Infertility, family planning

Medvedev M.V.

Definitions

• Infertility
• Inability to conceive after one year of unprotected intercourse (6 months for women over 35?)
• Fertility
• Ability to conceive
• Fecundity
• Ability to carry to delivery

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Statistics

• 80% of couples will conceive within 1 year of unprotected intercourse
• ~86% will conceive within 2 years
• ~14-20% of couples are infertile by definition (~3 million couples)
• Origin:
• Female factor ~40%
• Male factor ~30%
• Combined ~30%

Etiologies

• Male Factor 40%
• Tubal Factor 40%
• Ovulation Problem 10%
• Unexplained 10%

Associated Factors

• PID
• Endometriosis
• Ovarian aging
• Spermatic varicocoele
• Toxins
• Previous abdominal surgery (adhesions)
• Cervical/uterine abnormalities
• Cervical/uterine surgery
• Fibroids

Psychosocial Issues

• Expectations
• Stress on Relationships
• Stress on Finances
• Alternatives- Adoption or Childless
• Counseling, Support Groups

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Overview of Evaluation

• Female
• Ovary
• Tube
• Corpus
• Cervix
• Peritoneum
• Male
• Sperm count and function
• Ejaculate characteristics, immunology
• Anatomic anomalies

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The Most Important Factor in the Evaluation of the Infertile Couple Is:

HISTORY

History-General

• Both couples should be present
• Age
• Previous pregnancies by each partner
• Length of time without pregnancy
• Sexual history
• Frequency and timing of intercourse
• Use of lubricants
• Impotence, anorgasmia, dyspareunia
• Contraceptive history

History-Male

• History of pelvic infection
• Radiation, toxic exposures (include drugs)
• Mumps
• Testicular surgery/injury
• Excessive heat exposure (spermicidal)

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History-Female

• Previous female pelvic surgery
• PID
• Appendicitis
• IUD use
• Ectopic pregnancy history
• DES (?relation to infertility)
• Endometriosis

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History-Female

• Irregular menses, amenorrhea, detailed menstrual history
• Vasomotor symptoms
• Stress
• Weight changes
• Exercise
• Cervical and uterine surgery

Semen Analysis

Normal values:

Volume 2-5cc

Count >20 million

Motility >50%

Morphology >50% normal

(strict criteria >15%)

Male Factor Infertility

Evaluation:

Repeat semen analysis

Physical exam- varicocele, testicular size

Lab testing- testosterone, FSH, LH

Genetics for special cases

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IUI (intrauterine insemination)

ICSI (intracytoplasmic sperm injection)

Donor sperm

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Physical Exam-Female

• Pelvic masses
• Uterosacral nodularity
• Abdominopelvic tenderness
• Uterine enlargement
• Thyroid exam
• Uterine mobility
• Cervical abnormalities

Etiologies

• Male Factor 40%
• Tubal Factor 40%
• Ovulation Problem 10%
• Unexplained 10%

Tubal Function

• Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition
• Kartagener’s syndrome can be associated with decreased tubal motility
• Tests
• HSG
• Laparoscopy
• Falloposcopy (not widely available)

Hysterosalpingography (HSG)

• Radiologic procedure requiring contrast
• Performed optimally in early proliferative phase (avoids pregnancy)
• Low risk of PID except if previous history of PID (give prophylactic doxycycline or consider laparoscopy)
• Oil-based contrast
• Higher risk of anaphylaxis than H₂O-based
• May be associated with fertility rates

Hysterosalpingography (HSG)

• Can be uncomfortable
• Pregnancy test is advisable
• Can detect intrauterine and tubal disorders but not always definitive

Hysterosalpingogram

HSG: Unilateral Blocked Tube

HSG: Tubal Infertility

HSG: Hydrosalpinx

HSG of DES daughter

Laparoscopy

• Invasive; requires OR or office setting
• Can offer diagnosis and treatment in one sitting
• Not necessary in all patients
• Uses (examples):
• Lysis of adhesions
• Diagnosis and excision of endometriosis
• Myomectomy
• Tubal reconstructive surgery

