This document discusses infertility, including its definition, causes, evaluation, and treatment options. It begins by defining primary and secondary infertility and outlining the requirements for conception. Common causes of infertility for both men and women are then described. The document provides details on evaluating infertility, including medical history, physical exams, lab tests, and procedures like semen analysis and hysterosalpingography. Treatment options are covered, such as ovulation induction, surgery, assisted reproductive technologies like IUI, IVF, and surrogacy. The emotional impact of infertility is also addressed.

1. Infertility

2. ObjectivesDefine primary and secondary infertilityDescribe the causes of infertilityDiagnosis and management of infertility

3. Requirements for Conception Production of healthy egg and spermUnblocked tubes that allow sperm to reach the eggThe sperms ability to penetrate and fertilize the eggImplantation of the embryo into the uterusFinally a healthy pregnancy

4. InfertilityThe inability to conceive following unprotected sexual intercourse 1 year (age < 35) or 6 months (age >35)Affects 15% of reproductive couples6.1 million couples Men and women equally affected

5. Infertility - Statisticscauses are identified in 90 % of patientspregnancy results in 40 % of those30 % of couples have male AND female factorsOf 100 subfertile couples the break down is as follows:40 % male factor etiology20 % female hormonal imbalance30 % female peritoneal factor5 % ‘hostile’ cervical environment5 % unexplainedpsychological impact can be significant

6. InfertilityReproductive age for womenGenerally 15-44 years of ageFertility is approximately halved between 37th and 45th year due to alterations in ovulation20% of women have their first child after age 301/3 of couples over 35 have fertility problemsOvulation decreasesHealth of the egg declinesWith the proper treatment 85% of infertile couples can expect to have a child

7. InfertilityPrimary infertilitya couple that has never conceivedSecondary infertilityinfertility that occurs after previous pregnancy regardless of outcome

8. Causes for infertilityMaleETOHDrugsTobaccoHealth problemsRadiation/ChemotherapyAgeEnviromental factorsPesticidesLeadFemaleAge StressPoor dietAthletic trainingOver/underweightTobaccoETOHSTD’sHealth problems

9. Causes of InfertilityAnovulation (10-20%)Anatomic defects of the female genital tract (30%)Abnormal spermatogenesis (40%)Unexplained (10%-20%)

10. Evaluation of the Infertile coupleHistory and Physical examSemen analysisThyroid and prolactin evaluationDetermination of ovulationBasal body temperature recordSerum progesteroneOvarian reserve testingHysterosalpingogram

11. Abnormalities of Spermatogenesis

12. NormalSperm made in seminiferous tubulesTravel to epididymis to mature

13. Sperm exit through vas deferensSemen produced in prostate gland, seminal glands, cowpers glandsSperm only 5% of ejaculationSperm can live 5-7 daysNormal

14. Male Factor40% of the cause for infertilitySperm is constantly produced by the germinal epithelium of the testicleSperm generation time 73 daysSperm production is thermoregulated1° F less than body temperatureBoth men and women can produce anti-sperm antibodies which interfere with the penetration of the cervical mucus

15. Semen Analysis (SA)Obtained by masturbationProvides immediate informationQuantityQualityDensity of the spermMorphologyMotilityAbstain from coitus 2 to 3 days Collect all the ejaculateAnalyze within 1 hourA normal semen analysis excludes male factor 90% of the time

16. Normal Values for SAVolumeSperm ConcentrationMotilityViscosityMorphologypHWBC 2.0 ml or more

17. 20 million/ml or more

18. 50% forward progression 25% rapid progressionLiquification in 30-60 min

19. 30% or more normal forms

20. 7.2-7.8

21. Fewer than 1 million/mlCauses for Abnormal SANo spermKlinefelter’s syndromeSertoli only syndromeDuctal obstructionHypogonadotropic-hypogonadismFew spermGenetic disorderEndocrinopathiesVaricoceleExogenous (e.g., Heat) Abnormal Count

22. Continues: causes for abnormal SAAbnormal MorphologyVaricoceleStressInfection (mumps)Abnormal MotilityImmunologic factorsInfectionDefect in sperm structurePoor liquefactionVaricoceleAbnormal VolumeNo ejaculateDuctal obstructionRetrograde ejaculationEjaculatory failureHypogonadismLow VolumeObstruction of ductsAbsence of vas deferensAbsence of seminal vesiclePartial retrograde ejaculationInfection

