infertilityinfertility zeev blumenfeld, m.d. reproductive endocrinology, dept. obstetrics &...
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InfertilityInfertilityInfertilityInfertility
Zeev Blumenfeld, M.D.Zeev Blumenfeld, M.D.
Reproductive Endocrinology,Reproductive Endocrinology, Dept. Obstetrics & GynecologyDept. Obstetrics & Gynecology
Rambam Health Care Campus, Faculty of Medicine,Rambam Health Care Campus, Faculty of Medicine,Technion- Israel Institute of Technology (IIT)Technion- Israel Institute of Technology (IIT)
Haifa, IsraelHaifa, Israel
Zeev Blumenfeld, M.D.Zeev Blumenfeld, M.D.
Reproductive Endocrinology,Reproductive Endocrinology, Dept. Obstetrics & GynecologyDept. Obstetrics & Gynecology
Rambam Health Care Campus, Faculty of Medicine,Rambam Health Care Campus, Faculty of Medicine,Technion- Israel Institute of Technology (IIT)Technion- Israel Institute of Technology (IIT)
Haifa, IsraelHaifa, Israel
DefinitionsDefinitionsDefinitionsDefinitions
• Infertility– Inability to conceive after one year of
unprotected intercourse (6 months for women over 35?)
• Fertility– Ability to conceive
• Fecundity– Ability to carry to delivery
• Infertility– Inability to conceive after one year of
unprotected intercourse (6 months for women over 35?)
• Fertility– Ability to conceive
• Fecundity– Ability to carry to delivery
StatisticsStatisticsStatisticsStatistics• 80% of couples will conceive within 1 year of
unprotected intercourse• ~86% will conceive within 2 years• ~14-20% of US couples are infertile by definition
(~3 million couples)• Origin:
– Female factor ~40%– Male factor ~30%– Combined ~30%
• 80% of couples will conceive within 1 year of unprotected intercourse
• ~86% will conceive within 2 years• ~14-20% of US couples are infertile by definition
(~3 million couples)• Origin:
– Female factor ~40%– Male factor ~30%– Combined ~30%
EtiologiesEtiologiesEtiologiesEtiologies
• Sperm disorders 30%
• Anovulation/oligo-ovulation 30%
• Tubal disease 15%
• Unexplained 15%
• Cx factors 5%
• Peritoneal factors 5%
• Sperm disorders 30%
• Anovulation/oligo-ovulation 30%
• Tubal disease 15%
• Unexplained 15%
• Cx factors 5%
• Peritoneal factors 5%
Associated FactorsAssociated FactorsAssociated FactorsAssociated Factors• PID• Endometriosis • Ovarian aging• Spermatic varicocoele• Toxins • Previous abdominal surgery (adhesions)• Cervical/uterine abnormalities• Cervical/uterine surgery• Fibroids
• PID• Endometriosis • Ovarian aging• Spermatic varicocoele• Toxins • Previous abdominal surgery (adhesions)• Cervical/uterine abnormalities• Cervical/uterine surgery• Fibroids
Emotional & Educational NeedsEmotional & Educational NeedsEmotional & Educational NeedsEmotional & Educational Needs
• Disease of couples, not individuals
• Feelings of guilt
• Where to go for information?
• Options
• Feelings of frustration and anger
• Support groups (e.g. Resolve)
• Disease of couples, not individuals
• Feelings of guilt
• Where to go for information?