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Falloposcopy

• Hysteroscopic procedure with cannulation of the Fallopian tubes
• Can be useful for diagnosis of intraluminal pathology
• Promising technique but not yet widespread

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Uterine Corpus

Corpus

• Asherman Syndrome
• Diagnosis by HSG or hysteroscopy
• Usually s/p D+C, myomectomy, other intrauterine surgery
• Associated with hypo/amenorrhea, recurrent miscarriage
• Fibroids, Uterine Anomalies
• Rarely associated with infertility
• Work-up:
• Ultrasound
• Hysteroscopy
• Laparoscopy

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Cervical Function

• Infection
• Ureaplasma suspected
• Stenosis
• S/P LEEP, Cryosurgery, Cone biopsy (probably overstated)
• Immunologic Factors
• Sperm-mucus interaction

Etiologies

• Male Factor 40%
• Tubal Factor 40%
• Ovulation Problem 10%
• Unexplained 10%

Ovulation Physiology

• The LH (lutenizing hormone) surge occurs 34-36 hours prior to follicle rupture
• Progesterone is increasingly produced after the LH surge
• Secretory changes to the endometrium occur secondary to the increased progesterone levels

BBT

• Cheap and easy, but…
• Inconsistent results
• Provides evidence after the fact (like the old story about the barn door and the horse)
• May delay timely diagnosis and treatment
• 98% of women will ovulate within 3 days of the nadir
• Biphasic profiles can also be seen with LUF syndrome

Luteal Phase Progesterone

• Pulsatile release, thus single level may not be useful unless elevated
• Performed 7 days after presumptive ovulation
• Done properly, >15 ng/ml consistent with ovulation

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Urinary LH Kits

• Very sensitive and accurate
• Positive test precedes ovulation by ~24 hours, so useful for timing intercourse
• Downside: price, obsession with timing of intercourse

Salivary Estrogen: TCI Ovulation Tester- 92% accurate

Add Saliva Sample

Non-Ovulatory Saliva Pattern

High Estrogen/ Ovulatory �Saliva Pattern

Approach to Ovulation Disorders

• Evaluate- Hypothyroidism Prolactin Disorder Hyperandrogenism- PCOS Weight loss/ weight gain
• Induce Ovulation Clomid (clomiphene citrate)

Traditional Infertility Evaluation

1. Semen Analysis
2. Hysterosalpingogram (HSG)
3. Documentation of Ovulation

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• Post-coital Exam
• Diagnostic Laparoscopy

Current Infertility Evalution

1. Semen Analysis
2. Hysterosalpingogram (HSG)
3. Documentation of Ovulation

4) Ovarian Reserve Testing

Ovarian Reserve Testing

Day #3 FSH (<10 mIU/ml) and estradiol (<80 pg/ml)

-Correlates with the functional status of the ovaries and the quality of the oocytes

- FSH >15 only 5% success with IVF

- High estradiol level increases risk of cancelling IVF cycle

Ovarian Reserve Testing

Newest methods of ovarian reserve assesment:

• Serum Anti-Müllerian hormone (AMH) levels decrease with age in premenopausal women. In addition, serum levels of AMH correlate strongly with the number of antral follicles, suggesting that AMH levels by extension reflect the size of the primordial follicle pool
• Day 3 Inhibin B test. Levels of Inhibin B decrease with age. The amount of Inhibin B directly correlates to the follicular reserve.

Unexplained Infertility

• 12-15% of couples
• 3% chance of achieving a pregnancy
• Treatment:

Superovulate with IUI

(intrauterine insemination)-

Clomid 12% success

Pergonal 16%

IVF

Infertility?

