How to approach a case of infertility
Dr Manal BeheryAssistant professorZagazig University 2013
Definitions• Infertility = Inability of a couple practicing
frequent intercourse and not using contraception to conceive a child
Under 35 year :No conception after one year of unprotected intercourse
Over 35 year :No conception after 6months of unprotected intercourse
Types of Infertility
Primary infertility Couple Has Never Produced
A pregnancy
Secondary infertility Woman has previously been pregnant,
regardless of the outcome, and now is unable to conceive
Causes of infertility
• Tubal pathology 35%
• Male factor 35%
• Ovulatory dysfunction 15%
• Unexplained 10%
• Cervical/other 5%
Causes of tubal/ Pelvic pathology
• Congenital anomalies
• Tubal occlusion
• May occur as sequelae of– PID– endometriosis– abdominal/pelvic surgery– peritonitis
Causes of tubal/ Pelvic pathology
• Congenital anomalies
• Tubal occlusion
• May occur as sequelae of– PID– endometriosis– abdominal/pelvic surgery– peritonitis
Causes of Ovulatory Dysfunction
– polycystic ovary syndrome– hypothalamic anovulation– hyperprolactinemia– premature and age-related ovarian failure– luteal phase defect (theoretical)
Causes of male infertility:
– reversible conditions (varicocele, obstructive azoospermia)
– not reversible, but viable sperm available (ejaculatory dysfunction, inoperative obstructive azoospermia)
– not reversible, no viable sperm (hypogonadism)– genetic abnormalities– testicular or pituitary cancer
What Can I Do?
A PRACTICAL APPROCH
Counsel patient!
• In normal young couples:– 25% conceive after one month– 70% conceive after six months– 90% conceive by one year
• Only an additional 5% • will conceive in an additional 6-12 months
Councelling
Evaluating both partners is essential Couple should be informed about:
different causes of infertility tests and procedures required to make a diagnosis various therapeutic possibilities
Couple’s interview is conducted together as well as separately
to obtain confidential informationR
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Possible causes of infertility
Start with History. . .
General and Sexual HistoryObstetric and Gynecological History
What Clues Can You Find on History?
Step1 history:General and Sexual History
General history occupation and background use of tobacco, alcohol and drugs history of abdominal surgery and earlier
diseases/infections Sexual history
sexual disturbances or dysfunction such as vaginismus, dyspareunia or erectile dysfunction
sexually transmitted infections
Obstetric and Gynecological History
Reproductive history Gynecological history Age at menarche Menstrual periods: duration and intervals Previous contraceptive use Previous testing and treatment for infertility
Step2 : General and Gynecological Examination
Visual evaluation andpelvic exam for women
to rule out:
Visual evaluation andpelvic exam for women
to rule out:
Visual evaluation andpenile exam for men
to rule out:
Visual evaluation andpenile exam for men
to rule out:
EndocrinopathyEndocrinopathy
Congenital anomaliesCongenital anomalies
Uterine hypoplasiaUterine hypoplasia
Cervical lesionsCervical lesions
DyspareuniaDyspareunia
HypogonadismHypogonadism
TumorsTumors
Epididymal cystsEpididymal cysts
CryptorchidismCryptorchidism
HydroceleHydrocele
VaricoceleVaricocele
Male Partner: Semen Analysis
Semen is studied for a number of factors including:
Volume (1.5 cc to 5.0 cc) Number of sperm present (> 20 million/ml) Sperm motility (> 60%) and forward progression
(more than 2 on scale 1 to 4) Morphology (> 60% normal forms) Presence of any infection
Semen analysis
Other Tests
Urine analysis: to rule out infection Endocrine tests: to measure concentrations of hormones testosterone, FSH
and LH Anti-sperm antibodies Sperm penetration assay: to establish ability of
sperm to penetrate egg Postcoital test (low validity): to establish ability of sperm to penetrate cervical mucus
Male partner: Evaluation:
1) Repeat semen analysis2) Physical exam- varicocele, testicular size3) Lab testing- testosterone, FSH, LH4) Genetics for special cases
IUI (intrauterine insemination)
ICSI (intracytoplasmic sperm injection)
IUI VS ICSI
Don’t wait a year if:– irregular menses;
intermenstrual bleeding– h/o PID
– h/o appendicitis with rupture
– h/o abdominal surgery– dyspareunia– age > 35– male factors
On your first visit:
• Semen analysis • Confirm ovulation
– basal body temperature charting– ovulation predictor kits (detect LH surge)– consider serum progesterone on day 21
• Labs: – TSH and prolactin. DHEA-S if concern for PCOS.– FSH & estradiol on cycle day 3 if >35y. – Cervical cultures prn.