• Options
• Feelings of frustration and anger
• Support groups (e.g. Resolve)
Overview of EvaluationOverview of EvaluationOverview of EvaluationOverview of Evaluation• Female
– Ovary– Tube – Corpus– Cervix– Peritoneum
• Male– Sperm count and function– Ejaculate characteristics, immunology– Anatomic anomalies
• Female – Ovary– Tube – Corpus– Cervix– Peritoneum
• Male– Sperm count and function– Ejaculate characteristics, immunology– Anatomic anomalies
The Most Important Factor in The Most Important Factor in the Evaluation of the Infertile the Evaluation of the Infertile
Couple Is:Couple Is:
The Most Important Factor in The Most Important Factor in the Evaluation of the Infertile the Evaluation of the Infertile
Couple Is:Couple Is:
HISTORYHISTORYHISTORYHISTORY
History-GeneralHistory-GeneralHistory-GeneralHistory-General
• Both couples should be present• Age• Previous pregnancies by each partner• Length of time without pregnancy• Sexual history
– Frequency and timing of intercourse– Use of lubricants– Impotence, anorgasmia, dyspareunia– Contraceptive history
• Both couples should be present• Age• Previous pregnancies by each partner• Length of time without pregnancy• Sexual history
– Frequency and timing of intercourse– Use of lubricants– Impotence, anorgasmia, dyspareunia– Contraceptive history
History-MaleHistory-MaleHistory-MaleHistory-Male
• History of pelvic infection
• Radiation, toxic exposures (include drugs)
• Mumps
• Testicular surgery/injury
• Excessive heat exposure (spermicidal)
• History of pelvic infection
• Radiation, toxic exposures (include drugs)
• Mumps
• Testicular surgery/injury
• Excessive heat exposure (spermicidal)
History-FemaleHistory-FemaleHistory-FemaleHistory-Female
• Previous female pelvic surgery
• PID
• Appendicitis
• IUD use
• Ectopic pregnancy history
• DES (?relation to infertility)
• Endometriosis
• Previous female pelvic surgery
• PID
• Appendicitis
• IUD use
• Ectopic pregnancy history
• DES (?relation to infertility)
• Endometriosis
Mechanical/Pelvic factor infertilityMechanical/Pelvic factor infertilityDistal tubal occlusionDistal tubal occlusion
Mechanical/Pelvic factor infertilityMechanical/Pelvic factor infertilityDistal tubal occlusionDistal tubal occlusion
PID - 13% post PIDx1 - 39% post PIDx2 - 75% post PIDx3EndometriosisSurgical injuryPeritoneal infection
PID - 13% post PIDx1 - 39% post PIDx2 - 75% post PIDx3EndometriosisSurgical injuryPeritoneal infection
History-FemaleHistory-FemaleHistory-FemaleHistory-Female
• Irregular menses, amenorrhea, detailed menstrual history
• Vasomotor symptoms • Stress• Weight changes• Exercise• Cervical and uterine surgery
• Irregular menses, amenorrhea, detailed menstrual history
• Vasomotor symptoms • Stress• Weight changes• Exercise• Cervical and uterine surgery
When Not to Pursue an When Not to Pursue an Infertility EvaluationInfertility Evaluation
When Not to Pursue an When Not to Pursue an Infertility EvaluationInfertility Evaluation
• Patient not sexually-active
• Patient not in long-term relationship?
• Patient declines treatment at this time
• Couple does not meet the definition of an infertile couple
• Patient not sexually-active
• Patient not in long-term relationship?
• Patient declines treatment at this time
• Couple does not meet the definition of an infertile couple
Physical Exam-MalePhysical Exam-MalePhysical Exam-MalePhysical Exam-Male
• Size of testicles
• Testicular descent
• Varicocoele
• Outflow abnormalities (hypospadias, etc)
• Size of testicles
• Testicular descent
• Varicocoele
• Outflow abnormalities (hypospadias, etc)
Physical Exam-FemalePhysical Exam-FemalePhysical Exam-FemalePhysical Exam-Female
• Pelvic masses
• Uterosacral nodularity
• Abdominopelvic tenderness
• Uterine enlargement
• Thyroid exam
• Uterine mobility
• Cervical abnormalities
