Infertility: the role of the family doctor
Infertility: the role of the family doctor
By: Carroll Haymon, M.D.
Definitions
* Infertility = Inability of a couple practicing frequent intercourse and not using contraception to fail to conceive a child within one year.
* Infertility affects 15-20% of couples, or 11 million reproductive age people in the U.S.
Causes of infertility
* Tubal pathology 35%
* Male factor 35%
* Ovulatory dysfunction 15%
* Unexplained 10%
* Cervical/other 5%
Counsel patience!
* In normal young couples:
o 25% conceive after one month
o 70% conceive after six months
o 90% conceive by one year
* Only an additional 5% will conceive in an additional 6-12 months
By: Carroll Haymon, M.D.
Definitions
* Infertility = Inability of a couple practicing frequent intercourse and not using contraception to fail to conceive a child within one year.
* Infertility affects 15-20% of couples, or 11 million reproductive age people in the U.S.
Causes of infertility
* Tubal pathology 35%
* Male factor 35%
* Ovulatory dysfunction 15%
* Unexplained 10%
* Cervical/other 5%
Counsel patience!
* In normal young couples:
o 25% conceive after one month
o 70% conceive after six months
o 90% conceive by one year
* Only an additional 5% will conceive in an additional 6-12 months
Fecundity and Age
* In a federal survey:
o Impaired fertility in women < 25y is 11.7%
o Impaired fertility in women > 35y is 42.1%
* In another study:
o 74% of women < 31y conceived in one year.
o 54% of women >35y conceived in one year.
* Our challenge: presenting data in a supportive, non-judgmental manner
Tubal/ Pelvic pathology
* Congenital anomalies
* Tubal occlusion
* Evaluated by:
o hysterosalpingogram
o laparoscopy
o hysteroscopy
* May occur as sequelae of
o PID
o endometriosis
o abdominal/pelvic surgery
o peritonitis
Male factor
* Male partner should be evaluated simultaneously with female
* Causes of male infertility:
o reversible conditions (varicocele, obstructive azoospermia)
o not reversible, but viable sperm available (ejaculatorydysfunction, inoperative obstructive azoospermia)
o not reversible, no viable sperm (hypogonadism)
o genetic abnormalities
o testicular or pituitary cancer
Ovulatory dysfunction
* Causes 15% of infertility
* Diagnosed by menstrual irregularities, basal body temperature charting, ovulation prediction kits, serum progesterone levels.
* Causes of ovulatory dysfunction:
o polycystic ovary syndrome
o hypothalamic anovulation
o hyperprolactinemia
o premature and age-related ovarian failure
o luteal phase defect (theoretical)
Polycystic Ovarian Syndrome
* Oligomenorrhea/amenorrhea and hyperandrogenism
* Prevalence: 5%. Among women with O.D., 70% have PCOS.
* Clinical evidence: hirsutism, acne, obesity
* Lab evidence: elevated testosterone, elevated DHEA-S.
* “Polycystic ovaries” supportive, not diagnostic
PCOS: Treatment Approach
* Weight loss if BMI>30
* Clomiphene to induce ovulation
* If DHEA-S >2, clomiphene + glucocorticoid (dexamethasone)
* If clomiphene alone unsuccessful, try metformin + clomiphene.
Hypothalamic Anovulation
* Low levels of GnRH, low of normal levels of FSH/ LH, low levels of endogenous estrogen.
* Associated factors: low BMI (< 20), high-intensity exercise, extreme diets, stress.
* Treatment: lifestyle modification.
Hyperprolactinemia
* Causes: pituitary adenoma, psych meds.
* Test for: pregnancy, thyroid disease.
* Imaging: MRI for macro vs microadenoma
* Treament: Bromocriptine (dopamine agonist). After correction, 80% of women will ovulate, 80% will get pregnant.
* Discontinue treatment once pregnancy established.
What Can I Do?
Infertility Evaluation for the Family Doctor
History and Physical - Female
* History
o menarche, puberty
o menstrual hx
o preganancies, abortions, birth control
o dysparenunia, dysmenorrhea
o STD’s, abdominal surg, galactorrhea
o Weight loss/gain
o Stress, exercise, drugs, alcohol, psychological
* Physical
o weight/BMI
o thyroid
o skin (striae? Acanthosis nigracans?)
o pelvic (vaginal mucosa, masses, pain)
o rectal (uterosacral nodularity)
History and Physical - Male
* History
o prior fertility
o medications
o h/o diabetes, mumps, undescended testes
o genital surgery, trauma, infections
o ED
o drug/alcohol use, stress
o underwear, hot tubs, frequent coitus
* Physical
o habitus, gynecomastia
o sexual development
o testicular volume (5x3 cm)
o epididymis, vas, prostate by palpation
o check for varicocele
Trouble in Paradise
* Don’t wait a year if:
o irregular menses; intermenstrual bleeding
o h/o PID
o h/o appy with rupture
o h/o abdominal surgery
o dyspareunia
o age > 35
o male factors
On your first visit:
* Semen analysis
* Confirm ovulation
o basal body temperature charting
o ovulation predictor kits (detect LH surge)
o consider serum progesterone on day 21
* Labs:
o TSH and prolactin. DHEA-S if concern for PCOS.
o FSH & estradiol on cycle day 3 if >35y.
o Cervical cultures prn.
Three months later
* Hysterosalpingogram
o evaluates tubal patency and uterine cavity shape
o noninvasive but involves a tenaculum
o performed by radiology with gynecology supervision
o diagnostic and therapeutic
* Postcoital test
* endometrial biopsy
* immune testing for antisperm antibodies
* routine cervical cultures
Clomiphene citrate
* Effective for anovulatory patients.
o Also used in unexplained fertility, but no data to support.
o Most effective for women with nomal FSH and estrogen, least effective in hypothalamic amenorrhea or elevated FSH.
* Induces ovulation by unknown mechanism
* Most pregnancies occur in first 3 cycles. 80% will ovulate, 40% will become pregnant in 3 cycles.
Clomiphene - complications
* 7% twin gestations, 0.3% triplet gestations
* Miscarriage rate = 15%
* Birth defect rate unchanged from controls
* Side effects: hot flashes, adnexal tenderness, nausea, headache, blurry vision
* Contraindications: pregnancy, ovarian cysts.
Clomiphene - Administration
* 50 mg po qd, cycle day 3 through 7. Induce bleeding first with progesterone if amenorrheic.
* Intercourse QOD cycle days 12 - 17.
* Track ovulation with BBT or ovulation detection kits.
* Increase dose to 100 qd, then 150, if no ovulation occurs.
Bibliography
Case 1
* A 24 year old couple comes to see you. They have been trying to get pregnant for 8 months.
o What questions do you ask?
* 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”
o 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.
o What do you ask?
* 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.
o What do you look for on exam?
o What lab tests do you order today?
o Do you give them homework?
* They come back 3 months later with BBT charts showing no discernable pattern. Lab tests, including semen analysis, were all normal.
o What is the diagnosis?
o What do you do next?
* 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.
o What do you tell them?
o How do you administer the clomiphene?
* 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.
o What happens next?
Infertility: the role of the family doctor
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