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Infertility 30-34 14.

6
- It is generally used to indicate that a couple has a 35-39 21.9
reduced capacity to conceive as compared with the mean 40-49 28.7
capacity of the general population
Initial Assessment and Interview
Fecundability - most important as it sets the tone for subsequent
- probability of achieving pregnancy in a single menstrual evaluation and treatment
cycle (20-25%); at the end of 6 mos. (60%); end of 12 - physicians should be receptive to the needs of both
mos. (90%) male and female partners
- initial interview provides the physician with the
Criterion opportunity to assess the emotional impact of infertility
- 1 year unprotected sexual activity of 2-3x/week of the couple
- referral of the male partners to a urologist for
10-15 % of couples in the US ( almost the same in the examination is beneficial if history or subsequent
Phils.) evaluation suggests an abnormality

Prevalence of infertility has remained stable but the Initial Interview


demand for infertility case has significantly increased. History
Possible reasons: A. Woman
1. Heightened awareness that infertility is a medical - duration of infertility; fertility in other marriage
condition and may be treated in many cases. - obstetrical and gynecological history
2. Availabilty of new and specialized treatment options - medical history; chronic and hereditary disease
including assisted reproductive technology. - surgical history: abdominopelvic surgery
- sexual history
Average Conception Rates - psychosomatic history
Percentage of Length of time
Couples before conception B. Man
20 Within 1 mo. - fertility history
60 Within 6 mos. - medical history: STD, mumps, chronic dse., use of
75 Within 9 mos. prescription and recreational drugs
80 Within 12 mos. - surgical history
90 Within 18 mos. - occupational history
- sexual history
Indications for evaluation - duration of infertility previous tests and therapy
- Failure to achieve pregnancy within 1-2 years of regular
unprotected coitus Physical Examination of Couples
->35 y/o woman - Ht.
- Younger women with significant gynecological history - Wt.
and physical examination suggestive of an abnormality - Body habitus
-Hair distribution
Infertility and Age - Thyroid gland
1. Infertililty increases with increasing age of the female - Pelvic exam.
partner.
2. The total length of time during which conception is Causes
possible is less in older women. 1. Male factor
3. The probability of conception is substantially reduced 2. Decreased ovarian reserve
by delaying child bearing until late in life. 3. Ovulatory disorders (ovulatory factor)
4. Tubal injury, blockage, or paratubal adhesions
Percentage of Married Women who are Infertile by Age (including endometriosis with evidence of tubal or
Age Infertile (%) peritoneal adhesions)
20-24 7 5. Uterine factors
25-29 8.9 6. Systemic conditions (including infections or
chronic diseases such as autoimmune conditions or
chronic renal failure) 3. Bact. Culture of semen and cervical mucus
7. Cervical and immunologic factors 4. Hamster egg penetration assay
8. Unexplained factors (including endometriosis with - predict the fert. Capacity of the sperm
no evidence of tubal or peritoneal adhesions) Semen Analysis- 2-3 days abstinence
Volume Greater than 2ml
Relative prevalence of the etiologies of infertility (%) pH 7.2-7.8
Male Factor 25-40% Sperm density >20 million
Both 10% Sperm motility >50%
Female Factor 40-55% Vital staining >50%
Unexplained 10%
Approximate prevalence of the causes of infertility in Male factor
the female (%) Pathogenesis: multiple causes include endocrine d/o,
Ovulatory Dysfunction 30-40% anatomic defects, prob. Abnormal sperm production
Tubal/Peritoneal 30-40% and motility as well as sexual dysfunction
Unexplained infertility 10-15%
Musc. 10-15% Risk factors
1. Occupational and environmental exposure to
Initial lab. Work- up should include the following: chemicals, radiation and excessive heat
1. CBC 2. Use of certain drugs
2. U/A 3. History of acute or chronic infections
3. Cervical cytology 4. History of varicocele, pituitary tumors
4. FBS 5. History of surgery like hernia repair
Other Tests:
1. FSH and estradiol level Drugs that decrease sperm quality and quantity
2. Measure IgG against chlamydia A. Cimetidine
B. Sulfasalazine
Basic Infertility Investigation C. Spironolactone
1. Semen analysis D. Nitrofurantoin
2. Confirmation of ovulation E. Erythromycine
3. Documentation of tubal patency F. Tetracycline
G. Anabolic steroids
Documentation of Ovulation H. Chemotherapeutic agents
1. History of regular menses I. Heavy marijuana and alcohol use
2. Measurement of progesterone level
- midluteal level above 10pg/ml Dx evaluation
3. Daily BBT determination 1. Semen analysis
4. Serial Ultrasonography 2. Endocrine evaluation: Testosterone, prolactine,
5. Urinary LH measurement FSH, thyroid
6. Cervical mucus test- Spinbarkeit 3. Postcoital tests: check sperm and cervical mucus
7. Endometrial biopsy interaction
8. Transvaginal ultrasound
Treatment
Evaluation of tubal integrity and patency 1. Improvement of coital practice
1. HSG- SIS 2. Avoidance of use of tight underwear
- visualization of uterine tubules 3. Avoidance of saunas and hot tubs
2. Laparoscopy 4. Avoidance of unnecessary environment exposure
3. Insufflation test 5. Repair of anatomic defects
- IUI, ICSI-IVF, GIFT, ZIFT
Others
1. Serum TSH and Prolactin level Anatomic Causes of female factor
2. Measurement of antisperm antibodies 1. Anomalies of the cervix- mullerian duct anomalies,
cervical stenosis, surgical like conization
2. Abnormality of the uterine cavity
3. Tubal occlusion- PID
4. Peritoneal factor- endometriosis

Causes of ovulatory factor infertility


1. Central defects: hypothalamic insufficiency,
PCOS, pituitary insufficiency
2. Peripheral defect: ovarian tumors, POF, gonadal
dysgenesis
3. Metabolic disease: thyroid dse., liver dse., obesity,
androgen excess

WHO classification of ovulatory factor infertility


1. Hypothalamic- pituitary failure - hypothalamic
amenorrhea
2. Hypothalamic- pituitary dysfunction- PCOS,
thyroid dysfunction
3. Ovarian failure- premature ovarian failure (<40
y/o), advanced maternal age

Treatment
- depends on the underlying pathology
- regular ovulation- restored in 90% of infertility in
cases with an underlying endocrine d/o
- for WHO hypothalamic- pituitary dysfunction,
ovulation induction with Clomiphene citrate is the
first line of treatment
*Clomiphene citrate- maximum of 6 mos., following
sexual contact

Drugs used for infertility


1. Clomiphene citrate- stimulates follicular ___ for
ovulation induction
2. Human menopausal gonadotrophin
3. HCG- simular structure to LH

Adavanced Reproductive Technologies


IVF- In vitro fertilization
GIFT- Gamete intrafallopian transfer
ZIFT- Zygote intrafallopian transfer
ICSI- Intracytoplasmic sperm injection
-male factor infertility