• Pelvic masses
• Uterosacral nodularity
• Abdominopelvic tenderness
• Uterine enlargement
• Thyroid exam
• Uterine mobility
• Cervical abnormalities
Overall Guidelines for Work-upOverall Guidelines for Work-up Overall Guidelines for Work-upOverall Guidelines for Work-up
• Work- up can usually be accomplished in 1-2 cycles [“Cycle Evaluation”]
• Timing of tests
• Don’t over test
• Cut to the chase, i.e. proceed with laparoscopy if adhesive disease is likely
• Work- up can usually be accomplished in 1-2 cycles [“Cycle Evaluation”]
• Timing of tests
• Don’t over test
• Cut to the chase, i.e. proceed with laparoscopy if adhesive disease is likely
Work-up by Organ UnitWork-up by Organ Unit
OvaryOvary
Ovarian FunctionOvarian FunctionOvarian FunctionOvarian Function
• Document ovulation:– BBT– Luteal phase progesterone – LH surge– Endom. Bx
• If POF suspected, perform FSH• TSH, PRL, adrenal functions if indicated
• The only convincing proof of ovulation is pregnancy
• Document ovulation:– BBT– Luteal phase progesterone – LH surge– Endom. Bx
• If POF suspected, perform FSH• TSH, PRL, adrenal functions if indicated
• The only convincing proof of ovulation is pregnancy
Ovarian FunctionOvarian FunctionOvarian FunctionOvarian Function
• Three main types of dysfunction– Hypogonadotrophic, hypoestrogenic
(central)– Normogonadotropic,normoestrogenic
(e.g. PCOS)– Hypergonadotrophic, hypoestrogenic
(POF)
• Three main types of dysfunction– Hypogonadotrophic, hypoestrogenic
(central)– Normogonadotropic,normoestrogenic
(e.g. PCOS)– Hypergonadotrophic, hypoestrogenic
(POF)
BBTBBTBBTBBT• Cheap and easy, but…
Inconsistent resultsRetrospective May delay timely diagnosis and treatment98% of women will ovulate within 3 days
of the nadirBiphasic profiles can also be seen with
LUF syndrome
• Cheap and easy, but…Inconsistent resultsRetrospective May delay timely diagnosis and treatment98% of women will ovulate within 3 days
of the nadirBiphasic profiles can also be seen with
LUF syndrome
Luteal Phase ProgesteroneLuteal Phase ProgesteroneLuteal Phase ProgesteroneLuteal Phase Progesterone
Pulsatile release, thus single level may not be useful unless elevated
Performed 7 days after presumptive ovulation
Done properly, >15 ng/ml consistent with ovulation
Pulsatile release, thus single level may not be useful unless elevated
Performed 7 days after presumptive ovulation
Done properly, >15 ng/ml consistent with ovulation
Urinary LH KitsUrinary LH KitsUrinary LH KitsUrinary LH Kits
Sensitive and accuratePositive test precedes ovulation by ~24
hours, so useful for timing intercourseDownside: price, obsession with
timing of intercourse
Sensitive and accuratePositive test precedes ovulation by ~24
hours, so useful for timing intercourseDownside: price, obsession with
timing of intercourse
Endometrial BiopsyEndometrial Biopsy Endometrial BiopsyEndometrial Biopsy Invasive, but the only reliable way to diagnose
LPD ??Is LPD a genuine disorder??? Pregnancy loss rate <1% Perform around 2 days before expected
menstruation (= day 28 by definition) Lag of >2 days is consistent with LPD Must be done in two different cycles to confirm
diagnosis of LPD
Invasive, but the only reliable way to diagnose LPD
??Is LPD a genuine disorder??? Pregnancy loss rate <1% Perform around 2 days before expected
menstruation (= day 28 by definition) Lag of >2 days is consistent with LPD Must be done in two different cycles to confirm
diagnosis of LPD
Fallopian TubesFallopian Tubes
Tubal FunctionTubal FunctionTubal FunctionTubal Function
Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition
Kartagener’s syndrome can be associated with decreased tubal motility
Tests HSG Laparoscopy Falloposcopy (not widely available)
Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition
