INFERTILITY MALE AND FEMALE

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Infertility

• Dr Angelo Smith MD
• WHPL

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Definition

• Failure of a couple to conceive after 1 year of
  regular intercourse without use of contraception
• Primary infertility No prior pregnancies
• Secondary infertility Prior pregnancy

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Prevalence

• Infertility affects 10-15 of reproductive-age
  couples in the world.
• Approx. 85 of couples achieve pregnancy within 1
  year
• Conception rate (fecundability)
• 25 conceive within 1 mo.
• 60 conceive within 6 mo.s
• 75 conceive within 9 mo.s
• 90 conceive within 18 mo.s

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Etiology

• Successful conception requires a specific series
  of events
• Ovulation of competent oocyte
• Production of competent sperm
• Juxtaposition of sperm and oocyte in a patent
  reproductive tract
• Fertilization
• Generation of a viable embryo
• Transport of the embryo to the uterine cavity
• Implantation of the embryo into the endometrium

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Etiology

• Major causes of of infertility
• Female factor 60
• Ovulatory dysfunction
• Abnormalities of female reproductive tract
• Peritoneal factors
• Reproductive aging
• Male factor 20
• Abnormal semen quality
• Abnormalities of male reproductive tract
• Idiopathic 15
• Infertility in 20-40 of couples has multiple
  causes

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Infertility History

• Female
• Duration of infertility and prior evaluation or
  therapy
• Menstrual cycle (length and characteristics)
• Symptoms associated with ovulation (e.g. breast
  tenderness, bloating, mood changes)
• Full OBHx and GynHx
• Prior pregnancies, surgeries, or STDs
• Sexual history (frequency of intercourse)
• Chronic medical illness
• Family history (infertility, birth defects,
  genetic disorders)
• Social history (smoking, EtOH, drugs)

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Infertility History

• Male
• Prior children
• Genital tract infections
• Genital surgery or trauma
• Chronic medical illness
• Medications (e.g. Furantoins, CCB)
• EtOH, drugs, or smoking
• Sexual history (frequency of intercourse)

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Infertility Physical Exam

• Female
• Height, weight , BMI
• Pelvic exam
• Masses
• Tenderness (Adnexa, Cul-de-sac)
• Structural abnormalities (Vagina, Cervix, or
  Uterus)
• Male
• Evidence of androgen deficiency
• Structural defects (e.g. varicocele, hernia)

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Male factor Evaluation
Initial evaluation Further evaluation
Male Factor Semen analysis Urologic evaluation FSH, LH, and testosterone level Genetic evaluation Epididymal sperm aspiration (PESA, MESA) Testicular biopsy
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Male factor Evaluation

• Semen analysis
• Following 2-4 day period of abstinence
• Repeated x1 for accuracy

Element Reference value
Ejaculate volume 1.5-5.0 mL
pH gt 7.2
Sperm concentration gt 20 million/mL
Motility gt 50
Morphology gt 30 normal forms
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Male factor Evaluation

• Urologic evaluation
• Physical Exam
• Varicocele
• Congenital absence of vas deferens (CAVD)
• Transrectal ultrasound
• Vasography, Seminal vesiculography
• Epididymal sperm aspiration (PESA or MESA)

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Male factor Evaluation

• Endocrine evaluation
• Indication Oligospermia (lt 10million/mL) or
  sexual dysfunction (decreased libido, impotence)
• FSH, LH, testosterone
• Genetic evaluation
• Indication Azoospermia (no sperm)
• CF (Cystic fibrosis) mutation
• Karyotype (Klinefelters, Y chromosome deletion)
• Testicular biopsy
• Indication Nonobstructive azoospermia
• Palpable vasa
• Normal testis volume
• Normal FSH/LH

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Female factor Evaluation
Factor Initial evaluation Further evaluation
Ovulation History and physical exam Basal body temp charting Ovulation predictor kit Mid-luteal phase progesterone level Endocrine testing Endometrial biopsy
Reproductive tract (uterus or fallopian tubes) Hysterosalpingogram (HSG) Ultrasound Saline-infusion sonography Hysteroscopy Laparoscopy
Peritoneal Laparoscopy
Reproductive aging FSH, estradiol, or AMH
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Female factor Menstrual Cycle
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Female factor Evaluation

