Infertility

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infertility laura detti

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  • Fecundability: Probability that ONE CYCLE results in pregnancy = 20-25% in normal couples
  • Infertility

    1. 1. Basic infertility workup Laura Detti, MD Reproductive Endocrinology and Infertility University of Tennessee Health Science Center October 1, 2009
    2. 2. Normal reproductive efficiency <ul><li>Time required for conception in fertile couples </li></ul><ul><li> Time % pregnant </li></ul><ul><li>3 months 57% </li></ul><ul><li>6 months 72% </li></ul><ul><li>1 year 85% </li></ul><ul><li>2 years 93% </li></ul>
    3. 3. Physiology of reproductive aging in women <ul><li>Variation of oocyte number during a woman’s life </li></ul><ul><li>Period Number </li></ul><ul><li>16-20 weeks fetus 6-7 million </li></ul><ul><li>Birth 1-2 million </li></ul><ul><li>Puberty 300-500,000 </li></ul><ul><li>37-38 years 25,000 </li></ul><ul><li>Menopause 1,000 </li></ul>
    4. 4. Definition <ul><li>One year of unprotected intercourse without conception </li></ul><ul><li>After 35 yrs of age: </li></ul><ul><li>Six months of unprotected intercourse without conception </li></ul><ul><li>Affects 10-15% of couples in the US </li></ul>
    5. 5. Causes of infertility <ul><li>Cervical </li></ul><ul><li>Uterine/endometrial </li></ul><ul><li>Tubal </li></ul><ul><li>(30-40%) </li></ul><ul><li>Peritoneal </li></ul><ul><li>Ovulatory (15%) </li></ul><ul><li>Male Factor (40%) </li></ul><ul><li>Combined M-F (20%) </li></ul>
    6. 6. Human reproductive process <ul><li>Sperm has to ascend through Cx, Ut, Tubes and has to have the capacity to fertilize the oocyte (male factor) </li></ul><ul><li>Cx must filter and nurture sperm into Ut and Tubes (cervical factor) </li></ul><ul><li>Ovulation of a mature oocyte must occur (ovarian factor) </li></ul><ul><li>Tubes must capture ovulated oocyte and transport sperm and embryo (tubal/peritoneal factor) </li></ul><ul><li>Ut must be receptive to embryo implantation and support pregnancy (uterine factor) </li></ul>
    7. 7. Cervical factor <ul><li>Anatomical changes (DES exposure) </li></ul><ul><li>Infections (TB) </li></ul><ul><li>Changes in mucus characteristics </li></ul>
    8. 8. Evaluation of cervical factor <ul><li>Cultures </li></ul><ul><li>Post-coital test </li></ul>
    9. 9. Uterine/endometrial factor <ul><li>• Anatomical changes (congenital malformations, fibroids, adhesions) </li></ul><ul><li>• Functional abnormalities (endometritis, </li></ul><ul><li>receptivity) </li></ul>
    10. 10. Evaluation of Uterine/endometrial factor <ul><li>TV Ultrasound and Sonohysterography </li></ul><ul><li>Hysterosalpingography </li></ul><ul><li>Hysteroscopy </li></ul><ul><li>Endometrial biopsy </li></ul>
    11. 11. Tubal/peritoneal factor <ul><li>• Anatomical changes (congenital malformations, BTL, adhesions, endometriosis) </li></ul>
    12. 12. Evaluation of tubal/peritoneal factor <ul><li>Hysterosalpingography </li></ul><ul><li>Laparoscopy with chromopertubation </li></ul><ul><li>Sonohysterography </li></ul>
    13. 13. Ovarian factor <ul><li>Ovulatory dysfunction: </li></ul><ul><li>• Oligo/Anovulation </li></ul><ul><li>• Luteal phase deficiency </li></ul>