Kartagener’s syndrome can be associated with decreased tubal motility
Tests HSG Laparoscopy Falloposcopy (not widely available)
Hysterosalpingography (HSG)Hysterosalpingography (HSG)Hysterosalpingography (HSG)Hysterosalpingography (HSG)
Radiologic procedure requiring contrastPerformed optimally in early proliferative phase
(avoids pregnancy)Low risk of PID except if previous history of PID
(give prophylactic doxycycline or consider laparoscopy)
Oil-based contrast Higher risk of anaphylaxis than H2O-based May be associated with fertility rates
Radiologic procedure requiring contrastPerformed optimally in early proliferative phase
(avoids pregnancy)Low risk of PID except if previous history of PID
(give prophylactic doxycycline or consider laparoscopy)
Oil-based contrast Higher risk of anaphylaxis than H2O-based May be associated with fertility rates
Hysterosalpingography (HSG)Hysterosalpingography (HSG)Hysterosalpingography (HSG)Hysterosalpingography (HSG)
• Can be uncomfortable
• Pregnancy test is advisable
• Can detect intrauterine and tubal disorders but not always definitive
• Can be uncomfortable
• Pregnancy test is advisable
• Can detect intrauterine and tubal disorders but not always definitive
LaparoscopyLaparoscopy LaparoscopyLaparoscopy
• Invasive; requires OR or office setting• Can offer diagnosis and treatment in one sitting• Not necessary in all patients• Uses (examples):
– Lysis of adhesions– Diagnosis and excision of endometriosis– Myomectomy – Tubal reconstructive surgery
• Invasive; requires OR or office setting• Can offer diagnosis and treatment in one sitting• Not necessary in all patients• Uses (examples):
– Lysis of adhesions– Diagnosis and excision of endometriosis– Myomectomy – Tubal reconstructive surgery
FalloposcopyFalloposcopyFalloposcopyFalloposcopy
• Hysteroscopic procedure with cannulation of the Fallopian tubes
• Can be useful for diagnosis of intraluminal pathology
• Promising technique but not yet widespread
• Hysteroscopic procedure with cannulation of the Fallopian tubes
• Can be useful for diagnosis of intraluminal pathology
• Promising technique but not yet widespread
Uterine CorpusUterine Corpus
CorpusCorpusCorpusCorpus• Asherman Syndrome
– Diagnosis by HSG or hysteroscopy– Usually s/p D+C, myomectomy, other intrauterine
surgery– Associated with hypo/amenorrhea, recurrent miscarriage
• Fibroids, Uterine Anomalies– Rarely associated with infertility– Work-up:
• Ultrasound • Hysteroscopy• Laparoscopy
• Asherman Syndrome– Diagnosis by HSG or hysteroscopy– Usually s/p D+C, myomectomy, other intrauterine
surgery– Associated with hypo/amenorrhea, recurrent miscarriage
• Fibroids, Uterine Anomalies– Rarely associated with infertility– Work-up:
• Ultrasound • Hysteroscopy• Laparoscopy
CervixCervix
Cervical FunctionCervical FunctionCervical FunctionCervical Function
• Infection– Ureaplasma suspected
• Stenosis– S/P LEEP, Cryosurgery, Cone biopsy (probably
overstated)
• Immunologic Factors– Sperm-mucus interaction
• Infection– Ureaplasma suspected
• Stenosis– S/P LEEP, Cryosurgery, Cone biopsy (probably
overstated)
• Immunologic Factors– Sperm-mucus interaction
Cervical FunctionCervical FunctionCervical FunctionCervical Function
• Tests:– Culture for suspected pathogens – Postcoital test (PCT)
• Scheduled around 1-2d before ovulation (increased estrogen effect)
• 480 of male abstinence before test• No lubricants• Evaluate 8-12h after coitus (overnight is ok!)• Remove mucus from cervix (forceps, syringe)
• Tests:– Culture for suspected pathogens – Postcoital test (PCT)
• Scheduled around 1-2d before ovulation (increased estrogen effect)
• 480 of male abstinence before test• No lubricants• Evaluate 8-12h after coitus (overnight is ok!)• Remove mucus from cervix (forceps, syringe)
SpinnbarkeitSpinnbarkeit FerningFerningLate follicular Late follicular phasephase
