Fertility Facts Definition:unprotected sex for one year, not pregnant Frequency: 1 out of 6 couples in the US Responsibility: 35% female infertility 35% male 20% both 10% unknown Maternal Age USA 20-24 4.1% 30-34 9.4% 25-29 5.5% 35-39 19.7% 85% treated successfully Increase 1970-now-Why?

What can cause infertility? Unexplained-18% Female Male Ovulation disorders Tube/uterus blockage Cervix Endometriosis Other Sperm count and defects Erectile or ejaculation deficiency Intrinsic vs. Extrinsic, Environmental

More detail on female infertility Ovulatory failure-polycystic ovarian syndrome (high androgen/estrogenlevels), resistant ovarian syndrome, gonadal dysgenesis Impaired gamete/zygote transport-pelvic inflammatory disease, endometriosis Implantation defects-progesterone low Spontaneous abortion-chromosome abnormality

More detail on male infertility Cryptorchidism-Why? Chromosome disorders-gonadal dysgenesis Obstructions Gonadotropin deficiency Result in:Low sperm count, sperm of poor quality

Female Infertility Tests For ovulation Basal body temperature Ovulation kit (LH surge) Other hormone tests (steroids) Post ovulatory block Laparoscopy-fiber optic look Hysterosalpingogram-dye Post-coital /cervical mucous and sperm Sperm antibodies Endometrial biopsy

Sperm good for 2-3 days, egg for 2

Laparoscopy Can find adhesions, structural abnormality, etc

Hysterosalpingogram Blocked tubes

Male Infertility Tests Sperm count/motility > 20 million sperm/ml Check motility and morphology >50% motile >30% structurally normal If low check LH and androgen levels Testicular biopsy

Sperm Count

Older, low tech treatments Drug treatment for ovulation block Intrauterine insemination Tubal surgery High tech Assisted Reproduction Technologies IVF-in vitro fert and embryo transfer GIFT-gamete intrafallopian tube transfer ZIFT-zygote intrafallopian tube transfer Intracytoplasmic sperm injection

frozen eggs/ ovary transplant; cloned human embryo

First test-tube baby

Assisted Reproductive Technology Estimate 1/100 births now Around 40,000/year Costs between $7,000 to 15,000 per attempt

IVF In Vitro Fertilization and Embryo Transfer

Basic Steps in IVF Ovary stimulation Egg retrieval Sperm retrieval-wash sperm Fertilization Embryo transfer Progesterone

Start with more than 1 egg Drugs used for ovary stimulation Clomiphene (clomid)-anti-estrogen hMG (pergonal)-menopausal gonadotropin (FSH and LH) FSH-(metrodin) GnRH GnRH agonists (lupron)-FSH/LH first promoted, then inhibited hCG-acts like LH In a single cycle, could take clomid, pergonal, hCG shot, then progesterone

Why transfer more than one embryo? Increase the pregnancy rate Leads to increased risk of multiple pregnancies In future- Test embryos before transfer sHLA-G measure of embryo health

Egg retrieval, vaginal, with ultrasound

Modifications if tube not blocked Gametes mixed for GIFT

GIFT

If fertilization needs help-transfer zygote ZIFT

Intracytoplasmic sperm injection

ICSI

Additional twists Surrogacy Frozen embryos Egg donors Frozen eggs Gestational Egg donor plus gestational Egg donor plus sperm donor plus gestational Frozen embryos Egg donors Frozen eggs Cloning

From CDC

IVF Success Rates Stage Number of Women Cycle initiation 100 Ovulation 95 Oocyte retrieval 90 Fertilization 85 Embryo Transfer 70 Pregnancy 24 Birth 18

From The Baby Business by Debora Spar

Risks of ART? To woman To baby Overstimulation of ovary syndrome Multiple pregnancies Risk of ovarian cancer (clomid, pergonal) To baby ICSI associated with problems (XYY)

Discussion questions-what treatment(s) would you select given the following: Male with low sperm count 30 year-old female not ovulating 40 year-old female not ovulating Undiagnosed infertility