Infertility

Infertility
By:Stephanie R. Fugate D.O.
Dewitt Army Community Hospital
Department of OB/GYN

Objectives
* Define primary and secondary infertility
* Describe the causes of infertility
* Diagnosis and management of infertility

Requirements for Conception
* Production of healthy egg and sperm
* Unblocked tubes that allow sperm to reach the egg
* The sperms ability to penetrate and fertilize the egg
* Implantation of the embryo into the uterus
* Finally a healthy pregnancy

Infertility
* The inability to conceive following unprotected sexual intercourse
o 1 year (age < 35) or 6 months (age >35)
o Affects 15% of reproductive couples
+ 6.1 million couples
o Men and women equally affected
* Reproductive age for women
* With the proper treatment 85% of infertile couples can expect to have a child
* Health problems develop
* SAB
* Primary infertility
* Secondary infertility

Conception rates for fertile couples
Age and Pregnancy
Pregnancy
Age and related miscarriage
Causes for infertility

* Male
o ETOH
o Drugs
o Tobacco
o Health problems
o Radiation/Chemotherapy
o Age
o Enviromental factors
* Female
o Age
o Stress
o Poor diet
o Athletic training
o Over/underweight
o Tobacco
o ETOH
o STD’s
o Health problems

* Anovulation (10-20%)
* Anatomic defects of the female genital tract (30%)
* Abnormal spermatogenesis (40%)
* Unexplained (10%-20%)

Evaluation of the Infertile couple
* History and Physical exam
* Semen analysis
* Thyroid and prolactin evaluation
* Determination of ovulation
o Basal body temperature record
o Serum progesterone
o Ovarian reserve testing
* Hysterosalpingogram

Abnormalities of Spermatogenesis
Male Factor
Semen Analysis (SA)
* Obtained by masturbation
* Provides immediate information
o Quantity
o Quality
o Density of the sperm
* Abstain from coitus 2 to 3 days
* Collect all the ejaculate
* Analyze within 1 hour
* A normal semen analysis excludes male factor 90% of the time
* Morphology
* Motility

Normal Values for SA
Volume
Sperm Concentration
Motility
Viscosity
Morphology
pH
WBC

Causes for male infertility
Abnormal Semen Analysis
* Azospermia
* Oligospermia
* Abnormal volume

Evaluation of Abnormal SA
* Repeat semen analysis in 30 days
* Physical examination
o Testicular size
o Varicocele
* Laboratory tests
o Testosterone level
o FSH (spermatogenesis- Sertoli cells)
o LH (testosterone- Leydig cells)
* Referral to urology

Evaluation of Ovulation
Menstruation
* Ovulation occurs 13-14 times per year
* Menstrual cycles on average are Q 28 days with ovulation around day 14
* Luteal phase
* Progesterone causes
* Involution of the corpus luteum causes a fall in progesterone and the onset of menses
Menstrual Cycle
Ovulation

* A history of regular menstruation suggests regular ovulation
* The majority of ovulatory women experience
o fullness of the breasts
o decreased vaginal secretions
o abdominal bloating
* Absence of PMS symptoms may suggest anovulation
o mild peripheral edema
o slight weight gain
o depression

Diagnostic studies to confirm Ovulation
* Basal body temperature
o Inexpensive
o Accurate
* Endometrial biopsy
o Expensive
o Static information
* Serum progesterone
o After ovulation rises
o Can be measured
* Urinary ovulation-detection kits
o Measures changes in urinary LH
o Predicts ovulation but does not confirm it

Basal Body Temperature
* Excellent screening tool for ovulation
o Biphasic shift occurs in 90% of ovulating women
* Temperature
o drops at the time of menses
o rises two days after the lutenizing hormone (LH) surge
* Ovum released one day prior to the first rise
* Temperature elevation of more than 16 days suggests pregnancy

Serum Progesterone
* Progesterone starts rising with the LH surge
o drawn between day 21-24
* Mid-luteal phase
o >10 ng/ml suggests ovulation

Anovulation Symptoms Evaluation
* Irregular menstrual cycles
* Amenorrhea
* Hirsuitism
* Acne
* Galactorrhea
* Increased vaginal secretions
* Follicle stimulating hormone
* Lutenizing hormone
* Thyroid stimulating hormone
* Prolactin
* Androstenedione
* Total testosterone
* DHEAS
* Order the appropriate tests based on the clinical indications

Anatomic Disorders of the Female Genital Tract
Sperm transport, Fertilization, & Implantation
* The female genital tract is not just a conduit
o facilitates sperm transport
o cervical mucus traps the coagulated ejaculate
o the fallopian tube picks up the egg
* Fertilization must occur in the proximal portion of the tube
o the fertilized oocyte cleaves and forms a zygote
o enters the endometrial cavity at 3 to 5 days
* Implants into the secretory endometrium for growth and development

Acquired Disorders
* Acute salpingitis
* Intrauterine scarring
* Endometriosis, scarring from surgery, tumors of the uterus and ovary
* Trauma

Congenital Anatomic Abnormalities
Hysterosalpingogram
* An X-ray that evaluates the internal female genital tract
* Performed between the 7th and 11th day of the cycle
* Diagnostic accuracy of 70%

Hysterosalpingogram
* The endometrial cavity
* Fallopian tubes
* Dye should spill promptly

Unexplained infertility
Treatment of the Infertile Couple
Inadequate Spermatogenesis
Clomid
Superovulatory Medications
Anatomic Abnormalities
Assisted Reproductive Technologies (ART)
Emotional Impact
Conclusion
Test Question Case
Causes for Abnormal SA
* No sperm
o Klinefelter’s syndrome
o Sertoli only syndrome
o Ductal obstruction
o Hypogonadotropic-hypogonadism
* Few sperm
o Genetic disorder
o Endocrinopathies
o Varicocele
o Exogenous (e.g., Heat)
Abnormal Count
* Abnormal Morphology
o Varicocele
o Stress
o Infection (mumps)
* Abnormal Motility
o Immunologic factors
o Infection
o Defect in sperm structure
o Poor liquefaction
o Varicocele
* Abnormal Volume
o No ejaculate
+ Ductal obstruction
+ Retrograde ejaculation
+ Ejaculatory failure
+ Hypogonadism
o Low Volume
+ Obstruction of ducts
+ Absence of vas deferens
+ Absence of seminal vesicle
+ Partial retrograde ejaculation
+ Infection

Infertility.ppt