Approach in infertile couple Approach in infertile couple

Firouzeh Akbari AsbaghFirouzeh Akbari Asbagh

Prof. of GynaecologyProf. of Gynaecology

Tehran University of Medical Tehran University of Medical SciencesSciences

oct 2014oct 2014

IntroductionIntroduction

An infertility evaluation is usually An infertility evaluation is usually initiated initiated afterafter one year one year In women under In women under age 35 yearsage 35 years

WomenWomen age 35 years and older after six age 35 years and older after six monthsmonths

Evaluation sooner in women with Evaluation sooner in women with irregularirregular

menstrual cycles or known risk factors for menstrual cycles or known risk factors for infertility such as endometriosis, history of infertility such as endometriosis, history of PID, reproductive tract malformations PID, reproductive tract malformations

Initial approachInitial approach Both partners of an infertile couple Both partners of an infertile couple should be evaluated for factors that should be evaluated for factors that could be impairing fertilitycould be impairing fertility

Counsel the couple about the possible Counsel the couple about the possible etiology and offer a treatment planetiology and offer a treatment plan

The clinician should not ignore the The clinician should not ignore the couples emotional state witch may couples emotional state witch may include depression, anger, anxiety, include depression, anger, anxiety, andMaterial discord information should andMaterial discord information should be supportive and informativebe supportive and informative

HistoryHistory The most important points areThe most important points are::

Duration of infertility Duration of infertility and results of previous and results of previous evaluation and therapyevaluation and therapy

Menstrual history (cycle length and characteristic )Menstrual history (cycle length and characteristic )

Helps in determining ovulatory statusHelps in determining ovulatory status

Medical, surgical, and gynecology history Medical, surgical, and gynecology history PID thyroid disease, galactorrhea, hirsutism, PID thyroid disease, galactorrhea, hirsutism, pelvic, dysmenorrhea, or dyspareuniapelvic, dysmenorrhea, or dyspareunia

Young women who have undergone Young women who have undergone unilateral unilateral oophorectomy oophorectomy generally do not reduced fertility but in generally do not reduced fertility but in older women as they may develop diminished ovarian older women as they may develop diminished ovarian reserve sooner than women with two ovariesreserve sooner than women with two ovaries

Obstetrical history Obstetrical history outcome in a future outcome in a future pregnancypregnancy

Sexual history Sexual history including sexual including sexual dysfunction and frequency of coitusdysfunction and frequency of coitus

Family history Family history including family, birth including family, birth

defects, genetic mutations, or mental defects, genetic mutations, or mental retardationretardation

Women with fragile X permutation may Women with fragile X permutation may develop POF develop POF

Personal and lifestyle history Personal and lifestyle history including including age, occupation, exercise, stress, age, occupation, exercise, stress, dieting/changes in weight, smoking, and dieting/changes in weight, smoking, and alcohol use, all of which can affect alcohol use, all of which can affect fertilityfertility

Physical examination Physical examination Physical examination should assess for signs of potential causes Physical examination should assess for signs of potential causes of infertilityof infertility BMI ,secondary sexual characteristics BMI ,secondary sexual characteristics Hypogonadotropic hypoganadism , turner syndrome Hypogonadotropic hypoganadism , turner syndrome Abnormalities of the thyroid gland, galactorrhea, androgen Abnormalities of the thyroid gland, galactorrhea, androgen excess ( hirsutism …), PCOexcess ( hirsutism …), PCO Endometriosis (tenderness or masses in the adenxae or Endometriosis (tenderness or masses in the adenxae or posterior cul-de-sac (pouch of Douglas) posterior cul-de-sac (pouch of Douglas) Palpable tender nodulesPalpable tender nodules Vaginal / cervical structural abnormalities Vaginal / cervical structural abnormalities Uterine enlargement, irregularity, or lack of mobility are sings of Uterine enlargement, irregularity, or lack of mobility are sings of a uterine anomaly, leiomyoma, endometriosis, or pelvic a uterine anomaly, leiomyoma, endometriosis, or pelvic adhesive disease adhesive disease

Assessment of ovulatory functionAssessment of ovulatory function

Laboratory assessmentLaboratory assessment

Mid-luteal phase serum progesterone Mid-luteal phase serum progesterone

level >3 ng/ml level >3 ng/ml Urinary ovulation prediction kit ( detect Urinary ovulation prediction kit ( detect

LH surg) LH surg)

5 to 10 % false positive and negative 5 to 10 % false positive and negative Daily ultrasound to follow the Daily ultrasound to follow the

development of the follicle development of the follicle Endometrial biopsy Endometrial biopsy it is not good test it is not good test

((too expensive or invasive uncomfortable)too expensive or invasive uncomfortable)ASRMASRM affirmed the lack of benefit of the endometrial affirmed the lack of benefit of the endometrial

biopsy in the evaluation of the infertile female and dose biopsy in the evaluation of the infertile female and dose not recommendnot recommend

AAssessment of ovarian reservessessment of ovarian reserve Ovarian reserve can refer to diminished oocyte quality, Ovarian reserve can refer to diminished oocyte quality, oocyte quantity or reproductive potentialoocyte quantity or reproductive potential

Over 35 years of age and younger women with Over 35 years of age and younger women with risk factors POFrisk factors POF

