Infertility ppt

Infertility Definition

• Infertility: A couple's failure to achieve pregnancy after one year of regular, unprotected intercourse.
• Diagnosis can be made after 6 months for women over 35 years old.
• Incidence: 15-20% of couples in the United States.

When to Evaluate for Infertility

• Evaluate couples who meet the definition of infertility.
• Earlier evaluation for women over 35 years old due to the rapid increase in infertility after 35, especially after 42.
• Evaluate earlier for individuals with a history of amenorrhea, oligomenorrhea, suspected tubal disease, endometriosis, Mullerian variations, risk factors for ovarian insufficiency (chemotherapy, radiation, autoimmune diseases, ovarian surgery), and male risk factors (testicular torsion/cancer, orchitis/mumps, unsuccessful conception).

Infertility Causes

• Male factor (20% of cases).
• Ovarian/Tubal factors (more than 45% of cases).
• Infertility often results from more than one factor.

Infertility Workup: Exam

• Female:
  • Evaluate weight, BMI, and blood pressure.
  • Assess for signs of systemic illnesses like diabetes, autoimmune disorders, and metabolic syndrome.
  • Examine the thyroid for enlargement, nodules, and tenderness.
  • Assess for galactorrhea in the breasts.
  • Look for signs of androgen excess, including acne, hirsutism, and male escutcheon.
  • Evaluate for pelvic abnormalities.

Infertility Workup: Testing

• Female:
  • Conduct testing and schedule a preconception counseling appointment.
  • Perform hemoglobin A1C and fasting glucose tests for women with a history of diabetes or risk factors.
  • Screen for genetic disorders as indicated.

Infertility Workup: Prenatal Optimization

• Begin preconception care immediately.

Infertility Workup: Male Factor

• History:
  • Gather past medical, surgical, illness, and injury history.
  • Pay special attention to a history of mumps, as mumps orchitis is a known cause of infertility.
• Semen Analysis:
  • The #1 factor to assess.
  • Total sperm number (10^6 per ejaculate): 39 (33-46)
  • Total motility (%): 40 (38-42)
  • Normal forms (%): 4 (3-4)

Infertility Workup: Ovarian Factor

• Responsible for up to 40% of infertility in women.
• Fecundity decreases gradually around 32 years old and rapidly after 37.
• Associated with increased FSH and decreased AMH and Inhibin B.
• Assess:
  • Patient age.
  • Evidence of disordered ovulation.
  • Menstrual history, Basal Body Temperature (BBT), OTC ovulation test, luteal phase progesterone (day 21 or 23), and day 3 FSH for patients over 40 (an indicator of ovarian reserve).
  • Day 3 FSH levels above 13 indicate difficulty in stimulating ovulation.
• If disordered ovulation is present, determine the underlying cause.
• Labs:
  • TSH and PRL: assess for thyroid issues and prolactin levels.
  • Luteal phase progesterone: should be high if ovulation is occurring.

Luteal Phase Defect

• Definition: Shortened time between ovulation and menses.
• Cause: Corpus luteum involutes earlier than expected.
• Treatment: Supplemental progesterone.

Infertility Treatment: Ovarian Factor

• Most/all treatments require referral to a specialist.
• Refer quickly for women over 35 years old.

Infertility Treatment: Clomiphene Citrate

• Clomid (Clomiphene Citrate): Selective estrogen receptor modulator (SERM).
• Mechanism of action: Blocks estrogen receptors in the hypothalamus, leading to increased pulsatile release of GnRH and subsequently increased FSH.
• Effect: Recruitment of follicles and increased likelihood of reaching the estrogen level needed for ovulation.
• Side effects: Over-ovulation, menopausal symptoms (hot flashes, vaginal dryness), and OHSS (rare).

Infertility Treatment: Metformin

• Indication: Women with PCOS who do not ovulate on clomiphene citrate.
• Use for ovulation: Helpful for PCOS patients as a supplement to clomiphene citrate.
• Refer to a reproductive specialist for any other use.
• Evidence for metformin's efficacy is unclear.

Ovarian Hyperstimulation Syndrome (OHSS)

• Overproduction of large follicles.
• Results in increased capillary permeability in ovarian tissue with poor reabsorption.
• Severe OHSS: Ascites, hemoconcentration, and increased risk of clotting.

Infertility Treatment: Uterine and Tubal Factors

• Most common uterine issues: Asherman's syndrome, leiomyomata, congenital abnormalities (Mullerian).
• Most common tubal issues: Prior tubal ligation/surgeries, prior infection/PID.
• Assessment for both: Hysterosalpingography (HSG).

Mullerian Fusion Disorders

• Uterine septum is the most common disorder associated with pregnancy loss, and it's treatable.
• Resection of the septum can improve delivery rates.

Hydrosalpinx

• A common tubal factor.
• Always (99%) due to infection.
• No “spill” = blockage.
• Referral is critical.
• Some recommend immediate salpingectomy and assisted reproductive technology (ART).
• Others might attempt tubal reconstruction.

Infertility Definition

• Infertility is defined as a couple's inability to conceive after one year of regular, unprotected intercourse.
• For women over 35, the diagnosis can be made after 6 months.
• It affects 15-20% of couples in the United States.