Watery, thin & Watery, thin & acellularacellular
Cervical MucusCervical Mucus
Cervical FunctionCervical FunctionCervical FunctionCervical Function
• PCT, continued (normal values in yellow)– Quantity (very subjective)– Quality (spinnbarkeit) (>8 cm)– Clarity (clear)– Ferning (branched)– Viscosity (thin)– WBC’s (~0)
– # progressively motile sperm/hpf (5-10/hpf)– Gross sperm morphology (WNL)
• PCT, continued (normal values in yellow)– Quantity (very subjective)– Quality (spinnbarkeit) (>8 cm)– Clarity (clear)– Ferning (branched)– Viscosity (thin)– WBC’s (~0)
– # progressively motile sperm/hpf (5-10/hpf)– Gross sperm morphology (WNL)
Male factorsMale factorsMale factorsMale factors
Problems with the PCT Problems with the PCT Problems with the PCT Problems with the PCT
• Subjective
• Timing varies; may need to be repeated
• In some studies, “infertile” couples with an abnormal PCT conceived successfully during that same cycle
• Subjective
• Timing varies; may need to be repeated
• In some studies, “infertile” couples with an abnormal PCT conceived successfully during that same cycle
PeritoneumPeritoneum
Peritoneal FactorsPeritoneal FactorsPeritoneal FactorsPeritoneal Factors
• Endometriosis – 2x relative risk of infertility– Diagnosis (and best treatment) by laparoscopy – Can be familial; can occur in adolescents– Etiology unknown but likely multiple ones
• Retrograde menstruation• Immunologic factors• Genetics• Lymphatic or Hematogenic spread
– Medical options remain suboptimal
• Endometriosis – 2x relative risk of infertility– Diagnosis (and best treatment) by laparoscopy – Can be familial; can occur in adolescents– Etiology unknown but likely multiple ones
• Retrograde menstruation• Immunologic factors• Genetics• Lymphatic or Hematogenic spread
– Medical options remain suboptimal
Male FactorsMale Factors
Male FactorsMale FactorsMale FactorsMale Factors
• Serum T, FSH, PRL levels
• Semen analysis
• Testicular biopsy
• Sperm penetration assay (SPA)
• Serum T, FSH, PRL levels
• Semen analysis
• Testicular biopsy
• Sperm penetration assay (SPA)
Male Factors-Semen AnalysisMale Factors-Semen AnalysisMale Factors-Semen AnalysisMale Factors-Semen Analysis
• Collected after 480 of abstinence
• Evaluated within one hour of ejaculation
• If abnormal parameters, repeat twice, 2 weeks apart
• Collected after 480 of abstinence
• Evaluated within one hour of ejaculation
• If abnormal parameters, repeat twice, 2 weeks apart
Normal Semen AnalysisNormal Semen AnalysisNormal Semen AnalysisNormal Semen Analysis
Quality Normal Value
Volume >1 cc
Concentration >2 x 106/cc
Initial ForwardMotility
>50%
Normal Morphology >60%
Quality Normal Value
Volume >1 cc
Concentration >2 x 106/cc
Initial ForwardMotility
>50%
Normal Morphology >60%
Male factor evaluationMale factor evaluationSpermiogramSpermiogram
Sperm Penetration AssaySperm Penetration AssaySperm Penetration AssaySperm Penetration Assay
• “Zona-free Hamster Ova Assay”
• Dynamic test of fertilization capacity of sperm
• Failure to penetrate at least 10% of zona-free ova consistent with male factor
• False positives and negatives exist
• “Zona-free Hamster Ova Assay”
• Dynamic test of fertilization capacity of sperm
• Failure to penetrate at least 10% of zona-free ova consistent with male factor
• False positives and negatives exist
Male factor Male factor Endocrine evaluationEndocrine evaluation
Male Factor EvaluationMale Factor EvaluationGeneticsGenetics
• CBAVD, CUAVD
Epididymal obstruction Ejaculatory duct obstruction
• Non-obstructive AZO
Severe OTA
• Non-Obstructive AZO
Severe OTA
CF gene mutations
Karyotype
Y-microdeletions
Treatment OptionsTreatment Options
Ovarian DisordersOvarian DisordersOvarian DisordersOvarian DisordersAnovulation
Clomiphene Citrate ± hCG FSH, hMG/hCG Induction + IUI (often done but unjustified)
