Dr Angelo Smith MDWHPL

Failure of a couple to conceive after1 year of regular intercourse withoutuse of contraception

Primary infertility – No priorpregnancies

Secondary infertility – Prior pregnancy

Infertility affects 10-15% of reproductive-agecouples in the world.

Approx. 85% of couples achieve pregnancy within 1year

Conception rate (fecundability)

25% conceive within 1 mo.

60% conceive within 6 mo.’s

75% conceive within 9 mo.’s

90% conceive within 18 mo.’s

Successful conception requires a specific series of events:1. Ovulation of competent oocyte

2. Production of competent sperm

3. Juxtaposition of sperm and oocyte in a patent reproductive tract

4. Fertilization

5. Generation of a viable embryo

6. Transport of the embryo to the uterine cavity

7. Implantation of the embryo into the endometrium

Major causes of of infertility:

Female factor – 60% Ovulatory dysfunction

Abnormalities of female reproductive tract

Peritoneal factors

Reproductive aging

Male factor – 20% Abnormal semen quality

Abnormalities of male reproductive tract

Idiopathic – 15%

Infertility in ~ 20-40% of couples has multiple causes

Female Duration of infertility and prior evaluation or therapy

Menstrual cycle (length and characteristics) Symptoms associated with ovulation (e.g. breast tenderness,

bloating, mood changes)

Full OBHx and GynHx Prior pregnancies, surgeries, or STD’s

Sexual history (frequency of intercourse)

Chronic medical illness

Family history (infertility, birth defects, genetic disorders)

Social history (smoking, EtOH, drugs)

Male Prior children

Genital tract infections

Genital surgery or trauma

Chronic medical illness

Medications (e.g. Furantoins, CCB)

EtOH, drugs, or smoking

Sexual history (frequency of intercourse)

Female Height, weight , BMI

Pelvic exam Masses

Tenderness (Adnexa, Cul-de-sac)

Structural abnormalities (Vagina, Cervix, or Uterus)

Male Evidence of androgen deficiency

Structural defects (e.g. varicocele, hernia)

Initial evaluation

Further evaluation

MaleFactor

•Semenanalysis•Urologicevaluation

•FSH, LH, andtestosterone level•Genetic evaluation•Epididymal spermaspiration (PESA, MESA)•Testicular biopsy

Element Reference value

Ejaculate volume 1.5-5.0 mL

pH > 7.2

Sperm concentration > 20 million/mL

Motility > 50%

Morphology > 30% normal forms

Semen analysis Following 2-4 day period of abstinence

Repeated x1 for accuracy

Urologic evaluation Physical Exam

Varicocele

Congenital absence of vasdeferens (CAVD)

Transrectal ultrasound

Vasography, Seminalvesiculography

Epididymal sperm aspiration(PESA or MESA)

Endocrine evaluation Indication: Oligospermia (< 10million/mL) or sexual dysfunction (decreased

libido, impotence)

FSH, LH, testosterone

Genetic evaluation Indication: Azoospermia (no sperm)

CF (Cystic fibrosis) mutation

Karyotype (Klinefelter’s, Y chromosome deletion)

Testicular biopsy Indication: Nonobstructive azoospermia

Palpable vasa

Normal testis volume

Normal FSH/LH

Factor Initial evaluation Further evaluation

Ovulation •History and physical exam•Basal body temp charting•Ovulation predictor kit

•Mid-luteal phase progesterone level•Endocrine testing•Endometrial biopsy

Reproductive tract (uterus or fallopian tubes)

•Hysterosalpingogram(HSG)•Ultrasound

•Saline-infusion sonography•Hysteroscopy•Laparoscopy

Peritoneal Laparoscopy

Reproductive aging

•FSH, estradiol, or AMH

Ovulation

Initial evaluation: Basal body temp – rise for > 10 days indicates ovulation

Ovulation predictor kit – detects LH surge in urine

Further evaluation: Mid-luteal phase progesterone level - level > 3 ng/mL provides

qualitative evidence of recent ovulation

Endocrine testing (TSH, prolactin, FSH, LH, Estradiol, DHEA-S)

Endometrial biopsy

Not routinely performed

Reproductive tract

Initial evaluation: Hysterosalpingogram (HSG)

Detect uterine anomalies (septate or bicornuate uterus, uterineadhesions, uterine leiomyoma)

Detect patency of fallopian tubes (occlusion, hydrosalpinx, salpingitis)

Ultrasound – alternative to HSG to evaluate uterus

Reproductive tract

Further evaluation: Saline-infusion sonography (SIS)

Hysteroscopy

Laparoscopic chromotubation

Peritoneal factors

Laparoscopy

Endometriosis

Pelvic/adnexal adhesions

Reproductive aging

Indications:

> 35 years of age

1st degree relative with early menopause

Previous ovarian insult (surgery, chemotherapy,radiation)

Smoking

Poor response to ovarian stimulation

Unexplained infertility

Candidate for IVF

Reproductive aging

Cycle day 3 serum FSH and estradiol

Abnormal (“diminished ovarian reserve”)

FSH > 10 IU/L

Estradiol > 75-80 pg/mL

Clomiphene citrate challenge test Cycle day 10 serum FSH

Serum antimullerian hormone (AMH)

Prevalence ~ 15%

Factors that cannot be identified Sperm transport defects

Inability of sperm to fertilize egg

Implantation defects

Male Factor Avoidance of alcohol

Scheduled intercourse

Ligation of venous plexus for significant varicocele

Intrauterine insemination (IUI) with washed sperm

Intracytoplasmic sperm injection (ICSI) + IVF

Donor sperm insemination

Ovulation Induction (Clomid or low doseFSH)

IUI (low dose FSH)

IVF / ICSI (LHRH analogue, high dose FSHinjections, egg collection, embryotransfer)

Anovulation Oral medications:

Clomiphene citrate

Dopamine agonists (Bromocriptine) - hyperprolactinemia

Injectable medications:

Gonadotropins (FSH/hMG, hCG)

Laparoscopic “ovarian drilling” Complications: Ovarian hyperstimulation, Multiple pregnancy

Reproductive tract abnormality Uterine: Myomectomy, Septoplasty, Adhesiolysis

Tubal: Microsurgical tuboplasty, Neosalpigostomy

Peritoneal: Laparascopic treatment of endometriosis,Adhesiolysis

Idiopathic infertility Ovarian stimulation + IUI

Clomiphene or gonadotropins (hMG, hCG)

IVF

Used for:

Severe male factor

Tubal disease

Couples who failed other treatments

Requires Controlled ovarian hyperstimulation

Retrieval of oocytes

In vitro fertilization and embryo transfer

Procedures IVF + embryo transfer (IVF-ET)

Intracytoplasmic sperm injection + embryo transfer (ICSI-ET)

Donor egg IVF + embryo transfer

~ 40% of IVF cycles involve insemination by ICSI

Advantages

Embryo Selection

Reduction in number of embryos for ET resulting in reduction in multiple gestations

The psychological stressassociated with infertility mustbe recognized and patientsshould be counseledappropriately.

For patients with poor ovarianreserve

Alternative to adoption orchildlessness

Success Rate ~ 50% per cycle