Infertility Infertility workup/evaluation

- Inability to conceive after one year of coitus without contraception - Ovarian function
o Normal monthly fecundity rate (chance of pregnancy per - Testicular function
month): 20-25% for women 20-30 years of age - Tubal patency
Begins to decline by age 32 years - Normalcy of uterus
Decreases to <10% after age 35 years of age
Consider work up in women 35 History
years after 6 months w/o conception - Menstrual cycle determine ovulation status
- 10-20% of couples experience infertility - Couples pattern of coitus
- Nutritional status
Etiology - Caffeine intake
o Male factors 30-40% o >300mg/d is associated w/ infertility, should be <200
Varicocele (55%) MCC - Substance abuse smoking, alcohol, marijuana and other illicit drugs
Testicular failure (15%) - PMH thyroid disease, DM, STI, abnormal pap smears, h/o exposure
Vas deferens obstruction (10%) to DES in utero
Cryptorchidism (10%) o h/o sexual activity and partners PMH
Semen volume abnormalities (5%) - FMH h/o early ovarian failure, h/o infertility
Immunological factors (5%) - Meds
o Female factors 40% o recent history of discontinuation of Depo-Provera (18-22m)
Ovulatory dysfunction (40%) o men CCB reduce sperm capacity
PCOS - Normal gonadotropins: malformations and lesions
Hyerprolactinemia - Structural abnormalities of uterus and vagina?
Hypothyroidism - PCOS or symptoms of PCOS
Pituitary dysfunction - Hypogonadotropic: central problem
Adrenal hyperplasia - Galactorrhea? Vision problems?
Hypothalamic amenorrhea - Symptoms of brain tumor
Tubal Disease (30%) - Severe hypothyroidism?
Cervical Factors (15%) - Head trauma?
Uterine factors
Ashermans syndrome Physical Exam
Fibroids - BMI
Endometriosis (10%) - Thyroid
Immunological factors (5%) - Skin exam
o Unexplained infertility 10-20% o Signs of hyperandregenic state (acne, male-pattern hair loss
and hirsutism)
Risks factors o Striae (Cushings disease)
- Age - Breasts: nipple discharge
o Decline in womens fertility begins in 30s, - Obesity, atrophy of limb musculature (Cushings disease)
o progresses 35-40 years, and - Pelvic
o accelerates after 40 o Clitromegaly
- History of STI o Cul-de-sac nodularity (endometriosis)
- Endometriosis o Pelvic mass
- Fibroids o Chlamydia and gonorrhea screening
- Pelvic infection and/or Tubal disease
o RF for stated etiologies on previous slides.
For example:
Obesity
Ovulatory dysfunction
Testicular trauma

Ovarian Reserve
- Problem with quantity and quality of the eggs
- Normal female transition: lower egg quality with age

Fertility and Age

- Age and number of eggs:
o Birth: 1-2 million
o Puberty: 400,000
o Age 37: 25,000
o Age 51: 1,000
Diagnostics Treatments
- Address etiology
Ovarian Function Testing - Addressing ovarian reserve
- Cycle regularity o Egg freezing and storage
- Hirsutism o Ovarian tissue cryopreservation
- Galactorrhea o Embryo freezing
- Hormonal testing: FSH, LH, Estradiol (E2), TSH o What about cancer and reproduction?
o Consider total testosterone and/or prolactin - Interuterine insemination (IUI)
- AMH (anti-mullerian hormone) o Sperm placement timed with ovulatory cycle (women on
- Check Karyotype and Fragile-X hormones clomid-- to stimulate ovulation if needed),
sperm placed directly into uterus at time ovulation
Tubal Factor - IVF
- History of PID o Younger than 35-- 44.9%
- STDs (chlamydia, GC) o 35-37-- 37.0%
- Distal versus proximal obstruction o 38-40-- 26.6%
- Salpingitis isthmica nodoas (SIN) o 41-42--15.6%
- Hysterosalpingogram (HSG) o 43-44-- 6.7%
- Sonohysterogram o develop the embryo and implant them

Uterine Factor Pregnancy Rates in Women Undergoing Donor Insemination

- Myomas (Cumulative pregnancy rate in 12 insemination cycles)
- Adhesions (Ashermans) o Younger than 31 years old-- 74%
- Uterine abnormalities: malformations o Age 31-35-- 62%
o Older than 35-- 54%
Male Factor
- Morphology Infertility
- Anti-sperm antibodies (vasectomy reversal) - Emotional support
o Impact of failed fertility treatments: couples are 3 X more
Tests likely to break up
- Laboratory assessment of ovulation
o FSH
o TSH
o LH
o Prolactin (levels > 30ng/mL MRI to
r/o pituitary adenoma
o Progesterone levels (on day 21 of cycle)

o Estradiol (with FSH) on 3rd day of menses

o Total testosterone
o Free testosterone
o 17-hydroxyprogesterone (17-OHP)
o DHEA-S
o Anti-Mllerian Hormone indicator of ovarian reserve
o Androstenedione comes from adrenal cortex, coverted to
estrogrn
r/o adrenal cortex problem, ex: adrenal tumor will
increase androstendion

1st line analysis: TVUS, labs, semen analysis

- Semen analysis
- Ultrasonography
o Detect pelvic abnormalities
o Document ovulation
- Hysterosalpingography (HSG) evaluates patency of fallopian tubes
and uterine abnormalities

- Advanced testing
o Laparoscopy
o Hysteroscopy
o Hysterosonography
o MRI OF BRAIN AND PITUITARY -= when indicated???