Downloaded 50 times
Uploaded byMilie Nwoye
Management of the Infertile Couple in a Primary Care Setting. Part I
The document outlines the management of infertile couples in primary care, detailing gynecologic cancer screening, pre-conception counseling, and infertility evaluations. It includes guidelines on cervical, breast, endometrial, and ovarian cancer screening as well as definitions and causes of infertility, and emphasizes the need for various assessments and potential treatments. Additionally, it highlights the importance of optimally managing medical conditions and lifestyle factors in pre-conception care.
More Related Content
Similar to Management of the Infertile Couple in a Primary Care Setting. Part I
Management of the Infertile Couple in a Primary Care Setting. Part I
- 1. MANAGEMENT OF THE INFERTILECOUPLE IN A PRIMARY CARE SETTING PART ONE MILIE NWOYE MD SHAPE ARMY MEDICAL CLINIC FEBRUARY 20TH 2014
- 2. OUTLINE • GENERAL GYNECOLOGY •Gynecologic cancer screening • Pre-conception counselling • Tests for ovarian reserve • THE INFERTILE COUPLE • Definition • Evaluating the infertile couple • Managing the infertile couple (PART 1)
- 3. CERVICAL CANCER SCREENING •Screening starts at age 21 regardless of sex initiation • Ages 21-29: Pap test only every 3 years • Ages 30-65: Pap test every 3 years OR Pap and high risk HPV testing every 5 years • Women without a cervix: No Pap test required except less than 20 year history of high grade abnormality OR history of DES in-utero exposure
- 4. Population Recommended Screening Method Women youngerthan 21 years No screening Women aged 21–29 years Cytology alone every 3 years Women aged 30–65 years Human papillomavirus and cytology co-testing (preferred) every 5 years Comment Screening by HPV testing alone is not recommended Cytology alone (acceptable) every 3 years Women older than 65 years No screening is necessary after adequate negative prior screening results Women with a history of CIN 2, CIN 3 or adenocarcinoma in situ should continue routine age-based screening for at least 20 years Women who underwent total hysterectomy No screening is necessary Applies to women without a cervix and without a history of CIN 2, CIN 3, adenocarcinoma in situ, or cancer in the past 20 years Practice bulletin, ACOG, November 2012
- 5. BREAST CANCER SCREENING •Mammography has a false negative rate of 20%* • Age <40: Self breast awareness • Age >40: Self breast awareness, annual clinical breast exam and mammogram (except women with first degree relatives with premenopausal breast cancer OR women with BRCA mutation) ACOG guidelines *National Cancer Institute
- 6. Mammography American College of Obstetricians andGynecologists Age 40 years and older annually Clinical Breast Examination Age 20-39 years every 1-3 years Breast SelfExamination Instruction Consider for highrisk patients Breast SelfAwareness Recommended Age 40 years and older annually Practice Bulletin, ACOG, August 2011
- 7. ENDOMETRIAL CANCER SCREENING •Most common gynecologic cancer Risk Factor Relative Risk • No screening tool. Longterm high dose HRT 10-20 • Red flags: postmenopausal bleeding Tamoxifen 3-7 • Diagnosis: PCOS or estrogen producing tumor >5 • Endometrial biopsy or D&C Obesity 2-5 • Transvaginal ultrasound Nulliparity 3 ACOG practice bulletin, August 2005
- 8. OVARIAN CANCER SCREENING •Lifetime risk of 1/70 • No evidence that screening leads to earlier detection or improved survival • Diagnostic tests: CA 125 and transvaginal ultrasound ACOG, July 2007
- 9. PRE-CONCEPTION SCREENING • Folicacid 0.4mg (or 4mg with a history of open neural tube defects) • Risk factor-based genetic screening/ counselling • Optimize medical conditions (HTN, DM) • Domestic violence screening • Avoid alcohol, tobacco, radiation, and illegal drugs • Weight reduction • Vaccinations (Rubella, influenza) ACOG Committee opinion, 9/2005
- 10. TESTING FOR OVARIANRESERVE • ASRM, 2005 Speroff, 2005
- 11. THE INFERTILE COUPLE DEFINITION Forwomen ≤ 35: No conception after 1 year of unprotected intercourse For women >35: No conception after 6 months of unprotected intercourse Only 43% seek medical care Age (years) Infertility rates (%) 15-24 4 25-34 13 35-44 30 Age and infertility. Science 1986;233:1389-94
- 12. CAUSES OF INFERTILITY-COUPLES 5% 10% 35% 15% Tubal and pelvic pathlogy Male factor Ovulatory dysfunction Unexplained Unusual problems 35% Speroff, 2005
- 13. CAUSES OF FEMALEINFERTILITY 10% 10% 40% Ovulatory dysfunction Tubal and pelvic disease Unexplained Unusual problems 40% Speroff, 2005
- 14. STANDARD FERTILITY WORK-UP •Assessment of male factor infertility: semen analysis • Assessment of ovulation: history, BBT, day 21 progesterone • Assessment of uterus/endometrium and ovaries: transvaginal ultrasound • Assessment of tubal patency: hysterosalpingogram or laparoscopy • Assessment of endometriosis: laparoscopy ASRM Fact sheet 2005
- 15. INFERTILITY MANAGEMENT • Timedintercourse • Ovulation induction • Intrauterine insemination (+/- ovulation induction) • In-vitro fertilization (IVF) • Intracytoplasmic sperm injection (ICSI)