• Ovulation
• Initial evaluation
• Basal body temp rise for gt 10 days indicates
  ovulation
• Ovulation predictor kit detects LH surge in
  urine
• Further evaluation
• Mid-luteal phase progesterone level - level gt 3
  ng/mL provides qualitative evidence of recent
  ovulation
• Endocrine testing (TSH, prolactin, FSH, LH,
  Estradiol, DHEA-S)
• Endometrial biopsy
• Not routinely performed

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Female factor Evaluation

• Reproductive tract
• Initial evaluation
• Hysterosalpingogram (HSG)
• Detect uterine anomalies (septate or bicornuate
  uterus, uterine adhesions, uterine leiomyoma)
• Detect patency of fallopian tubes (occlusion,
  hydrosalpinx, salpingitis)
• Ultrasound alternative to HSG to evaluate
  uterus

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Female factor Evaluation

• Reproductive tract
• Further evaluation
• Saline-infusion sonography (SIS)
• Hysteroscopy
• Laparoscopic chromotubation

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Female factor Evaluation

• Peritoneal factors
• Laparoscopy
• Endometriosis
• Pelvic/adnexal adhesions

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Female factor Evaluation

• Reproductive aging
• Indications
• gt 35 years of age
• 1st degree relative with early menopause
• Previous ovarian insult (surgery, chemotherapy,
  radiation)
• Smoking
• Poor response to ovarian stimulation
• Unexplained infertility
• Candidate for IVF

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• Reproductive aging
• Cycle day 3 serum FSH and estradiol
• Abnormal (diminished ovarian reserve)
• FSH gt 10 IU/L
• Estradiol gt 75-80 pg/mL
• Clomiphene citrate challenge test
• Cycle day 10 serum FSH
• Serum antimullerian hormone (AMH)

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Idiopathic Infertility

• Prevalence 15
• Factors that cannot be identified
• Sperm transport defects
• Inability of sperm to fertilize egg
• Implantation defects

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Management

• Male Factor
• Avoidance of alcohol
• Scheduled intercourse
• Ligation of venous plexus for significant
  varicocele
• Intrauterine insemination (IUI) with washed sperm
• Intracytoplasmic sperm injection (ICSI) IVF
• Donor sperm insemination

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• Ovulation Induction (Clomid or low dose FSH)
• IUI (low dose FSH)
• IVF / ICSI (LHRH analogue, high dose FSH
  injections, egg collection, embryo transfer)

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Management

• Anovulation
• Oral medications
• Clomiphene citrate
• Dopamine agonists (Bromocriptine) -
  hyperprolactinemia
• Injectable medications
• Gonadotropins (FSH/hMG, hCG)
• Laparoscopic ovarian drilling
• Complications Ovarian hyperstimulation, Multiple
  pregnancy

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Management

• Reproductive tract abnormality
• Uterine Myomectomy, Septoplasty, Adhesiolysis
• Tubal Microsurgical tuboplasty, Neosalpigostomy
• Peritoneal Laparascopic treatment of
  endometriosis, Adhesiolysis
• Idiopathic infertility
• Ovarian stimulation IUI
• Clomiphene or gonadotropins (hMG, hCG)
• IVF

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Management (IVF)

• Used for
• Severe male factor
• Tubal disease
• Couples who failed other treatments
• Requires
• Controlled ovarian hyperstimulation
• Retrieval of oocytes
• In vitro fertilization and embryo transfer
• Procedures
• IVF embryo transfer (IVF-ET)
• Intracytoplasmic sperm injection embryo
  transfer (ICSI-ET)
• Donor egg IVF embryo transfer

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Intracytoplasmic sperm injection (ICSI)
40 of IVF cycles involve insemination by ICSI
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Day 2 - Day 3 Embryo Development

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Day 5 Embryo development

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Day 5 Embryo Transfer

• Advantages
• Embryo Selection
• Reduction in number of embryos for ET resulting
  in reduction in multiple gestations

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Psychological

• The psychological stress associated with
  infertility must be recognized and patients
  should be counseled appropriately.

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Egg Donation

• For patients with poor ovarian reserve
• Alternative to adoption or childlessness
• Success Rate 50 per cycle

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