Male and Female Infertility
Goals
Enhance comfort level with workup
Basic Management Strategies
TRICARE Coveragehttp://www.rotundaivf.com/
Definition
12 months of unprotected intercourse
Earlier for certain historical factors
Older than 35
Infertility Etiology
Female Factors
Male Factors General Causes
Unknown: 40-50%
1° Hypogonadism: 30-40%
Altered Sperm Transport: 1020%
Meds
1° or 2° Hypogonadism
Common medications
2° Hypogonadism: 1-2%
Ketoconazole Cimetidine Spironolactone
The Scenario
Tech: “Husband and wife can’t get pregnant.”
You: OB rotation was last infertility workup
What now?
Workup
History is KEY
Focused Physical Exam
Labs and Specialized Tests
Workup: History
Coital Practices Gestational History PMHx/PSHx Meds Menstrual History Substances Recent High Fever
Our Couple: History Female
G1 P0010
No hx of STIs
Normal menses
Unprotected sex for 15 months
Male
No previous partner pregnancies
Gonorrhea hx
No meds
Occasional EtOH
Workup: Physical Exam Female
Breast Formation
Male
Galactorrhea
Genitalia
Hyperandrogenism?
Infection Hernia Vas deferens Androgen deficiency Testicular mass Varicocele
Workup: Labs Female
Ovulation problems
Male
Ovulatory Dysfunction Ovarian Reserve
CBC FSH, Testosterone GC/Chlam, UA Renal and Liver Function Semen analysis Postejaculatory urinalysis
WHO Seminal Fluid Analysis (1999)
Volume: >2ml Sperm concentration: >20 million/ml Total Sperm Number: >40 million/ejaculate Sperm Motility: >50% motile and/or >25% progressively motile
Sperm Morphology: >14% normal forms
Workup: Special Tests Female
Transvaginal Ultrasonography (TVUS)
Hysterosalpingography (HSG)
Hysteroscopy
Laparoscopy
Male
Scrotal Ultrasonography
Transrectal Ultrasonography (TRUS)
Our Couple: Exam, Labs & Tests
Normal male exam
Normal initial labs
Oligospermia on 2 separate semen analyses
TRUS and postejaculatory UA normal
Management: General Concepts
41 different methods
“Fertile window” intercourse
“E-type” vaginal discharge
Avoid lubricants and douches
Management: Female
Treat underlying cause
Hyperprolactinemia
PCOS
Gonadotropin therapy
Management: Female
Ovulatory dysfunction (Unknown etiology) Clomiphene 50mg PO daily x 5 days Start on days 3-5 Can increase to 100mg daily next cycle Results
80% will ovulate Hyperstimulation and Twinning Higher-order multiples rare
Management: Female
Clomiphene Failure?
IVF
Injectable ovulation-inducing agents
Management: Female
Tubal/Pelvic/Uterine Issues Reparative Surgery (low success) IVF
Endometriosis Laparoscopic ablation Laparotomy Ovulation induction +/- IUI and IVF
Management: Male
Hyperprolactinemia
Surgical repair
Fertility Specialist
Stress and Infertility
69% Women and 21% Men have preexisting condition
Greater risk for psychological stress
No significant difference in psychopathology
Stress and Infertility
Men have increased stress over time, same as women
Watch for normal grief vs. psychopathology
Same rates of depression as other chronic disease
Stress and Infertility ď Ž
Bottom line: Not a means to improve pregnancy rates.
Management: Our Couple
Male: Imipramine Mar 08
Pregnant inhttp://www.rotundaivf.com/ June 2008!
Separated from USAF in July 2008
Questions?