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

2. 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

3. 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

4. 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

5. 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

6. 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……

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

8. 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)

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

10. 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

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

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

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

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

15. 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

16. 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)

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

18. 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

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

20. 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)

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

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

23. 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)

24. 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

25. 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

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