PRLBromocriptine [ Parlodel,Parilac 1.25-10 mg/day, bid],Cabergoline [Dostinex 0.5 mg/week]], Octahydrobenzoquinoline [Norprolac 75-300g/day]TSR if macroadenoma
POF ?high-dose hMG (not very effective)
Anovulation Clomiphene Citrate ± hCG FSH, hMG/hCG Induction + IUI (often done but unjustified)
PRLBromocriptine [ Parlodel,Parilac 1.25-10 mg/day, bid],Cabergoline [Dostinex 0.5 mg/week]], Octahydrobenzoquinoline [Norprolac 75-300g/day]TSR if macroadenoma
POF ?high-dose hMG (not very effective)
Ovulatory DisordersOvulatory DisordersOvulatory DisordersOvulatory Disorders
• Central amenorrhea– CC first, then hMG– Pulsatile GnRH
• LPD– Progesterone suppositories during luteal phase– CC ± hCG
• Central amenorrhea– CC first, then hMG– Pulsatile GnRH
• LPD– Progesterone suppositories during luteal phase– CC ± hCG
Ovarian MatrixOvarian MatrixOvarian MatrixOvarian MatrixGonadotropins E2 Treatment
High Low ??high-dose hMG, r/oautoimmune diseases
WNL WNL CC ± hCG
Low Low CC first, then hMG
Gonadotropins E2 Treatment
High Low ??high-dose hMG, r/oautoimmune diseases
WNL WNL CC ± hCG
Low Low CC first, then hMG
Ovulatory factor Ovulatory factor Endocrine evaluationEndocrine evaluation
FSH LH E2 PRL
• Hypothalamic Insufficiency ↓ ↓ ↓ N
• Pituitary adenoma/ N/↓ N/↓ N/↓ N/↑
HyperPRLemia
• PCO N/low ↑ N N/↑
• Ovarian failure ↑ ↑ ↓ N
Ovulation InductionOvulation InductionOvulation InductionOvulation Induction
• CC– 70% induction rate, ~40% pregnancy rate– Patients should typically be normoestrogenic– Induce menses and start on day 3-5– With dosages, antiestrogen effects dominate– Multifetal rates 5-10%– Monitor effects with PCT, pelvic exam
• CC– 70% induction rate, ~40% pregnancy rate– Patients should typically be normoestrogenic– Induce menses and start on day 3-5– With dosages, antiestrogen effects dominate– Multifetal rates 5-10%– Monitor effects with PCT, pelvic exam
Clomiphene CitrateClomiphene CitrateMechanism of ActionMechanism of Action
Response to clomipheneResponse to clomiphene
No responseNo response
OvulationOvulation & pregnancy& pregnancy
OvulationOvulation- no - no pregnancypregnancy
33%33%
Clomiphene CitrateClomiphene CitrateSide EffectsSide Effects
Clomiphene CitrateClomiphene CitrateSide EffectsSide Effects
Dysmucorrhea - 15%Hot flushes - 10%Abdominal pain - 5.5% (OHSS usually mild)Breast discomfort - 2%Nausea and vomiting - 2.2% Visual symptoms - 1.5%Headache - 1.3%Emotional liability and depression
Dysmucorrhea - 15%Hot flushes - 10%Abdominal pain - 5.5% (OHSS usually mild)Breast discomfort - 2%Nausea and vomiting - 2.2% Visual symptoms - 1.5%Headache - 1.3%Emotional liability and depression
CC- Mechaniam of ActionCC- Mechaniam of Action
hMG hMG (Pergonal,Menogon,Menopur)(Pergonal,Menogon,Menopur)
• LH +FSH (also FSH alone = Gonal-F,Puregon)• For patients with hypogonadotrophic
hypoestrogenism or normal FSH and E2 levels
• Close monitoring essential, including estradiol levels
• 60-80% pregnancy rates overall, lower for PCOS patients
• 10-15% multifetal pregnancy rate
• LH +FSH (also FSH alone = Gonal-F,Puregon)• For patients with hypogonadotrophic
hypoestrogenism or normal FSH and E2 levels
• Close monitoring essential, including estradiol levels
• 60-80% pregnancy rates overall, lower for PCOS patients
• 10-15% multifetal pregnancy rate
hMG- Mechanism of ActionhMG- Mechanism of Action
Human GonadotropinsHuman GonadotropinsResultsResults
Human GonadotropinsHuman GonadotropinsResultsResults
• Group I
Cumulative pregnancy rate after 6 months
90%
• Group II
Cumulative pregnancy rate after 6 months
40%
• Group I
Cumulative pregnancy rate after 6 months
90%
• Group II
Cumulative pregnancy rate after 6 months
40%
RisksRisks RisksRisks
CC Vasomotor symptoms Head Ache Ovarian enlargement Multiple gestation NO risk of SAb or
