
  20. 20. History and Physical - Female <ul><li>History </li></ul><ul><ul><li>Menarche, puberty </li></ul></ul><ul><ul><li>Menstrual history </li></ul></ul><ul><ul><li>Pregnancies, abortions, birth control </li></ul></ul><ul><ul><li>Dyspareunia, dysmenorrhea </li></ul></ul><ul><ul><li>STDs, abdominal surgery, galactorrhea </li></ul></ul><ul><ul><li>Weight loss/gain </li></ul></ul><ul><ul><li>Stress, exercise, drugs, alcohol, psychological </li></ul></ul><ul><li>Physical </li></ul><ul><ul><li>Weight/BMI </li></ul></ul><ul><ul><li>Thyroid </li></ul></ul><ul><ul><li>Skin (striae, acanthosis nigricans) </li></ul></ul><ul><ul><li>Pelvic (vaginal mucosa, masses, pain) </li></ul></ul><ul><ul><li>Rectal (uterosacral nodularity) </li></ul></ul>
  21. 21. History and Physical - Male <ul><li>History </li></ul><ul><ul><li>Prior fertility </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>History of diabetes, mumps, undescended testes </li></ul></ul><ul><ul><li>Genital surgery, trauma, infections </li></ul></ul><ul><ul><li>ED </li></ul></ul><ul><ul><li>Drug/alcohol use, stress </li></ul></ul><ul><ul><li>Underwear, hot tubs, frequent coitus </li></ul></ul><ul><li>Physical </li></ul><ul><ul><li>Habitus, gynecomastia </li></ul></ul><ul><ul><li>Sexual development </li></ul></ul><ul><ul><li>Testicular volume (5x3 cm) </li></ul></ul><ul><ul><li>Epididymis, vas, prostate by palpation </li></ul></ul><ul><ul><li>Check for varicocele </li></ul></ul>
  22. 22. How Long To Wait Before Work-up <ul><li>For young patients, wait a year </li></ul><ul><li>Don’t wait a year if: </li></ul><ul><ul><li>Irregular menses; intermenstrual bleeding </li></ul></ul><ul><ul><li>History of PID </li></ul></ul><ul><ul><li>History of appendicitis with rupture </li></ul></ul><ul><ul><li>History of abdominal surgery </li></ul></ul><ul><ul><li>Dyspareunia </li></ul></ul><ul><ul><li>Age > 35 </li></ul></ul><ul><ul><li>Male factors </li></ul></ul>
  23. 23. On The First Visit <ul><li>Semen analysis </li></ul><ul><li>Confirm ovulation </li></ul><ul><ul><li>Basal body temperature charting </li></ul></ul><ul><ul><li>Ovulation predictor kits (detect LH surge) </li></ul></ul><ul><ul><li>Consider serum progesterone on day 21 </li></ul></ul><ul><li>Labs: </li></ul><ul><ul><li>TSH and prolactin </li></ul></ul><ul><ul><li>DHEA-S if concern for PCOS </li></ul></ul><ul><ul><li>FSH and estradiol on cycle day 3 and 10 if >35y </li></ul></ul><ul><ul><li>Cervical cultures prn </li></ul></ul>
  24. 24. Three Months Later <ul><li>Hysterosalpingogram </li></ul><ul><ul><li>Evaluates tubal patency and uterine cavity shape </li></ul></ul><ul><ul><li>Noninvasive but involves a tenaculum </li></ul></ul><ul><ul><li>Not a painless test </li></ul></ul><ul><ul><li>Performed by radiology with gynecology supervision </li></ul></ul><ul><ul><li>Diagnostic and therapeutic </li></ul></ul>
  25. 25. Hysterosalpingogram
  26. 26. Limited Clinical Utility <ul><li>Postcoital test </li></ul><ul><ul><li>Limited diagnostic potential, poor predictive value </li></ul></ul><ul><li>Endometrial biopsy (luteal phase defect) </li></ul><ul><li>BBTs </li></ul><ul><ul><li>Very inexpensive but interpretation difficult </li></ul></ul><ul><ul><li>Temperature changes too late to be useful for timing intercourse </li></ul></ul><ul><li>Zona-free hamster oocyte penetration test </li></ul><ul><ul><li>Not sure if hamster oocytes predict human oocytes </li></ul></ul><ul><li>Immune testing for antiphospholipid, antisperm, antinuclear, antithyroid antibodies </li></ul><ul><li>Routine cervical cultures </li></ul><ul><ul><li>Mycoplasma hominis or Ureaplasma urealyticum </li></ul></ul><ul><li>Karyotype </li></ul>
  27. 27. Clomiphene Citrate <ul><li>Effective for anovulatory patients </li></ul><ul><ul><li>Also used in unexplained fertility, but no data to support </li></ul></ul><ul><ul><li>Most effective for women with normal FSH and estrogen, least effective in hypothalamic amenorrhea or elevated FSH </li></ul></ul><ul><li>Induces ovulation by unknown mechanism </li></ul><ul><li>Most pregnancies occur in first 3 cycles </li></ul><ul><li>80% will ovulate, 40% will become pregnant in 3 cycles </li></ul>
  28. 28. Clomiphene - Complications <ul><li>7% twin gestations, 0.3% triplet gestations </li></ul><ul><li>Miscarriage rate = 15% </li></ul><ul><li>Birth defect rate unchanged from controls </li></ul><ul><li>Side effects: hot flashes, adnexal tenderness, nausea, headache, blurry vision </li></ul><ul><li>Contraindications: pregnancy, ovarian cysts </li></ul>
  29. 29. Clomiphene - Administration <ul><li>50 mg daily, cycle day 3 through 7 </li></ul><ul><ul><li>Induce bleeding first with progesterone if amenorrheic </li></ul></ul><ul><li>Intercourse QOD cycle days 12 - 17 </li></ul><ul><li>Track ovulation with BBT or ovulation detection kits </li></ul><ul><li>Increase dose to 100 mg daily, then 150, if no ovulation occurs </li></ul>
  30. 30. Thank You!