Follow up to the infertility management in a primary care setting

1. MANAGEMENT OF THE
INFERTILE COUPLE IN A
PRIMARY CARE SETTING
PART TWO
MILIE NWOYE MD
SHAPE ARMY MEDICAL CLINIC
MARCH 27TH 2014
MILIE.NWOYE@GMAIL.COM

2. INFERTILITY MANAGEMENT
• Timed intercourse
• Ovulation induction
• Intrauterine insemination (+/- ovulation induction)
• In-vitro fertilization (IVF)
• Intracytoplasmic sperm injection (ICSI)

3. TIMED INTERCOURSE
• DEFINITION: SEXUAL INTERCOURSE AT THE FERTILE PERIOD OF THE
MENSTRUAL CYCLE, WITHOUT OVULATION INDUCTION
• INDICATION: UNEXPLAINED INFERTILITY- INFERTILE COUPLE (NO CONCEPTION
AFTER 1 YEAR OF TRYING), WITH NORMAL FERTILITY TESTS, <35
• PREGNANCY RATE: 3.4% PER CYCLE*
* Fertil steril 1991 jul 56 (1)

4. TIMED INTERCOURSE- PROCESS
• STEP 1: RULE OUT PREGNANCY AND CONFIRM EARLY FOLLICULAR PHASE
• HCG TESTS (URINE OR BLOOD)
• FSH AND ESTRADIOL BLOOD TESTS (IDEALLY <10 IU/L AND <80PG/ML RESPECTIVELY) OR OBTAIN
GOOD MENSTRUAL HISTORY
• STEP 2: DETERMINE LH RISE
• LH KIT TESTS
• OR BLOOD LH TESTING
• STEP 3: SEXUAL INTERCOURSE THE EVENING OF LH RISE AND THE NEXT EVENING
• STEP 4: PREGNANCY TEST
• 10 DAYS AFTER SEXUAL INTERCOURSE IS NO PERIOD

5. OVULATION INDUCTION
• DEFINITION: USING MEDICATIONS TO INDUCE OVULATION TO INITIATE OVULATION OR TO INCREASE THE NUMBER
OF OVULATORY FOLLICLES
• INDICATION:
• UNEXPLAINED INFERTILITY
• OVULATION DYSFUNCTION
• LUTEAL PHASE DEFECT
• FAILED TIMED INTERCOURSE
• FEMALE > 35 UNDERGOING HER FIRST TREATMENT AND NORMAL FERTILITY TESTS
• CONTRAINDICATION:
• SEVERE PCOS
• ALLERGY OR SEVERE REACTION TO OVULATION INDUCTION AGENT
• PREGNANCY RATES:
• CC+TI 2.7%/CYCLE*
• FSH+TI 8.2%/CYCLE*
*Zollner et al; J Reprod Med , 2013

6. OVULATION INDUCTION AGENTS
• CLOMIPHENE CITRATE (50-150MG):
• INCREASE IN ENDOGENOUS FSH BY ER ANTAGONISM AND REMOVING CENTRAL
NEGATIVE FEEDBACK*
• 8% CHANCE OF MULTIPLES**
• LETROZOLE
• INCREASES ENDOGENOUS FSH BY DECREASING PERIPHERAL ESTROGEN*
• FSH
• INCREASE IN EXOGENOUS FSH
• 20% CHANCE OF MULTIPLES***
*Speroff
** ASRM practice bulletin
*** Check et al; J Perinat Med 1993

7. CLOMIPHENE CITRATE- PROCESS
• STEP 1: RULE OUT PREGNANCY AND CONFIRM EARLY FOLLICULAR PHASE
• STEP 2: START CC AT LOWEST DOSE ON DAY 2 OF CYCLE AND CONTINUE FOR 5 DAYS
• STEP 3: CHECK FOLLICULAR RESPONSE
• STEP 4: LH SURGE (SPONTANEOUS OR AFTER HCG TRIGGER)
• STEP 5: SEXUAL INTERCOURSE THE EVENING OF LH SURGE AND THE NEXT EVENING OR 36
HOURS AFTER HCG TRIGGER OR IUI IN 24 HOURS
• STEP 6: PREGNANCY TEST
• IF NO PERIOD AFTER 10 DAYS

