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INFERTILITY MALE AND FEMALE

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Title: INFERTILITY MALE AND FEMALE


1
Infertility
  • Dr Angelo Smith MD
  • WHPL

2
Definition
  • Failure of a couple to conceive after 1 year of
    regular intercourse without use of contraception
  • Primary infertility No prior pregnancies
  • Secondary infertility Prior pregnancy

3
Prevalence
  • Infertility affects 10-15 of reproductive-age
    couples in the world.
  • Approx. 85 of couples achieve pregnancy within 1
    year
  • 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

4
Etiology
  • Successful conception requires a specific series
    of events
  • Ovulation of competent oocyte
  • Production of competent sperm
  • Juxtaposition of sperm and oocyte in a patent
    reproductive tract
  • Fertilization
  • Generation of a viable embryo
  • Transport of the embryo to the uterine cavity
  • Implantation of the embryo into the endometrium

5
Etiology
  • 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

6
Infertility History
  • 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 STDs
  • Sexual history (frequency of intercourse)
  • Chronic medical illness
  • Family history (infertility, birth defects,
    genetic disorders)
  • Social history (smoking, EtOH, drugs)

7
Infertility History
  • 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)

8
Infertility Physical Exam
  • 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)

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Male factor Evaluation
Initial evaluation Further evaluation
Male Factor Semen analysis Urologic evaluation FSH, LH, and testosterone level Genetic evaluation Epididymal sperm aspiration (PESA, MESA) Testicular biopsy
13
Male factor Evaluation
  • Semen analysis
  • Following 2-4 day period of abstinence
  • Repeated x1 for accuracy

Element Reference value
Ejaculate volume 1.5-5.0 mL
pH gt 7.2
Sperm concentration gt 20 million/mL
Motility gt 50
Morphology gt 30 normal forms
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Male factor Evaluation
  • Urologic evaluation
  • Physical Exam
  • Varicocele
  • Congenital absence of vas deferens (CAVD)
  • Transrectal ultrasound
  • Vasography, Seminal vesiculography
  • Epididymal sperm aspiration (PESA or MESA)

16
Male factor Evaluation
  • Endocrine evaluation
  • Indication Oligospermia (lt 10million/mL) or
    sexual dysfunction (decreased libido, impotence)
  • FSH, LH, testosterone
  • Genetic evaluation
  • Indication Azoospermia (no sperm)
  • CF (Cystic fibrosis) mutation
  • Karyotype (Klinefelters, Y chromosome deletion)
  • Testicular biopsy
  • Indication Nonobstructive azoospermia
  • Palpable vasa
  • Normal testis volume
  • Normal FSH/LH

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Female factor Evaluation
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
20
Female factor Menstrual Cycle
21
Female factor Evaluation
  • Ovulation
  • Initial evaluation
  • Basal body temp rise for gt 10 days indicates
    ovulation
  • Ovulation predictor kit detects LH surge in
    urine
  • Further evaluation
  • Mid-luteal phase progesterone level - level gt 3
    ng/mL provides qualitative evidence of recent
    ovulation
  • Endocrine testing (TSH, prolactin, FSH, LH,
    Estradiol, DHEA-S)
  • Endometrial biopsy
  • Not routinely performed

22
Female factor Evaluation
  • Reproductive tract
  • Initial evaluation
  • Hysterosalpingogram (HSG)
  • Detect uterine anomalies (septate or bicornuate
    uterus, uterine adhesions, uterine leiomyoma)
  • Detect patency of fallopian tubes (occlusion,
    hydrosalpinx, salpingitis)
  • Ultrasound alternative to HSG to evaluate
    uterus

23
Female factor Evaluation
  • Reproductive tract
  • Further evaluation
  • Saline-infusion sonography (SIS)
  • Hysteroscopy
  • Laparoscopic chromotubation

24
Female factor Evaluation
  • Peritoneal factors
  • Laparoscopy
  • Endometriosis
  • Pelvic/adnexal adhesions

25
Female factor Evaluation
  • Reproductive aging
  • Indications
  • gt 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

26
  • Reproductive aging
  • Cycle day 3 serum FSH and estradiol
  • Abnormal (diminished ovarian reserve)
  • FSH gt 10 IU/L
  • Estradiol gt 75-80 pg/mL
  • Clomiphene citrate challenge test
  • Cycle day 10 serum FSH
  • Serum antimullerian hormone (AMH)

27
Idiopathic Infertility
  • Prevalence 15
  • Factors that cannot be identified
  • Sperm transport defects
  • Inability of sperm to fertilize egg
  • Implantation defects

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Management
  • 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

31
  • Ovulation Induction (Clomid or low dose FSH)
  • IUI (low dose FSH)
  • IVF / ICSI (LHRH analogue, high dose FSH
    injections, egg collection, embryo transfer)

32
Management
  • Anovulation
  • Oral medications
  • Clomiphene citrate
  • Dopamine agonists (Bromocriptine) -
    hyperprolactinemia
  • Injectable medications
  • Gonadotropins (FSH/hMG, hCG)
  • Laparoscopic ovarian drilling
  • Complications Ovarian hyperstimulation, Multiple
    pregnancy

33
Management
  • 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

34
Management (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

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Intracytoplasmic sperm injection (ICSI)
40 of IVF cycles involve insemination by ICSI
38
Day 2 - Day 3 Embryo Development

39
Day 5 Embryo development

40
Day 5 Embryo Transfer
  • Advantages
  • Embryo Selection
  • Reduction in number of embryos for ET resulting
    in reduction in multiple gestations

41
Psychological
  • The psychological stress associated with
    infertility must be recognized and patients
    should be counseled appropriately.

42
Egg Donation
  • For patients with poor ovarian reserve
  • Alternative to adoption or childlessness
  • Success Rate 50 per cycle

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