Ovulation
Basal body temprature
Ovulation Predictor Kits
Salivary Estrogen: TCI Ovulation Tester- 92% accurate
Add Saliva Sample
Non-Ovulatory Saliva Pattern
High Estrogen/ Ovulatory Saliva Pattern
Approach to Ovulation Disorders
• Evaluate- HypothyroidismProlactin Disorder
Hyperandrogenism- PCOSWeight loss/ weight gain
• Induce OvulationClomid (clomiphene citrate)
Three months later
• Hysterosalpingogram– evaluates tubal patency and uterine cavity shape– noninvasive but involves a tenaculum– performed by radiology with gynecology supervision– diagnostic and therapeutic
Hysterosalpingogram
HSG: Unilateral Blocked Tube
HSG: bilateral tubal block
HSG: Hydrosalpinx
Diagram shows the appropriate steps in an imaging evaluation for fallopian tube abnormalities.
©2009 by
Other Tests
Laparoscopy to evaluate for pelvic disease, such as endometriosis
check patency of fallopian tubes
Hysteroscopy to evaluate condition of uterine cavity (polyps, fibroids)
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• Post coital test
• endometrial biopsy
• immune testing for antisperm antibodies
• routine cervical cultures
Traditional Infertility Evaluation
1) Semen Analysis
2) Hysterosalpingogram (HSG)
3) Documentation of Ovulation
4) Post-coital Exam
5) Diagnostic Laparoscopy
Current Infertility Evalution
1) Semen Analysis2) Hysterosalpingogram (HSG) 3) Documentation of Ovulation
4) Ovarian Reserve Testing
Ovarian Reserve Testing
Day #3 FSH (<10 mIU/ml) and estradiol (<80 pg/ml)
-Correlates with the functional status of the ovaries and the quality of the oocytes
- FSH >15 only 5% success with IVF
- High estradiol level increases risk of cancelling IVF cycle
Treatment Possibilities:Female Infertility
Ovulation disordersOvulation disorders Ovulation-inducing drugsOvulation-inducing drugs
HyperprolactinemiaHyperprolactinemia Prolactin-suppressing drugs
Prolactin-suppressing drugs
Uterine and tubal abnormalities
Uterine and tubal abnormalities Surgical proceduresSurgical procedures
Cervical mucus problemsCervical mucus problems Intrauterine inseminationIntrauterine insemination
EndometriosisEndometriosis Suppressing hormones or surgical procedure
Suppressing hormones or surgical procedure
Case 1
• A 24 year old couple comes to see you. They have been trying to get pregnant for 8 months.– What questions do you ask?
Case 1
• The woman tells you she has never been pregnant. She has a regular 28 day cycle and bleeds for 4 days each month. Her medical history is unremarkable except she “got really sick” when she was 16 and had “nasty stuff coming from down there”– what do you do next?
Case 2
• A 35 year old woman and her 31 year old male partner come to see you. They have been trying to get pregnant for 6 months.– What do you ask?
Case 2
• She says her periods have been irregular since she went off the pill a year ago. She has never been pregnant. He has fathered a child by another woman several years ago.– What do you look for on exam?– What lab tests do you order today?– Do you give them homework?
Case 2
• They come back 3 months later with BBT charts showing no discernable pattern. Lab tests, including semen analysis, were all normal.– What is the diagnosis?– What do you do next?
Case 2
• You begin discussion of clomiphene. They want to know the side effects, and if this means they’ll have sextuplets and get a free house like the folks on TV.– What do you tell them?– How do you administer the clomiphene?
Case 2
• They come back in one month. She feels “like a total bitch - excuse me, doctor” on the clomiphene. She is not pregnant. BBT charting shows a mid-cycle temperature rise.– What happens next?
Case 3
A 31-year-old G1 P1 woman presents with a history of infertility of 2-year duration.
Manarche at 12 years and occurs at28-day intervals.
A biphasic basal body temperature chart is recorded.
She denies sexually transmitted diseases, hysterosalpingogram shows patent tubes and a
normal uterine cavity. Her husband is 34 years old and his semen
analysis is normal.
➤ What is the most likely etiology of the infertility?
• ➤ Most likely etiology: Endometriosis (peritoneal factor).
