1. Infertility By as. Stelmakh O.

2. Objectives Define primary and secondary infertility Describe the causes of infertility Diagnosis and management of infertility

3. Infertility - Statistics causes are identified in 90 % of patients pregnancy results in 40 % of those 30 % of couples have male AND female factors Of 100 subfertile couples the break down is as follows: 40 % male factor etiology 20 % female hormonal imbalance 30 % female peritoneal factor 5 % ‘hostile’ cervical environment 5 % unexplained psychological impact can be significant

4. Infertility Primary infertility –a couple that has never conceived Secondary infertility –infertility that occurs after previous pregnancy regardless of outcome

5. Causes for infertility Male –Drugs –Tobacco –Health problems –Radiation/Chemotherapy –Age –Enviromental factors Pesticides Lead Female –Age –Stress –Poor diet –Athletic training –Over/underweight –Tobacco –STD’s –Health problems

6. Causes of Infertility Anovulation (10- 20%) Anatomic defects of the female genital tract (30%) Abnormal spermatogenesis (40%) Unexplained (10%- 20%)

7. Evaluation of the Infertile couple History and Physical exam Semen analysis Thyroid and prolactin evaluation Determination of ovulation –Basal body temperature record –Serum progesterone –Ovarian reserve testing Hysterosalpingogram

8. Abnormalities of Spermatogenesis

9. Normal Sperm made in seminiferous tubules Travel to epididymis to mature

10. Sperm exit through vas deferens Semen produced in prostate gland, seminal glands, cowpers glands Sperm only 5% of ejaculation Sperm can live 5-7 days Normal

11. Semen Analysis (SA) Obtained by masturbation Provides immediate information –Quantity –Quality –Density of the sperm –Morphology –Motility Abstain from coitus 2 to 3 days Collect all the ejaculate Analyze within 1 hour A normal semen analysis excludes male factor 90% of the time

12. Normal Values for SA Volume Sperm Concentration Motility Viscosity Morphology pH WBC –2.0 ml or more –20 million/ml or more –50% forward progression 25% rapid progression –Liquification in 30-60 min –30% or more normal forms –7.2-7.8 –Fewer than 1 million/ml

13. Causes for male infertility 42% varicocele –repair if there is a low count or decreased motility 22% idiopathic 14% obstruction 20% other (genetic abnormalities)

14. Abnormal Semen Analysis Azoospermia –Klinefelter’s (1 in 500) –Hypogonadotropic- hypogonadism –Ductal obstruction (absence of the Vas deferens) Oligospermia –Anatomic defects –Endocrinopathies –Genetic factors –Exogenous (e.g. heat) Abnormal volume –Retrograde ejaculation –Infection –Ejaculatory failure

15. Evaluation of Ovulation

16. Female Reproductive System Ovaries –Two organs that produce eggs –Size of almond –30,000-40,000 eggs –Eggs can live for 12-24 hours

17. Menstruation Ovulation occurs 13-14 times per year Menstrual cycles on average are Q 28 days with ovulation around day 14 Luteal phase –dominated by the secretion of progesterone –released by the corpus luteum Progesterone causes –Thickening of the endocervical mucus –Increases the basal body temperature (0.6° F) Involution of the corpus luteum causes a fall in progesterone and the onset of menses

19. Menstrual cycle

22. Serum Progesterone Progesterone starts rising with the LH surge –drawn between day 21-24 Mid-luteal phase –>10 ng/ml suggests ovulation

23. Salivary Estrogen: Ovulation Tester- 92% accurate

24. Add Saliva Sample

27. Non-Ovulatory Saliva Pattern

28. High Estrogen/ Ovulatory Saliva Pattern

29. Anovulation

30. Anovulation Symptoms Evaluation* Irregular menstrual cycles Amenorrhea Hirsuitism Acne Galactorrhea Increased vaginal secretions Follicle stimulating hormone Lutenizing hormone Thyroid stimulating hormone Prolactin Androstenedione Total testosterone *Order the appropriate tests based on the clinical indications

31. Fertilization

32. Implantation

34. Anatomic Disorders of the Female Genital Tract

35. Congenital Anatomic Abnormalities

36. Hysterosalpingogram An X-ray that evaluates the internal female genital tract –architecture and integrity of the system Performed between the 7 th and 11 th day of the cycle Diagnostic accuracy of 70%

37. Hysterosalpingogram The endometrial cavity –Smooth –Symmetrical Fallopian tubes –Proximal 2/3 slender –Ampulla is dilated Dye should spill promptly

38. HSG: Tubal Infertility

39. Some women have trouble getting pregnant because scar tissue prevents eggs from traveling down the fallopian tubes. This scarring can be caused by endometriosis, the overgrowth of tissue that lines the uterus, a history of pelvic infections, or previous surgeries

40. Treatment of the Infertile Couple

41. Inadequate Spermatogenesis Laparoscopy surgery Eliminate alterations of thermoregulation Clomiphene citrate is occasionally used for induction of spermatogenesis –20% success In vitro fertilization may facilitate fertilization Artificial insemination with donor sperm is often successful

42. Intrauterine insemination (artificial insemination)

43. Artificial Insemination Sperm donation or sperm aspiration

44. In Vitro Fertilization

45. IVF Protocol GnRH agonist (e.g. Lupron) for 7 days FSH agonist (follistim, Gonal-F, Repronex) until follicles measure 17-20 mm in diameter hCG given to induce egg maturation Egg retrieval (transvaginally) 34-35 h later

46. IVF Protocol, cont’d. 3 to 5 embryos are injected to increase chances of pregnancy woman given progestagen to prevent miscarriage

47. Surrogate mother –Woman unable to have children may have IVF in another woman who has the child

48. IVF With Donor Eggs Women who are over 40, have poor egg quality, or have not had success with previous IVF cycles may consider IVF with donor eggs

50. Conclusion Infertility should be evaluated after one year of unprotected intercourse. History and Physical examination usually will help to identify the etiology. If patients fail the initial therapies then the proper referral should be made to a reproductive specialist.