The McCoughey Septuplets

Infertility 101 Definitions Under 35 yoNo conception after one year of unprotected intercourse Over 35 yoNo conception after 6 months of unprotected intercourse

Your Infertility Patient yo woman presents to your clinic to discuss her concerns about infertility

Psychosocial Issues Expectations Expectations Stress on Relationships Stress on Relationships Stress on Finances Stress on Finances Alternatives- Adoption or Childless Alternatives- Adoption or Childless Counseling, Support Groups Counseling, Support Groups

Etiologies Male Factor40% Male Factor40% Tubal Factor40% Tubal Factor40% Ovulation Problem10% Ovulation Problem10% Unexplained10% Unexplained10%

Start with History... What Clues Can You Find on History? Male Factor Male Factor Tubal Factor Tubal Factor Ovulation Ovulation

Semen Analysis Normal values: Volume 2-5cc Count>20 million Motility>50% Morphology>50% normal (strict criteria >15%)

Male Factor Infertility Evaluation: Repeat semen analysis Physical exam- varicocele, testicular size Lab testing- testosterone, FSH, LH Genetics for special cases IUI (intrauterine insemination) ICSI (intracytoplasmic sperm injection) Donor sperm

Etiologies Male Factor40% Male Factor40% Tubal Factor40% Tubal Factor40% Ovulation Problem10% Ovulation Problem10% Unexplained10% Unexplained10%

Hysterosalpingogram

HSG: Unilateral Blocked Tube

HSG: Tubal Infertility

HSG: Hydrosalpinx

HSG of DES daughter

Etiologies Male Factor40% Male Factor40% Tubal Factor40% Tubal Factor40% Ovulation Problem10% Ovulation Problem10% Unexplained10% Unexplained10%

Ovulation Physiology The LH (lutenizing hormone) surge occurs hours prior to follicle rupture The LH (lutenizing hormone) surge occurs hours prior to follicle rupture Progesterone is increasingly produced after the LH surge Progesterone is increasingly produced after the LH surge Secretory changes to the endometrium occur secondary to the increased progesterone levels Secretory changes to the endometrium occur secondary to the increased progesterone levels

Ovulation Predictor Kits

Salivary Estrogen: TCI Ovulation Tester- 92% accurate

Add Saliva Sample

Non-Ovulatory Saliva Pattern

High Estrogen/ Ovulatory Saliva Pattern

Approach to Ovulation Disorders Evaluate- Hypothyroidism Prolactin Disorder Hyperandrogenism- PCOS Weight loss/ weight gain Evaluate- Hypothyroidism Prolactin Disorder Hyperandrogenism- PCOS Weight loss/ weight gain Induce Ovulation Clomid (clomiphene citrate) Induce Ovulation Clomid (clomiphene citrate)

Traditional Infertility Evaluation 1) Semen Analysis 2) Hysterosalpingogram (HSG) 3) Documentation of Ovulation 4) Post-coital Exam 5) Diagnostic Laparoscopy

Current Infertility Evalution 1) Semen Analysis 2) Hysterosalpingogram (HSG) 3) Documentation of Ovulation 4) Ovarian Reserve Testing

Ovarian Reserve Testing Day #3 FSH (<10 mIU/ml) and estradiol (<80 pg/ml) -Correlates with the functional status of the ovaries and the quality of the oocytes - FSH >15 only 5% success with IVF - High estradiol level increases risk of cancelling IVF cycle

Unexplained Infertility 12-15% of couples 12-15% of couples 3% chance of achieving a pregnancy 3% chance of achieving a pregnancy Treatment: Treatment: Superovulate with IUI (intrauterine insemination)- Clomid12% success Pergonal16% IVF

Infertility?