• What further support the diagnosis ?
• if the patient complained of the three Ds of endometriosis (dysmenorrhea, dyspareunia, anddyschezia), then the examiner would be pointed toward the peritoneal factor.
• A 22-year-old G0 P0 woman complains of irregular menses every 30 to 65 days. The semen analysis is normal. The hysterosalpingogram is normal. Which of the following is the most likely treatment for this patient?
• A. Laparoscopy• B. Intrauterine insemination• C. In vitro fertilization• D. Clomiphene citrate
• A 26-year-old G0 P0 woman has regular menses every 28 days. The semen analysis is normal
• . The patient had a postcoital test revealing motile sperm and stretchy watery cervical mucus. She has been treated for chlamydial infection in the past.
• Which of the following is the most likely etiology of her infertility?
• A. Peritoneal factor• B. Male factor• C. Cervical factor• D. Uterine and tubal factor• E. Ovulatory factor
• A 28-year-old G1 P1 woman complains of painful menses and pain with intercourse. She has menses every month and denies a history of STD
• Which of the following tests would most likely identify the etiology of the infertility?
• A. Semen analysis
• B. Laparoscopy
• C. Basal body temperature chart
• D. Hysterosalpingogram
• E. Progesterone assay
• A 34-year-old infertile woman is noted to have evidence of blocked fallopian tubes by HSG
• Which of the following is the best next step for this patient?
• A. FSH therapy
• B. Clomiphene citrate therapy
• C. Laparoscopy
• D. Intrauterine insemination
Case 4
A 37-year-old female and her 37-year-old husband present with the complaint of a possible fertility problem. The couple has been married for 2 years.
The patient has a 4-year-old daughter from a previous relationship.
The patient used birth control pills until one-and-a- half-years-ago
. The couple has been trying to conceive since then and report a high degree of stress related to their lack of success.
Case cont’ The patient reports good health and no
problems in conceiving her previous pregnancy or in the vaginal delivery of her daughter.
She reports that her periods were regular on the birth control pill, but have been irregular since she discontinued taking them.
She reports having periods every 5-7 weeks.
Past history is remarkable only for mild depression. Imipramine 150 mg qhs for the last 8 months is her only medication
Case cont’ has no history of STDs, abnormal Paps, smoking,
alcohol or other drugs. She has had no surgery. The patient’s partner also reports good health and
reports no problems with erection, ejaculation or pain with intercourse.
He has had no prior urogenital infections or exposure to STDs
. He has had unprotected sex prior to his current relationship, but has not knowingly conceived.
He has no medical problems or past surgery
Case cont’;
He works as a long-distance truck driver and is on the road 2-3 weeks each month.
He smokes a pack of cigarettes a day since age 18 and drinks 2-3 cans of beer 3-4 times a week when he’s not driving.
He occasionally uses amphetamines to stay awake while driving at night. The couple has vaginal intercourse 3-5 times per week when he is at home.
Physical exam
The patient is 5’9” and weighs 130 pounds. Breast exam reveals no tenderness or masses,
but bilateral galactorrhea on compression of the areola.
Pelvic exam reveals normal genitalia, a well-estrogenized vaginal vault mucosa and cervical mucus consistent with the proliferative phase.
The uterus is anteflexed and normal in size without masses or tenderness.
Patient Laboratory
• Results Normal Values• TSH 2.1 mIU/ml 0.5-4.0 mIU/ml• Free T4 1.1 ng/dl 0.8-1.8 ng/dl• Prolactin 60 ng/ml <20 ng/ml• FSH 6 mIU/ml 5-25 mIU/ml• LH 4 mIU/ml 5-25 mIU/ml
• Basal body temperature chart shows a monophasic temperature graph.
Partner
• Semen analysis revealed 2 cc of semen, 4 million per mL, 30% normal forms and 20% motility.
Management
• The patient’s major infertility factor is anovulation; • the most likely cause is hyperprolactinemia from
imipramine. • The prolactin level is elevated, consistent with drug-
induced hyperprolactinemia.
• The patient was instructed, in conjunction with her therapist, to taper off the imipramine.
• Her follow-up basal body temperature chart was biphasic, consistent with ovulatory cycles.
•
Management cont’
The patient’s partner, however, has a semen analysis that is consistent with oligospermia.
The couple was given their options of: 1) In Vitro fertilization with ISCI; 2) artificial insemination with partner’s sperm; 3) artificial insemination with donor sperm; or 4) adoption
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