23. Causes for male infertility42% varicocelerepair if there is a low count or decreased motility22% idiopathic14% obstruction20% other (genetic abnormalities)

24. Abnormal Semen AnalysisOligospermiaAnatomic defectsEndocrinopathiesGenetic factorsExogenous (e.g. heat)Abnormal volumeRetrograde ejaculationInfectionEjaculatory failureAzoospermiaKlinefelter’s (1 in 500)Hypogonadotropic-hypogonadismDuctal obstruction (absence of the Vas deferens)

25. Evaluation of Abnormal SARepeat semen analysis in 30 daysPhysical examinationTesticular sizeVaricoceleLaboratory testsTestosterone levelFSH (spermatogenesis- Sertoli cells)LH (testosterone- Leydig cells)Referral to urology

26. Evaluation of Ovulation

27. Female Reproductive SystemOvariesTwo organs that produce eggsSize of almond30,000-40,000 eggsEggs can live for 12-24 hours

28. MenstruationOvulation occurs 13-14 times per yearMenstrual cycles on average are Q 28 days with ovulation around day 14Luteal phasedominated by the secretion of progesteronereleased by the corpus luteumProgesterone causesThickening of the endocervical mucusIncreases the basal body temperature (0.6° F)Involution of the corpus luteum causes a fall in progesterone and the onset of menses

30. OvulationA history of regular menstruation suggests regular ovulationThe majority of ovulatory women experiencefullness of the breastsdecreased vaginal secretionsabdominal bloatingAbsence of PMS symptoms may suggest anovulation mild peripheral edema

31. slight weight gain

32. depression

33. Diagnostic studies to confirm OvulationSerum progesteroneAfter ovulation risesCan be measuredUrinary ovulation-detection kitsMeasures changes in urinary LHPredicts ovulation but does not confirm itBasal body temperatureInexpensive AccurateEndometrial biopsyExpensiveStatic information

34. Basal Body TemperatureExcellent screening tool for ovulationBiphasic shift occurs in 90% of ovulating womenTemperature drops at the time of menses rises two days after the lutenizing hormone (LH) surgeOvum released one day prior to the first riseTemperature elevation of more than 16 days suggests pregnancy

36. Serum ProgesteroneProgesterone starts rising with the LH surgedrawn between day 21-24Mid-luteal phase>10 ng/ml suggests ovulation

37. Salivary Estrogen: TCI Ovulation Tester- 92% accurate

38. Add Saliva Sample

41. Non-Ovulatory Saliva Pattern

42. High Estrogen/ Ovulatory Saliva Pattern

43. Anovulation

44. Anovulation Symptoms Evaluation*Irregular menstrual cyclesAmenorrheaHirsuitismAcneGalactorrheaIncreased vaginal secretionsFollicle stimulating hormoneLutenizing hormoneThyroid stimulating hormoneProlactinAndrostenedioneTotal testosteroneOrder the appropriate tests based on the clinical indicationsAnatomic Disorders of the Female Genital Tract

45. Sperm transport, Fertilization, & ImplantationThe female genital tract is not just a conduitfacilitates sperm transportcervical mucus traps the coagulated ejaculatethe fallopian tube picks up the eggFertilization must occur in the proximal portion of the tubethe fertilized oocyte cleaves and forms a zygote enters the endometrial cavity at 3 to 5 daysImplants into the secretory endometrium for growth and development

46. Fertilization

47. Implantation

49. Acquired DisordersAcute salpingitisAlters the functional integrity of the fallopian tubeN. gonorrhea and C. trachomatisIntrauterine scarring Can be caused by curettageEndometriosis, scarring from surgery, tumors of the uterus and ovaryFibroids, endometriomasTrauma

50. Congenital Anatomic Abnormalities

51. HysterosalpingogramAn X-ray that evaluates the internal female genital tractarchitecture and integrity of the systemPerformed between the 7th and 11th day of the cycleDiagnostic accuracy of 70%

