bunt - male and female infertility usafp 2009-v2 (pptminimizer).ppt

7/28/2019 Bunt - Male and Female Infertility USAFP 2009-v2 (PPTminimizer).ppt

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Male and Female

Infertility

Capt. Christopher W. Bunt, MDEhrling Bergquist Family Medicine Residency

Offutt AFB, NE


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Goals

Enhance comfort level with workup

Basic Management Strategies

TRICARE Coverage


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Demographics

80-168 million people worldwide

2.1 million couples in the US

9.3 million US women


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Definition

12 months of unprotected intercourse

Earlier for certain historical factors

Older than 35


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Infertility Etiology


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Female Factors


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Male Factors

General Causes

Unknown: 40-50%

1 Hypogonadism: 30-

40%

Altered SpermTransport: 10-20%

2 Hypogonadism: 1-2%

Meds

1 or 2

Hypogonadism

Common medications

Ketoconazole

Cimetidine Spironolactone


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The Scenario

Tech: Husband and wife cant get

pregnant.

You: OB rotation was last infertility workup

What now?A. Refer

B. Google

C. Use online EBM resources


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Online EBM Resources

www.aafp.org/afp

American Family Physician

March 2007: Jose-Miller, Boyden and Frey.

www.infopoems.com

Cochrane Systematic reviews

Original research
http://www.aafp.org/afphttp://www.infopoems.com/http://www.infopoems.com/http://www.aafp.org/afp


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Workup

History is KEY

Focused Physical Exam

Labs and Specialized Tests


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Workup: History

Coital Practices

Gestational History

PMHx/PSHx

Meds

Menstrual History

Substances

Recent High Fever


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Our Couple: History

Female

G1 P0010

No hx of STIs

Normal menses

Unprotected sex for

15 months

Male

No previous partner

pregnancies

Gonorrhea hx

No meds

Occasional EtOH


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Workup: Physical Exam

Male

Infection

Hernia

Vas deferens

Androgen deficiency

Testicular mass

Varicocele

Female

Breast Formation

Galactorrhea

Genitalia

Hyperandrogenism?


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Workup: Labs

Female

Ovulation problems

Ovulatory Dysfunction

Ovarian Reserve

Male

CBC

FSH, Testosterone

GC/Chlam, UA

Renal and Liver

Function

Semen analysis

Postejaculatory

urinalysis


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WHO Seminal Fluid

Analysis (1999)

Volume: >2ml

Sperm concentration: >20 million/ml

Total Sperm Number: >40 million/ejaculate Sperm Motility:

>50% motile and/or

>25% progressively motile Sperm Morphology: >14% normal forms


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Workup: Special Tests

Female

Transvaginal

Ultrasonography

(TVUS)

Hysterosalpingography

(HSG)

Hysteroscopy

Laparoscopy

Male

Scrotal

Ultrasonography

Transrectal

Ultrasonography(TRUS)


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Our Couple: Exam,

Labs & Tests Normal male exam

Normal initial labs

Oligospermia on 2 separate semen

analyses

TRUS and postejaculatory UA normal


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Management: General

Concepts 41 different methods

Fertile window intercourse

E-type vaginal discharge

Avoid lubricants and douches


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Management: Female

Treat underlying cause

Hyperprolactinemia

PCOS

Gonadotropin therapy


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Management: Female

Ovulatory dysfunction (Unknown etiology)

Clomiphene 50mg PO daily x 5 days

Start on days 3-5

Can increase to 100mg daily next cycle

Results

80% will ovulate

Hyperstimulation and Twinning Higher-order multiples rare


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Management: Female

Clomiphene Failure?

IVF

Injectable ovulation-inducing agents


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Management: Female

Tubal/Pelvic/Uterine Issues

Reparative Surgery (low success)

IVF

Endometriosis

Laparoscopic ablation

Laparotomy

Ovulation induction +/- IUI and IVF


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Management: Male

Hyperprolactinemia

Surgical repair

Fertility Specialist


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Stress and Infertility

69% Women and 21% Men have

preexisting condition

Greater risk for psychological stress

No significant difference inpsychopathology


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Men have increased stress over time,

same as women

Watch for normal grief vs. psychopathology

Same rates of depression as other chronicdisease


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Bottom line: Not a means to improve

pregnancy rates.

Websites and Organizations:

American Society for Reproductive Medicine

www.asrm.org

American Fertility Association www.theafa.org

RESOLVE: The National Infertility Association

www.resolve.org
http://www.asrm.org/http://www.theafa.org/http://www.resolve.org/http://www.resolve.org/http://www.theafa.org/http://www.asrm.org/


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Management: Our Couple

Male: Imipramine Mar 08

Pregnant in June 2008!

Separated from USAF in July 2008


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TRICARE Coverage

Will cover diagnostic tests, workup and

treatment of physical conditions

Will cover some fertility drug prescriptions

May require pre-authorization

Will cover any pregnancy issues once

pregnant


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TRICARE Coverage

Exceptions

Artificial methods of reproduction:

Artificial insemination

IVF

Gamete intrafallopian transfer (GIFT)

ICSI

Reversal of prior surgical sterilization


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Military Infertility Specialists

All 3 Services have treatment centers

Many can be accessed throughPermissive TAD/TDYs or Leave

(Command-dependent)

Some are restricted to locally assigned

members only


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USA Options

Walter Reed (DC)

IVF, ICSI (Intracytoplasmic Sperm Injection),Assisted Hatching (AH)

Tripler (HI) IVF, IUI (Intra Uterine Insemination)

Womack (NC)

IVF, ICSI, IUI, AH, Frozen Embryo Transfer(FET)

Madigan (WA)

IVF, ICSI, AH, FET


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USN Options

San Diego

IVF, IUI, AH, ICSI

Portsmouth

IUI only


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USAF Options

Wilford Hall (TX)

IVF, ICSI, AH

Wright-Patterson (OH)

Locally stationed military only

IUI only

Keesler (MS)

IUI only

Hope to start IVF program soon


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Review

Comfort level

Demographics

Workup and Management

TRICARE options


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Questions?

bunt - male and female infertility usafp 2009-v2 (pptminimizer).ppt

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