Female infertility James N Anasti, M.D. Dept OB/GYN

Definition Infertility Fecundablity Fecundity

Just the Facts 1790 Birth rate : 55/ Birth rate: 14.7/1000 Fertitlity services 1982:12% (6.6 mil) Fertility services 1995:15% (9.3 mil) Services used: 53% ovulatory drugs, 1.6% ART

What physical attribute is an important factor for infertility?

AGE: the Hutterites Peaks at age (2.6% infertile) Age decrease by % (11% infertile) Age decrease by 26-46% (33% infertile) Age decrease by 95% (87% infertile) Data confirmed by insemination studies

Age: IVF Younger than 35: 42% Live birth per embryo Age 35-37: 35.1% Live birth per embryo Age 38-40: 25% Live birth per embryo Age 41-42: 14.5% Live birth per embryo Age 43: 5.9% Live birth per embryo Greater than 43: 2.9% Live birth per embryo

Age: Miscarriage Recognized –Age 30: 7-15% –Age 31-34: 17-21% –Age 35-39: 17-28% –Age 40: 40-52% Unrecognized: 60%

What is the mechanism of age that causes infertility?

Physiology of Aging Ovary

Why are older women Infertile? They less eggs develop? They ovulate less? They produce less steroids? NO

Chromosomes:Aneuploidy Young women 10% eggs are aneuploidic Age 40: 30% abnormal Age 43: 50 % abnormal Age 45: 100% abnormal

How does one check for ovarian reserve?

Checking for Ovarian Reserve Success of IVF: the outcome Physiology : age related increase of FSH –Day 3 FSH: >10-15 mIu/mL –Day 3 Estradiol: >80 pg/mL Clomiphene Challenge Test (CCT) –Day 3 & Day 10 FSH ( after clomid 50mg day 5-9) –IVF success <10%

Who to Screen? Age >35 Family Hx POF Ovarian Surgery Smoking Poor Gonadotropin response

Infertility: Guiding Principles Identify the cause Provide accurate information Emotional Support; RESOLVE group Guide treatments

What life style behaviors decrease infertility?

Basic Info: Life style 62% of US have BMI > 25 25% female in US smoke: 13% infertile Mary Jane factor ETOH Caffeine??

Normal Reproductive Efficiency Fecundity: baboons 80% Human 20% 93% of couples pregnant in 2 years Egg hrs, Sperm 3-5 days

How can we help? Assume day before temp spike on BBT Peak fertility 2 days prior to ovulation LH detection But easiest: Intercourse Twice a week

When should a work-up begin? Most people need no treatment 3 year rule –5% decrease per year in age –15-25% per year of infertile >35 don’t wait Obvious reasons

History & Physical Exam G’s P’s and complicaion LNMP, Sexual Activity Surgery’s Meds, symptoms FmHX menopause, reproductive

Physical Exam: BMI Thyroid Skin Breast Pelvic

Screening Test PAP, STD Rh, Cystic Fibrosis,Rubella Varicella

What are the main causes of infertility?

Infertility: Causes

Infertility: KISS it Sperm in cervix Mature Oocyte Cervix must nurture sperm Capture the oocyte in tube Uterus enviroment

How do we screen for male infertility?

Male Factor

How do we check for ovulatory defects?

Infertility: Ovarian Factor Menstrual History: 97.7% predictor BBT –Thermogenic potential of progesterone (.4-.8) –Ovulation when see rise (1-5 days after) –12 or more days to menses Progesterone 3-4 ng/mL –7-8 days post ovulation –Luteal pahse function

Ovulatory Factor LH excretion: Ovulation prediction (24-48 h) –Start 2-3 days before LH Surge –Late afternoon testing, Concentrate urine –Day of surge and next 2 Ultrasound

How do we check for tubal factor?

Tubal Factor Risk factors –PID; 12%,24%,75%, Ectopic 6 fold HSG –2-5 days after menses –1-3 % infection rate high risk –Increase preg rate –False positive obstruction rate (15-30%)

Hydrosalpinges Myoma Normal HSG

Tubal Factor: Laparoscopy Chromotubation with indigo carmine –Why not methylene blue? Possibility of Treatment Tubal surgery: Is it worth it??

Tubal Factor: Chlamydia Antibody testing Pretest: Laparoscope or not HSG sooner than latter Not yet defined

Uterine Factors Hysterosalpingography (HSG) –HSG v Hysterscope: Sens 98%, Spec 35% –All polyp vs submucous myomas Ultrasound/Sonohysterography –SIS 75 sens, spec 90%

Bicornate Polyp Early Prolif Late Prolif Mid secr

Endometrial Biopsy Proliferative Secretory

Uterine Factors: Bottom Line Congenital Malformation Leiomyomas Intrauterine Adhesions Endometrial Polyps Yes, Septum only Maybe, submucous Yes Maybe

Cervical Factor Postcotial test (Sims-Huhner) Intercourse (2-12 hrs) for test Look at: pH, Sperm, Spinnbarkeit, Ferning Cellularity, Sperm Shaking, sperm Agglutanation Has seen better days

Unexplained Infertility Defined 10-30% incidence Laparoscope necessary: – Canadian Study: 17% v 29% (NTT:9) Just slower to get pregnant 3 year data –Spontaneous conception falls 40%

UI:Who should you treat? No treatment % IUI3.8% Clomid5.6% Clomid & IUI8.3% Gonadotropins7.7% Gonadotropins & IUI17.1% IVF20.7%