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INFERTILITY

dr. Amelia Wahyuni, SpOG

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Definition

Infertility

Inability to conceive after one year of unprotected

intercourse

Fertility

Ability to conceive

Fecundity

Ability to carry to delivery

Incidence

80% conceive within 1 year of unprotected

intercourse

~14-20% of US couples are infertile by

definition

Origin:

Female factor ~40%

Male factor ~30%

Combined ~30%

Etiologies

Sperm disorders 30.6%

Anovulation/oligoovulation 30%

Tubal disease 16%

Unexplained 13.4%

Cx factors 5.2%

Peritoneal factors 4.8%

Male infertility

Male infertility

Associated Factors

PID

Endometriosis

Ovarian aging

Spermatic varicocoele

Toxins

Previous abdominal surgery (adhesions)

Cervical/uterine abnormalities

Cervical/uterine surgery

Fibroids

Overview of Evaluation

Female

Ovary

Tube

Corpus

Cervix

Peritoneum

Male

Sperm count and function

Ejaculate characteristics, immunology

Anatomic anomalies

The Most Important Factor in the

Evaluation of the Infertile Couple

Is:

HISTORY

History-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

History-Male

History of pelvic infection

Radiation, toxic exposures (include drugs)

Mumps

Testicular surgery/injury

Excessive heat exposure (spermicidal)

History-Female

Previous female pelvic surgery

PID

Appendicitis

IUD use

Ectopic pregnancy history

Endometriosis

History-Female

Irregular menses, amenorrhea, detailed menstrual history

Vasomotor symptoms

Stress

Weight changes

Exercise

Cervical and uterine surgery

Physical Exam-Male

Size of testicles

Testicular descent

Varicocoele

Outflow abnormalities (hypospadias, etc)

Physical Exam-Female

Pelvic masses

Uterosacral nodularity

Abdominopelvic tenderness

Uterine enlargement

Thyroid exam

Uterine mobility

Cervical abnormalities

Work-up by Organ Unit

Female

Ovary

Tube

Corpus

Cervix

Peritoneum

Ovarian Function

Document ovulation:

BBT

Luteal phase progesterone

LH surge

If POF suspected, perform FSH

TSH, PRL, adrenal functions if indicated

The only convincing proof of ovulation is pregnancy

Ovarian Function

Three main types of dysfunction

Hypogonadotrophic, hypoestrogenic (central)

Normogonadotrophic, normoestrogenic (e.g.

PCOS)

Hypergonadotrophic, hypoestrogenic (POF)

Siklus Haid

Siklus Haid

BBT

Cheap and easy, but…

Inconsistent results

Provides evidence after the fact (like the old story

about the barn door and the horse)

May delay timely diagnosis and treatment

98% of women will ovulate within 3 days of the nadir

BBT

BBT

Luteal 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

Urinary LH Kits

Very sensitive and accurate

Positive test precedes ovulation by ~24 hours,

so useful for timing intercourse

Downside: price, obsession with timing of intercourse

LH Surge

LH Surge

Endometrial Biopsy

Invasive

Pregnancy loss rate <1%

Perform around 2 days before expected menstruation (= day 28 by definition)

Endometrial Biopsy

Endometrial Biopsy

Tubal 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)

Hysterosalpingography (HSG)

Radiologic procedure requiring contrast

Performed 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 H 2 O-based May be associated with fertility rates

HSG

HSG

HSG

HSG

Laparoscopy

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

Laparoscopy

Laparoscopy

Laparoscopy

Laparoscopy

Corpus

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

Hysteroscopy

Hysteroscopy

Hysteroscopy

Hysteroscopy
Hysteroscopy

Cervical Function

Infection

Ureaplasma suspected

Stenosis

Immunologic Factors

Sperm-mucus interaction

Male Factors

Male Factors

Male Factors

Serum FSH, PRL levels

Semen analysis

Testicular biopsy

Sperm penetration assay (SPA)

Male Factors-Semen Analysis

Collected after 48 hour of abstinence

Evaluated within one hour of ejaculation

If abnormal parameters, repeat twice, 2 weeks

apart

Normal Semen Analysis

Quality Volume Concentration Initial Forward Motility Normal Morphology Normal Value >1 cc >2 x 10
Quality Volume Concentration Initial Forward Motility Normal Morphology Normal Value >1 cc >2 x 10
Quality Volume Concentration Initial Forward Motility Normal Morphology Normal Value >1 cc >2 x 10
Quality Volume Concentration Initial Forward Motility Normal Morphology Normal Value >1 cc >2 x 10

Quality

Volume

Concentration

Initial Forward

Motility

Normal Morphology

Normal Value

>1 cc

>2 x 10 6 /cc

>50%

>60%

Sperm Penetration 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

Treatment Options

Ovarian Disorders

Anovulation

Clomiphene Citrate ± hCG

hMG

Induction + IUI (often done but unjustified)

PRL

Bromocriptine

macroadenoma

POF

?high-dose hMG (not very effective)

Ovarian Disorders

Central amenorrhea

CC first, then hMG

Pulsatile GnRH

LPD

Progesterone suppositories during luteal phase

CC ± hCG

Ovulation Induction

CC

70% induction rate, ~40% pregnancy rate

Patients should typically be normoestrogenic

Induce menses and start on day 5

With

Multifetal rates 5-10%

dosages, antiestrogen effects dominate

Corpus

Asherman syndrome

Hysteroscopic lysis of adhesions (scissor)

Postop Abx, E 2

Fibroids (rarely need treatment)

Myomectomy(hysteroscopic, laparoscopic, open)

??UAE

Uterine anomalies (rarely need treatment)

metroplasty

Cervix

Repeat test to rule out inaccurate timing of test

If cervicitis

If scant mucus

Sperm motility issues (? Antisperm AB’s)

Abx

• If scant mucus • Sperm motility issues (? Antisperm AB’s) Abx low-dose estrogen – Steroids?

low-dose estrogen

• If scant mucus • Sperm motility issues (? Antisperm AB’s) Abx low-dose estrogen – Steroids?

Steroids?

IUI

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)

Chances of pregnancy highest within 6

mos-1 year after treatment

Male Factor

Hypogonadotrophism

GnRH

CC, hCG results poor

Varicocoele

Ligation? (no definitive data yet)

Male Factor

Idiopathic oligospermia

No effective treatment

?IVF

donor insemination

Unexplained 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

Summary

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

Thank you!

Thank you!