When to Evaluate for Infertility

• Evaluate couples who meet the definition of infertility.
• Evaluate sooner for women over 35 years old.
• Consider earlier evaluation for women with a history of amenorrhea or oligomenorrhea, suspected tubal disease, endometriosis, Mullerian variations, or risk factors for ovarian insufficiency such as prior chemo/radiation, other autoimmune diseases, or significant ovarian surgery.
• Evaluate males with a history of testicular torsion/cancer, orchitis/mumps, or unsuccessful conception.

Causes of Infertility

• Male factors account for 20% of infertility cases.
• Ovarian/Tubal factors are present in over 45% of cases.
• More than one factor is often involved.

Infertility Workup: Examination for Females

• Assess weight, BMI, and blood pressure.
• Look for signs of systemic illness like diabetes, autoimmune disorders, and metabolic syndrome.
• Examine the thyroid for enlargement, nodules, or tenderness.
• Check for galactorrhea in the breasts.
• Observe for signs of androgen excess like acne, hirsutism, and male escutcheon.
• Conduct a pelvic examination to assess for any abnormalities.

Infertility Workup: Testing for Females

• Perform testing and schedule a preconception counseling appointment.
• Test for hemoglobin A1C and fasting glucose in women with a history of diabetes or risk factors.
• Conduct genetic screening as indicated.

Infertility Workup: Preconception Care

• Start preconception care immediately.

Infertility Workup: Male Factor

• Obtain a detailed medical, surgical, and illness history, particularly focusing on any history of mumps.
• Perform a semen analysis.
• Aim for a total sperm number of 39 million per ejaculate (33-46 million).
• Target a total motility of 40% (38-42%).
• Look for 4% of normal forms (3-4%).

Infertility Workup: Ovarian Factor

• Responsible for up to 40% of female infertility.
• Fecundity gradually declines after age 32, rapidly decreasing after age 37.
• An increase in FSH and decreases in AMH and Inhibin B are associated with ovarian aging.
• A decrease in ovarian reserve is indicated by a day 3 FSH level over 13.
• Consider checking day 3 FSH levels in women over 40.
• Assess the patient's age and search for evidence of disordered ovulation.
• Analyze menstrual history, basal body temperature (BBT), over-the-counter ovulation tests, and luteal phase progesterone levels (on day 21 or 23).
• Investigate suspected causes of disordered ovulation by checking TSH and PRL levels.

Luteal Phase Defect

• A shortened period between ovulation and menses.
• The corpus luteum involutes earlier than it should.
• Treatment involves supplemental progesterone.

Infertility Treatment: Ovarian Factor

• Referral to a specialist is generally required for most or all ovarian factor infertility treatments.
• Quickly refer women over 35 years old.

Infertility Treatment: Ovarian Factor: Clomiphene Citrate

• Clomiphene citrate (Clomid) is a selective estrogen receptor modulator (SERM).
• Blocks estrogen receptors in the hypothalamus.
• Increased pulsatile release of GnRH, leading to increased FSH.
• Increased follicle recruitment, making ovulation more likely.
• Side effects include over-ovulation, menopausal symptoms (hot flashes, vaginal dryness), and OHSS (rare).

Infertility Treatment: Ovarian Factor: Metformin

• Used for women with PCOS who don't ovulate with clomiphene citrate.
• Helpful as a supplement to Clomid for PCO patients.
• Referral to a reproductive specialist is required for any use other than ovulation.

Infertility Treatment: Ovarian Factor: Ovarian Hyperstimulation Syndrome (OHSS)

• Excess production of large follicles.
• Increased capillary permeability in ovarian tissue with poor reabsorption.
• Severe OHSS can lead to ascites, hemoconcentration, and a risk of clotting.

Infertility Treatment: Uterine and Tubal Factors

• Most common uterine issues: Asherman's syndrome, leiomyomata, and congenital abnormalities (Mullerian).
• Most common tubal issues: prior tubal ligation/surgeries and prior infection/pelvic inflammatory disease (PID).
• Hysterosalpingogram (HSG) is used to assess uterine and tubal factors.

Mullerian Fusion Disorders

• Uterine septa are the most common disorder associated with pregnancy loss.
• Resection of the septum can improve delivery rates.

Infertility Treatment: Uterine and Tubal Factors: Hydrosalpinx

• Almost always caused by infection.
• A blocked fallopian tube with no "spill".
• Referral for immediate salpingectomy and assisted reproductive technology (ART) may be recommended.
• Tubal reconstruction may be attempted.

Infertility Definition

• Infertility is defined as a couple’s inability to conceive after 1 year of regular, unprotected intercourse.
• For women over 35 years old, the diagnosis can be made after 6 months of attempting conception.

Infertility Incidence

• Approximately 15-20% of couples in the United States experience infertility.

When to Evaluate for Infertility

• Evaluate couples who meet the definition of infertility.
• Evaluate earlier for women over 35 years old.
• Consider earlier evaluation for individuals with a history of amenorrhea or oligomenorrhea, suspected tubal disease, endometriosis, Müllerian variations, risk factors for ovarian insufficiency like prior chemo/radiation, other autoimmune diseases, or history of significant ovarian surgery.
• Evaluate males with risk factors such as history of testicular torsion/cancer, orchitis/mumps, or unsuccessful conception.