malformations
CC Vasomotor symptoms Head Ache Ovarian enlargement Multiple gestation NO risk of SAb or
malformations
hMGMultiple gestationOHSS (~1%)
– Can often be managed as outpatient
– Diuresis– Severe cases fatal if
untreated in ICU setting
hMGMultiple gestationOHSS (~1%)
– Can often be managed as outpatient
– Diuresis– Severe cases fatal if
untreated in ICU setting
Fallopian TubesFallopian TubesFallopian TubesFallopian Tubes
TuboplastyIVFGIFT, ZIFT not options
TuboplastyIVFGIFT, ZIFT not options
CorpusCorpusCorpusCorpus
• Asherman syndrome– Hysteroscopic lysis of adhesions (scissor)– Postop Abx, E2
• Fibroids (rarely need treatment)– Myomectomy ( hysteroscopic, laparoscopic,
open)
• Uterine anomalies (rarely need treatment)– Metroplasty, Hysteroscopy
• Asherman syndrome– Hysteroscopic lysis of adhesions (scissor)– Postop Abx, E2
• Fibroids (rarely need treatment)– Myomectomy ( hysteroscopic, laparoscopic,
open)
• Uterine anomalies (rarely need treatment)– Metroplasty, Hysteroscopy
CervixCervixCervixCervix
• Repeat PCT to rule out inaccurate timing of test
• If cervicitis Abx
• If scant mucus low-dose estrogen
• Sperm motility issues (? Antisperm AB’s)– Steroids?– IUI
• Repeat PCT to rule out inaccurate timing of test
• If cervicitis Abx
• If scant mucus low-dose estrogen
• Sperm motility issues (? Antisperm AB’s)– Steroids?– IUI
Peritoneum (Endometriosis)Peritoneum (Endometriosis)Peritoneum (Endometriosis)Peritoneum (Endometriosis)• From a fertility standpoint, excision beats medical
management• Lysis of adhesions • GnRH-a (not a cure and has side effects, expense)• Danazol (side effects, cost)• Continuous OCP’s (poor fertility rates)• Chances of pregnancy highest within 6 m’s-1 year
after treatment
• From a fertility standpoint, excision beats medical management
• Lysis of adhesions • GnRH-a (not a cure and has side effects, expense)• Danazol (side effects, cost)• Continuous OCP’s (poor fertility rates)• Chances of pregnancy highest within 6 m’s-1 year
after treatment
Male FactorMale FactorMale FactorMale Factor
• Hypogonadotrophism– hMG– GnRH– CC, hCG results poor
• Varicocoele– Ligation? (no definitive data yet)
• Retrograde ejaculation– Ephedrine, imipramine– AIH with recovered sperm
• Hypogonadotrophism– hMG– GnRH– CC, hCG results poor
• Varicocoele– Ligation? (no definitive data yet)
• Retrograde ejaculation– Ephedrine, imipramine– AIH with recovered sperm
Male FactorMale FactorMale FactorMale Factor• Idiopathic oligospermia
– No effective treatment
– ?IVF
– donor insemination
• Idiopathic oligospermia
– No effective treatment
– ?IVF
– donor insemination
Unexplained InfertilityUnexplained InfertilityUnexplained InfertilityUnexplained Infertility• 5-10% of couples• Consider PRL, laparoscopy, other hormonal tests,
cultures, ASA testing, SPA if not done• Review previous tests for validity• Empiric treatment:
– Ovulation induction– Abx– IUI– Consider IVF and its variants
• Adoption
• 5-10% of couples• Consider PRL, laparoscopy, other hormonal tests,
cultures, ASA testing, SPA if not done• Review previous tests for validity• Empiric treatment:
– Ovulation induction– Abx– IUI– Consider IVF and its variants
• Adoption
SummarySummarySummarySummary
• Infertility is a common problem• Infertility is a disease of couples• Evaluation must be thorough, but
individualized• Treatment is available, including IVF, but can
be expensive, invasive, and of limited efficacy in some cases
• Consultation with a expert reproductive endocrinologist is advisable
• Infertility is a common problem• Infertility is a disease of couples• Evaluation must be thorough, but
individualized• Treatment is available, including IVF, but can
be expensive, invasive, and of limited efficacy in some cases
• Consultation with a expert reproductive endocrinologist is advisable
Thank you!