8. FSH INDUCTION- PROCESS
• STEP 1: RULE OUT PREGNANCY AND CONFIRM EARLY FOLLICULAR PHASE
• STEP 2: START FSH AT LOWEST DOSE ON DAY 2 OF CYCLE AND CONTINUE UNTIL ADEQUATE
FOLLICULAR RESPONSE
• STEP 3: ADMINISTER HCG FOR OVULATION TRIGGER
• STEP 4: SEXUAL INTERCOURSE THE EVENING OF LH SURGE AND THE NEXT EVENING OR 36
HOURS AFTER HCG TRIGGER OR IUI IN 24 HOURS
• STEP 5: PREGNANCY TEST
• IF NO PERIOD AFTER 10 DAYS

9. INTRAUTERINE INSEMINATION (IUI)
• DEFINITION: PLACEMENT OF PREPARED SPERMS IN THE UTERINE CAVITY AT TIME OF OVULATION
• INDICATION:
• UNEXPLAINED INFERTILITY
• MILD MALE FACTOR
• CERVICAL FACTOR
• FAILED TIMED INTERCOURSE
• UNAVAILABLE MALE
• CONTRAINDICATION
• CERVICAL STENOSIS
• SEVERE MALE FACTOR
• PREGNANCY RATE
• CC+IUI 10.3%/CYCLE*
• FSH+IUI 15.5%/CYCLE*
*Zollner et al; J Reprod Med , 2013

10. INTRAUTERINE INSEMINATION- PROCESS
• WASHED SPERM INTRODUCED INTO
UTERINE CAVITY WITH A CATHETER
36 HOURS AFTER HCG TRIGGER
• CHECK PREGNANCY TEST 10 DAYS
AFTER IUI IF NO PERIOD

11. IN-VITRO FERTILIZATION (IVF)
• DEFINITION: A PROCESS OF CONTROLLED OVARIAN STIMULATION, OVULATION TRIGGER,
OOCYTE ASPIRATION, SPERM PREPARATION, IN-VITRO FERTILIZATION, EMBRYO TRANSFER
• INDICATION:
• UNEXPLAINED INFERTILITY
• TUBAL FACTOR INFERTILITY
• FAILED INTRAUTERINE INSEMINATION
• OTHER EG. NEED FOR PRE-GENETIC DIAGNOSIS (PGD)
• CONTRAINDICATION:
• SEVERE PCOS
• ALLERGY OR SEVERE REACTION TO OVULATION INDUCTION AGENT
• PREGNANCY RATES:
• 35.5% PER EMBRYO TRANSFER (EUROPE 2010)*
*www.eshre.eu

12. OVARIAN STIMULATION PROTOCOLS
GNRH AGONIST GNRH ANTAGONIST

13. INTRACYTOPLASMIC SPERM INDUCTION
(ICSI)
• DEFINITION: SIMILAR TO IVF EXCEPT THAT THE SPERM IS DIRECTLY INJECTED INTO
THE OOCYTE
• INDICATION:
• SAME AS IVF
• FAILED IVF
• TESTICULAR SPERM
• CONTRAINDICATION:
• SEVERE PCOS
• ALLERGY OR SEVERE REACTION TO AGENTS
• PREGNANCY RATES:
• 32.1% PER EMBRYO TRANSFER- EUROPE 2010*
*www.eshre.eu

14. IN-VITRO MATURATION
• IN-VITRO MATURATION (IVM): LIGHT OVARIAN STIMULATION, ASPIRATION OF
IMMATURE OOCYTE, AND OOCYTE MATURATION IN-VITRO