Infertility Causes

• Infertility can be caused by male factors, ovarian/tubal factors, or a combination of both.
• Male factor is the sole cause in 20% of cases.
• Ovarian/tubal factors are present in over 45% of cases.

Infertility Workup: Exam

• Evaluate weight, BMI, and blood pressure.
• Assess for signs of systemic illness like diabetes, autoimmune disorders, or metabolic syndrome.
• Examine the thyroid for enlargement, nodules, or tenderness.
• Check breasts for galactorrhea.
• Look for signs of androgen excess, such as acne, hirsutism, or a male escutcheon.
• Conduct a pelvic exam and consider all previously discussed disorders.

Infertility Workup: Testing in Females

• Perform testing and schedule a preconception counseling appointment.
• Check hemoglobin A1C and fasting glucose levels for women with a history of diabetes or risk factors.
• Screen for genetic disorders as indicated.

Infertility Workup: Preconception Optimization

• Initiate preconception care immediately.

Infertility Workup: Male Factor

• History: Gather past medical, surgical, illness, and injury history.
• Specifically inquire about a history of mumps, as it is a known cause of mumps orchitis.
• Semen Analysis: This is the primary assessment for male factor infertility.
  • Total Sperm Number: 39 million per ejaculate (33-46 million)
  • Total Motility: 40% (38-42%)
  • Normal Forms: 4% (3-4%)

Infertility Workup: Ovarian Factor

• Responsible for up to 40% of female infertility.
• Fecundity gradually declines around 32 years of age and rapidly after 37 years.
• Associated with increased FSH and decreased AMH and Inhibin B levels.
• Assess patient age and evidence of disordered ovulation.
• Menstrual History: Retrieve information about menstrual cycles.
• Basal Body Temperature (BBT): Analyze BBT charts to identify potential ovulation patterns.
• Over-the-Counter Ovulation Test: Evaluate results for ovulation detection.
• Luteal Phase Progesterone: Measure levels on day 21 or 23 to assess ovulation.
• Day 3 FSH: Assess ovarian reserve, particularly in women over 40 years old. A value of 13 or higher indicates very difficult stimulation.
• Labs: Evaluate TSH and PRL if disordered ovulation is suspected.

Luteal Phase Defect

• Definition: A shortened time between ovulation and menstruation.
• Cause: The corpus luteum involutes earlier than it should.
• Treatment: Supplemental progesterone.

Infertility Treatment: Ovarian Factor

• Referral: For most/all treatment options, refer to a specialist.
• Immediate referral: For women over 35 years old.

Infertility Treatment: Ovarian Factor - Clomiphene Citrate

• Mechanism of Action: Clomiphene Citrate (Clomid) is a selective estrogen receptor modulator (SERM).
• Clomiphene blocks estrogen receptors in the hypothalamus, leading to an increase in pulsatile GnRH release and subsequently increased FSH.
• This enhanced FSH recruitment increases the likelihood of follicles reaching the estrogen level required for ovulation.
• Side Effects:
  • Over-ovulation.
  • Menopausal symptoms, such as hot flashes and vaginal dryness.
  • Ovarian hyperstimulation syndrome (OHSS) - rare.

Infertility Treatment: Ovarian Factor - Metformin

• Indication: Women with PCOS who do not ovulate with clomiphene citrate.
• Ovulation Use: Metformin can be utilized as a supplement to Clomid for PCOS patients.
• Referral: For any use beyond ovulation induction, refer to a reproductive specialist.
• Evidence: The evidence regarding metformin's efficacy for infertility is unclear.

Infertility Treatment: Ovarian Factor - Ovarian Hyperstimulation Syndrome (OHSS)

• Definition: Overproduction of very large follicles.
• Mechanism: Increased capillary permeability in ovarian tissue with poor reabsorption.
• Severe OHSS: Can lead to ascites, hemoconcentration, and an increased risk of clotting.

Infertility Treatment: Uterine and Tubal factors

• Most Common Uterine Issues:
  • Asherman's syndrome.
  • Leiomyomata (fibroids).
  • Congenital abnormalities (Müllerian).
  • Most Common Tubal Issues:
  • Prior tubal ligation or surgeries.
  • Previous infection or pelvic inflammatory disease (PID).
• Assessment for Uterine and Tubal Factors: Hysterosalpingography (HSG).

Mullerian Fusion Disorders

• Most Common: Uterine septum.
• Association: Increased pregnancy loss.
• Treatment: Resection of the septum, which can improve delivery rates.

Infertility Treatment: Uterine and Tubal Factors - Hydrosalpinx

• Definition: Fluid accumulation in a fallopian tube.
• Cause: Almost always (99%) due to infection.
• Characteristic: Blockage preventing fluid outflow.
• Referral: Recommended for further evaluation and management.
• Consideration: Some recommend immediate salpingectomy and assisted reproductive technologies (ART).
• Alternative: Some attempt tubal reconstruction.