52. HysterosalpingogramThe endometrial cavitySmoothSymmetricalFallopian tubesProximal 2/3 slenderAmpulla is dilated Dye should spill promptly

53. HSG: Tubal Infertility

54. Unexplained infertility10% of infertile couples will have a completely normal workupPregnancy rates in unexplained infertilityno treatment 1.3-4.1%clomid and intrauterine insemination 8.3%gonadotropins and intrauterine insemination 17.1%

55. Treatment of the Infertile Couple

56. Inadequate SpermatogenesisLaparoscopy surgeryEliminate alterations of thermoregulationClomiphene citrate is occasionally used for induction of spermatogenesis20% successIn vitro fertilization may facilitate fertilizationArtificial insemination with donor sperm is often successful

57. adhesiolysis

58. Tubalcystectomy

59. AnovulationRestore ovulationAdminister ovulation inducing agents Clomiphene citrateAntiestrogenCombines and blocks estrogen receptors at the hypothalamus and pituitary causing a negative feedbackIncreases FSH production stimulates the ovary to make follicles

60. ClomidGiven for 5 days in the early part of the cycle

61. Maximum dose is usually 150mg50mg dose - 50% ovulate100mg -25% more ovulate150mg lower numbers of ovulationNo changes in birth defects If no pregnancy in 6 months refer for advanced therapies7% risk of twins 0.3% triplets

62. Superovulatory MedicationsIf no response with clomid then gonadotropins- FSH (e.g. pergonal) can be administered intramuscularlyThis is usually given under the guidance of someone who specializes in infertility This therapy is expensive and patients need to be followed closelyAdverse effectsHyperstimulation of the ovariesMultiple gestationFetal wastage

63. Anatomic AbnormalitiesSurgical treatmentsLysis of adhesionsSeptoplastyTuboplastyMyomectomySurgery may be performed laparoscopicallyhysteroscopicallyIf the fallopian tubes are beyond repair one must consider in vitro fertilization

64. Assisted Reproductive Technologies (ART)Explosion of ART has occurred in the last decade.Theses technologies help provide infertile couples with tools to bypass the normal mechanisms of gamete transportation.Probability of pregnancy in healthy couples is 30-40% per cycle, live birth rate 25%.this varies depending on age

65. Intrauterine insemination (artificial insemination)definition: sperm introduced into female reproductive tract by means other than coitussperm can come from donor / sperm bank or from husband usually, several ejaculations are pooled often used when male has low sperm count or antibodies present in ejaculate

66. Artificial InseminationSperm donation or sperm aspiration

67. In Vitro Fertilization“test - tube babies”1st performed in 1978 (Louise Joy Brown)often performed on infertile women with tubal blockageSperm and egg combined in the lab, fertilization Zygote placed back into the uterusVery expensive and not always successfulOldest woman in the US to give birth using in vitro was 62 years old and an Romanian woman gave birth at 66

68. In Vitro Fertilization

69. IVF ProtocolGnRH agonist (e.g. Lupron) for 7 daysFSH agonist (follistim, Gonal-F, Repronex) until follicles measure 17-20 mm in diameterhCG given to induce egg maturationEgg retrieval (transvaginally) 34-35 h later

70. IVF protocolsperm and ova added to dish; fertilization occurs 12-14hrs.eggs transferred to new dish and cell division occursembryos squirted into uterus at 4- to 32-cell stage (optimal: blastocyst stage)

71. IVF Protocol, cont’d.3 to 5 embryos are injected to increase chances of pregnancywoman given progestagen to prevent miscarriage

72. IVF Protocol, cont’d.new variations / improvements:Intracytoplasmic sperm injection (ICSI)use of frozen embryos27,000 attempts made per year; 18.6% successful (success rates are increasing)http://www.advancedfertility.com/sampleivfcalendar.htm

73. GIFT and ZIFTGIFT = gamete intrafallopian transferuseful for tubal blockageova are collected and inserted into oviducts below point of blockagehusband’s sperm are placed in oviduct

74. GIFT and ZIFTwoman is treated with hormones to prevent miscarriage4200 attempts made / year; 28% successfulZIFT = zygote intrafallopian transferZIFT is like IVF, only zygotes (1 cell stage) are inserted below blockage in oviduct (24% success rate)