Day 3 FSH (advantage: cost , simple ) Day 3 FSH (advantage: cost , simple ) less than 10 mlU /ml adequate ovarian reserve less than 10 mlU /ml adequate ovarian reserve

Levels 10 to 15 mlU /ml borderline Levels 10 to 15 mlU /ml borderline

FSH more than 20 mlU /ml insufficient FSH more than 20 mlU /ml insufficient

day 3 estradiol levels day 3 estradiol levels <80 pg/ml adequate ovarian <80 pg/ml adequate ovarian reserve reserve

day 3 estradiol levels >80 pg/ml high cancellation day 3 estradiol levels >80 pg/ml high cancellation ratesrates

Low pregnancy Low pregnancy raterate

day 3 estradiol levels >100 pg/ml 0% pregnancy day 3 estradiol levels >100 pg/ml 0% pregnancy raterate

Clomiphene citrate challenge test (CCCT) Clomiphene citrate challenge test (CCCT)

Antral follicle count (AFC)Antral follicle count (AFC)

TVSTVSSize (2 to 10 mm)Size (2 to 10 mm) low AFC ranging from 4 to 10 antral follicles between low AFC ranging from 4 to 10 antral follicles between days two and four of a regular menstrual cycle suggests days two and four of a regular menstrual cycle suggests poor ovarian reservepoor ovarian reserve

AFC is a good predictor of ovarian reserve and AFC is a good predictor of ovarian reserve and response less predictive of oocyte quality theresponse less predictive of oocyte quality the

ability to conceive with IVF and pregnancy ability to conceive with IVF and pregnancy outcomeoutcome

Anti- Mullerian hormone (AMH)Anti- Mullerian hormone (AMH)

AMH level an early, reliable, direct indicator AMH level an early, reliable, direct indicator of declining ovarian function of declining ovarian function Patients have had significant ovarian injury from Patients have had significant ovarian injury from radiation or surgery radiation or surgery

Patient planning IVF AMH level correlates Patient planning IVF AMH level correlates with the number of oocytes retrieved after with the number of oocytes retrieved after stimulation and is the stimulation and is the best biomarkerbest biomarker for for predicting poor and excessive ovarian responsepredicting poor and excessive ovarian response

Measured anytime during the menstrual cycle Measured anytime during the menstrual cycle

General guidelinesGeneral guidelines

AMHAMH <0.5 ng/ml <0.5 ng/ml predicts reduced ovarian predicts reduced ovarian reserve with less than three follicles in an IVF cyclereserve with less than three follicles in an IVF cycle

AMH <1.0 ng/ml AMH <1.0 ng/ml predicts baseline ovarian predicts baseline ovarian reserve with a likelihood of limited eggs at retrievalreserve with a likelihood of limited eggs at retrieval

AMH >1.0 ng/ml but <3.5 ng/ml AMH >1.0 ng/ml but <3.5 ng/ml suggests a good suggests a good response to stimulationresponse to stimulation

AMHAMH >3.5 ng/ml >3.5 ng/ml predicts a vigorous response to predicts a vigorous response to ovarian stimulation and caution should be ovarian stimulation and caution should be exercised in order to avoid OHSS exercised in order to avoid OHSS

Assessment fallopian tube patencyAssessment fallopian tube patency&&

Uterine cavityUterine cavity

HSGHSG

first -line testfirst -line testWater or lipid soluble contrastWater or lipid soluble contrast

Abnormalities such as Submucous fibroids a T- shaped cavity, Abnormalities such as Submucous fibroids a T- shaped cavity, polips, synechiae, and congenital Mullerian anomaliespolips, synechiae, and congenital Mullerian anomalies

HSG is not useful for detecting peritubal adhesions HSG is not useful for detecting peritubal adhesions or endometriosisor endometriosis

Abnormalities found on HSG hysteroscopy, or Abnormalities found on HSG hysteroscopy, or laparoscopylaparoscopy

hysteroscopy definitive method for evaluation abnormalities hysteroscopy definitive method for evaluation abnormalities of the endometrial cavity diagnosis and treatmentof the endometrial cavity diagnosis and treatment

Chlamydia antibodiesChlamydia antibodies

Hysterosalpango- contrast Hysterosalpango- contrast sonography (HyCoSy)sonography (HyCoSy)

Safe well tolerated, quick and easy Safe well tolerated, quick and easy method for obtaining information on method for obtaining information on tubal status the uterine cavity, the tubal status the uterine cavity, the ovaries, and the myometrium using ovaries, and the myometrium using conventional ultrasoundconventional ultrasound

HyCoSyHyCoSy is a simple time –efficient and is a simple time –efficient and effective method for evaluation of tubal effective method for evaluation of tubal patency, the uterine cavity , and the patency, the uterine cavity , and the myometriummyometrium

Role of laparoscopyRole of laparoscopy

The evaluation of infertility is ControversialThe evaluation of infertility is Controversial

Invasive and expensiveInvasive and expensive

IndicationIndication

Endometriosis and adhesions/tubal disease…Endometriosis and adhesions/tubal disease…

Laparoscopy and hysteroscopy Laparoscopy and hysteroscopy

Test of limited clinical utilityTest of limited clinical utility

postictal testpostictal testNot recommendNot recommendBasal body temperature recordsBasal body temperature recordsZona- free hamster oocyte Zona- free hamster oocyte penetration testpenetration testMycoplasma culturesMycoplasma cultureskaryotypekaryotype