E.Naghshineh M.D OB&GYN,Infertility fellowship

Definition:1 year of unprotected intercourse without conception Prevalence: Infertility affects 10-15% of reproductive-age couples in the U.S. Definition:1 year of unprotected intercourse without conception Primary infertility – No prior pregnancies Secondary infertility – Prior pregnancy

Fecundability : the chance of conception in one menstrual cycle 15-20% of healthy young couples will conceive in a single cycle Wait a year to begin the infertility evaluation for young couples with no history suggestive of reproductive disorders Earlier workup in couples with a positive history of for a fertility lowering disease or advancing maternal age

Evaluation Medical history Physical examination (abdominal & pelvic exam) Family history (fragile X syndrome, down) Ovulatory dysfunction tubal risk factors Uterine & cervical abnormalities peritoneal factors male factor

Both members of the couple to be interviewed at the first visit Evaluate ovulatory dysfunction: endocrine review, thyroid, androgen excess, marked weight fluctuations, galactorrhea Tubal damage: Hx of STDs, PID, pelvic surgery, ruptured appendix, septic abortion, endometriosis, EP uterine leiomyoma, uterine & cervical surgery

Causes of infertility Male factor: 30-40% -STD & other GU infections -chemo or radiation therapy -mumps during adolescence -testicular surgery or injury -decreased ejaculatory function -chronic occupational exposure ( heat, gametotoxic chemicals) -drugs……

Male ph.exam Abnormal body habitus Lack of testicular descent Penile abnormalities Diminished size or abnormal consistency of the testes Presence of the varicocele

Social & life style Hx: -smoking (oocyte toxicity, premature menopause, decreased sperm motility and number) -alcohol abuse -illicit drug -excessive exercise & anorexia -exposure to teratogens (lead)

Evaluation: testing Three tests in basic evaluatins: 1.semen analysis 2.ovulation documentation 3.Uterine/tubal evaluation

Semen analysis ≤2 ml Ejaculation volume 7.2-7.8 PH 20 mil/ml≤ Sperm density 40 mil≤ Total sperm count 50%≤ Motility 25%≤ 3 and 4+ forward progression 30% normal forms< Morphology No significant sperm agglutination No significant pyospermia No hyper viscosity

A repeat semen analysis is typically obtained to confirm an abnormal semen analysis 90 to 108 days 1 month is acceptable

Confirmed ovulation 3 methods for Confirmed ovulation: -BBT chart -LH ovulation kit -midluteal serum progesterone >3ng/ml -serial ultrasound -cervical mucus examination -endometrial biopsy

Ovarian reserve tests Age >30 years : - day 3 FSH level - CC chalenge test - AFC count

Evaluation of uterus & fallopian tubes HSG SIS (only uterus) Office hysteroscopy (only uterus) Laparoscopy & hysteroscopy

Male factor Surgical ligation of varicocele: increase sperm motility, density, morphology and the pregnancy rate Hormonal testing: T,FSH, LH, PRL -in sperm count <10 mil/ml -low male libido Fructose level Testicular biopsy Leukocyte in semen: bacterial cultures & antibiotic treatment

Most men have idiopathic oligoasthenospermia Retrograde ejaculation: DM, Neurologic disorders, after pelvic surgery Congenital bilateral absence of vas defrens:CF Non-obstractive oligo and azoospermia: genetic screening (karyotype and PCR analysis of the Y chromosome)

Treatment Sperm donor IUI, IVF, ICSI Surgery for obstructive azoospermia Surgical ligation of varicocele Medical therapy: only for hypothalamic hypogonadism MESA, PESA, TESE

Ovulatory dysfunction Hypothalamic: weight loss, excessive exercise, kallmann syndrome, hypothalamic lesions Pituitary: HPL, thyroid disease, Cushing disease, sheehan syndrome Ovarian: PCOS, POF Adrenal Lab tests: FSH,PRL,TSH T, 17(OH)P in hirsutism or acne

Treatment Hypothalamic: -Due to weight loss or excessive exercise: change in life style -Hypogonadotropic hypogonadism: gonadotropins administrations HPL: Dopamine-agonist therapy (bromocriptine, cabergolin)

PCOS: -losing 5-10% of body weight - CC (85% ovulate) -surgical treatment (laparoscopic cautery, diathermy, laser) -human gonadotropins injection: (multiple gestation, OHSS) -Insulin-sensitizing agents (metformin)

POF: -HRT: prevent osteoporosis, minimize hypoesterogenic symptoms -Donor oocytes -Adoption -Remain child free

Uterine/tubal factor HSG Laparoscopic surgery most common finding: Endometriosis IVF Evaluation of cervical mucus(PCT)?

Treatment of uterine disease 16% intra cavitory lesions (endometrial polyps or sub mucosal myoma) Asherman syndrome Uterine septum ------------Hysteroscopy Intramural or subserosal myoma ? (>4cm: deacrease pregnancy rate)

of tubal disease Treatment Depends on the severity of disease Hysteroscopically Radiographically Micro surgical reanastomosis Laparoscopic removal of adhesions IVF: much superior treatment Removal or occlusion of damaged fallopian tubes and hydrosalpinx prior to IVF

Unexplained infertility 15-25% 1.No therapy: -50% conceive in 2 years -70-80% conceive in 5 years 2.woman>30: treatment -CC+IUI -Gn+IUI -IVF

women with endometriosis:liked unexplained infertility GnRH agonist (3-6 m) prior to proceeding IVF