    14. 14. Evaluation of ovulatory dysfunction <ul><li>Menstrual history </li></ul><ul><li>Basal body temperature </li></ul><ul><li>Serum progesterone </li></ul><ul><li>Urinary LH excretion (ov. predictor kits) </li></ul><ul><li>Basal FSH/Clomiphene challenge test </li></ul><ul><li>Oligo-amenorrhea testing </li></ul>
    15. 15. Male Factor <ul><li>Medical History </li></ul><ul><li>Semen analysis: </li></ul><ul><li>Volume 1.5-5.0 ml </li></ul><ul><li>Concentration > 20 Mil/ml </li></ul><ul><li>Motility > 40% </li></ul><ul><li>Morphology > 14% </li></ul><ul><li>pH > 7.2 </li></ul><ul><li>Round cells < 1 Mil/ml </li></ul>
    16. 16. Male Factor <ul><li>Low volume and other parameters: </li></ul><ul><li>Retrograde ejaculation </li></ul><ul><li>Duct obstruction </li></ul><ul><li>Hypogonadism </li></ul><ul><li>CBAVD </li></ul><ul><li>Evaluation of male factor infertility: </li></ul><ul><ul><li>FSH, LH, PRL, Testosterone </li></ul></ul><ul><ul><li>Karyotype </li></ul></ul><ul><ul><li>Y chromosome microdeletions </li></ul></ul>
    17. 17. Male Factor <ul><li>Low volume and other parameters: </li></ul><ul><li>Retrograde ejaculation </li></ul><ul><li>Duct obstruction </li></ul><ul><li>Hypogonadism </li></ul><ul><li>CBAVD </li></ul><ul><li>Treatment of male factor infertility: </li></ul><ul><ul><li>Endocrine treatment </li></ul></ul><ul><ul><li>IUI, TDI </li></ul></ul><ul><ul><li>ART </li></ul></ul>
    18. 18. Treatment of infertility <ul><li>Correction of anatomical defects </li></ul><ul><li>Rx of infections </li></ul><ul><li>Restoration of a regular ovulatory pattern </li></ul><ul><li>Ovulation induction: </li></ul><ul><li>Clomiphene Citrate, Aromatase Inhibitors, Gonadotropins </li></ul>
    19. 19. Assisted Reproduction Techniques <ul><li>IUI = intra-uterine sperm injection </li></ul><ul><li>IVF-ET = in vitro fertilization and embryo transfer </li></ul><ul><li>ICSI = intra-cytoplasmic sperm injection </li></ul>
    20. 20. ART overview <ul><li>Preliminary Testing </li></ul><ul><li>Multiple Follicular Recruitment </li></ul><ul><li>Oocyte Retrieval </li></ul><ul><li>Oocyte Identification, Grading and Preparation for Insemination or ICSI </li></ul><ul><li>Sperm Preparation </li></ul><ul><li>Insemination or ICSI </li></ul><ul><li>Embryo Culture </li></ul><ul><li>Embryo Transfer or Cryopreservation </li></ul><ul><li>Luteal Support </li></ul><ul><li>Early Pregnancy Support </li></ul>
    21. 21. Multiple Follicular Recruitment
    22. 22. Multiple Follicular Recruitment
    23. 24. <ul><li>IVF-ET / ICSI </li></ul>
    24. 25. Micromanipulation in ART ● Intracytoplasmic Sperm Injection ● Blastomere Biopsy for Preimplantation Genetic Diagnosis ● Assisted Hatching
    25. 26. Embryo Transfer, Luteal Support and Pregnancy Support <ul><li>Embryo transfer 3 – 6 days after oocyte retrieval (2 – 5 days after fertilization) </li></ul><ul><li>Luteal support </li></ul><ul><ul><li>hCG </li></ul></ul><ul><ul><li>Progesterone </li></ul></ul><ul><li>Pregnancy diagnosis by serially rising hCG levels starting 12 days after transfer </li></ul><ul><li>Continue supplemental progesterone until viability diagnosed and placental progesterone production established </li></ul>

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