Infertility: the role of the family doctor

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Infertility the role of the family doctor

• Carroll Haymon, M.D.
• January 7, 2002

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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.

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Causes of infertility

• Tubal pathology 35
• Male factor 35
• Ovulatory dysfunction 15
• Unexplained 10
• Cervical/other 5

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Counsel patience!

• 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

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Fecundity and Age

• In a federal survey
• Impaired fertility in women lt 25y is 11.7
• Impaired fertility in women gt 35y is 42.1
• In another study
• 74 of women lt 31y conceived in one year.
• 54 of women gt35y conceived in one year.
• Our challenge presenting data in a supportive,
  non-judgmental manner

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Tubal/ Pelvic pathology

• Congenital anomalies
• Tubal occlusion
• Evaluated by
• hysterosalpingogram
• laparoscopy
• hysteroscopy

• May occur as sequelae of
• PID
• endometriosis
• abdominal/pelvic surgery
• peritonitis

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Male factor

• Male partner should be evaluated simultaneously
  with female
• Causes of male infertility
• reversible conditions (varicocele, obstructive
  azoospermia)
• not reversible, but viable sperm available
  (ejaculatorydysfunction, inoperative obstructive
  azoospermia)
• not reversible, no viable sperm (hypogonadism)
• genetic abnormalities
• testicular or pituitary cancer

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Ovulatory dysfunction

• Causes 15 of infertility
• Diagnosed by menstrual irregularities, basal body
  temperature charting, ovulation prediction kits,
  serum progesterone levels.

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Ovulatory Dysfunction - 2

• Causes of ovulatory dysfunction
• polycystic ovary syndrome
• hypothalamic anovulation
• hyperprolactinemia
• premature and age-related ovarian failure
• luteal phase defect (theoretical)

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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

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PCOS Treatment Approach

• Weight loss if BMIgt30
• Clomiphene to induce ovulation
• If DHEA-S gt2, clomiphene glucocorticoid
  (dexamethasone)
• If clomiphene alone unsuccessful, try metformin
  clomiphene.
• Source ACOG Bulletin, 34, Management of
  Infertility caused by Ovulatory Dysfunction Feb
  2002.

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Hypothalamic Anovulation

• Low levels of GnRH, low of normal levels of FSH/
  LH, low levels of endogenous estrogen.
• Associated factors low BMI (lt 20),
  high-intensity exercise, extreme diets, stress.
• Treatment lifestyle modification.

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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.

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What Can I Do?

• Infertility Evaluation
• for the Family Doctor

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History and Physical - Female

• History
• menarche, puberty
• menstrual hx
• preganancies, abortions, birth control
• dysparenunia, dysmenorrhea
• STDs, abdominal surg, galactorrhea
• Weight loss/gain
• Stress, exercise, drugs, alcohol, psychological

• Physical
• weight/BMI
• thyroid
• skin (striae? Acanthosis nigracans?)
• pelvic (vaginal mucosa, masses, pain)
• rectal (uterosacral nodularity)

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History and Physical - Male

• History
• prior fertility
• medications
• h/o diabetes, mumps, undescended testes
• genital surgery, trauma, infections
• ED
• drug/alcohol use, stress
• underwear, hot tubs, frequent coitus

• Physical
• habitus, gynecomastia
• sexual development
• testicular volume (5x3 cm)
• epididymis, vas, prostate by palpation
• check for varicocele

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Trouble in Paradise

• Dont wait a year if
• irregular menses intermenstrual bleeding
• h/o PID
• h/o appy with rupture
• h/o abdominal surgery
• dyspareunia
• age gt 35
• male factors

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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 gt35y.
• Cervical cultures prn.

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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

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Sorry, no data for...

• Postcoital test
• endometrial biopsy
• immune testing for antisperm antibodies
• routine cervical cultures

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Clomiphene citrate

• Effective for anovulatory patients.
• Also used in unexplained fertility, but no data
  to support.
• 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.

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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.

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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.

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Bibliography

• Bradshaw, Karen. Evaluation and Management of the
  Infertile Couple. Ob/Gyn vol 5, chapter 50, 1998.
• Penzias, Alan. Infertility Contemporary
  office-based evaluation and treatment. Obstet
  Gynecol Clinics, vol 27, no 3, Sept 2000.
• ACOG Practice Bulletin. Management of Infertility
  Caused by Ovulatory Dysfunction. Number 34,
  February 2002.
• Royal College of Obstetricians and Gynecologists,
  The Management of Infertility in Secondary Care
  National Evidence-Based Clinical Guidelines.
  www.rcog.org.uk.

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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?

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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?

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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?

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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?

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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?

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Case 2

• You begin discussion of clomiphene. They want to
  know the side effects, and if this means theyll
  have sextuplets and get a free house like the
  folks on TV.
• What do you tell them?
• How do you administer the clomiphene?

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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?