Contraception

Methods

• Oral Contraceptive Pills (OCP’s)
• Depo-Provera, Norplant
• Intrauterine Device (IUD)
• Male / Female Condom
• Diaphragm
• Emergency Contraception (EC)
• Spermicides

Efficacy (modified from trussell, et. al 1990)

Failure Rate (Percent) During First Year of Use

Hormonal Contraception: Combination OCP’s

• Contain Synthetic Estrogen/Progestin
• Modern E₂ Dosage ≤ 50 Mcg
• Despite Diversity, Side Effects and Efficacies Similar
• Requires Patient Compliance
• May Be Monophasic or Triphasic

Combination OCP’s:�Mechanism of Action

• Suppresses LH / FSH Release

(E₂ FSH, P LH)

• Progestin Thickens Cervical Mucus and Alters Endometrium
• Major Effect Is Anovulation and Impairment of Sperm Transport and Oöcyte Implantation

Combination OCP’s:�Additional Benefits

• Menstrual Regulation
• Decreased Risk of Anemia
• Ovarian, Endometrial CA: Risk
• Lower PID Risk
• Prevention of Benign Breast Disease

Combination OCP’s:�Side Effects

• Breakthrough Bleeding (≤ 25%)
• Amenorrhea
• Breast Tenderness, Nausea
• H/A (+/–)
• ?HTN
• ?Weight Gain

Combination OCP’s:�Risks

• Thromboembolism (≥ 35 yo, Smoker)
• MI (Smokers Only):
• < 15 cig/day: 3X Risk
• > 15 cig/day : 21X Risk
• Liver Adenomas (Very Rare)

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Depo-Provera:

• Inhibits Ovulation
• 150 mg q3months (14 day grace period)
• Delayed Ovulation After Discontinuation
• Main Side-Effects:
• Amenorrhea
• AUB
• Weight Gain
• Hair Loss

Norplant:

• Implantable for ≤ 5 Years
• Similar Side Effects as Depo-Provera
• Avg. Yearly Failure Rate: 0.8/100 (Increases : > 2/100 after 5 years)
• Occasionally Difficult to Remove

Barrier Methods:

• Diaphragm: High Failure Rates

– Must Remain in ~6 Hrs post-coitus

– Best if Combined with Spermicide

– UTI Potential

• Condom: STD Protection, Inconsistent Use by Men
• Female Condom: Cumbersome, Learning Curve
• Today Sponge: As seen on Seinfeld

IUD: Overview

• ParaGard (CuT380A), Progestasert
• Very Effective (~ TL), Reversable
• Risks OVERBLOWN
• Monogamy Essential, However
• Does Not Protect Against STD’s
• Can Remain for ≤ 10 Years

IUD:�Mechanisms of Action

• NOT ABORTIFACIENT!!!!!!!!
• Prevents Conception:

– Sperm Transport Inhibited

– Sperm Survival / Capacitation Diminished

• Prevents Implantation: hCG Levels = 0

IUD:�Work-up

• History: STD’s, Sexual History, Ectopic
• PEx: Size / Configuration of Uterus
• Cervical Cultures, Pap
• Counseling

IUD:�Contraindications

• Lack of Monogomy, High Risk for STD’s
• Abnormal Uterine Bleeding
• Current Pelvic Infection (GC, Chl)
• Actinomyces on Pap
• ???Nulliparity
• Pregnancy
• Wilson’s Dz, Cu Allergy (both rare)

IUD:�Complications

• PID: Usually 2⁰ Insertional Contamination

– Unproven Role for Prophylactic ABx

• Hypermenorrhea
• Expulsion
• Perforation (< 0.1%)
• Failure: IUD Should be Removed
• ??Ectopic

Emergency Contraception

• IUD, OCP’s
• Specific OCP Regimens Given ≤ 72 Hours After Unprotected Intercourse

~ 75% Effective

• Yuzpe Method: Ovral 2 tabs po now and 2 tabs 12⁰ later
• May Cause Nausea
• Consider Dispensing at Yearly Visit

Special Circumstances

• Postpartum/Postabortion:

– IUD, Progestins, Combination OCP’s*

• Anticonvulsant/Antibiotic Use:

– TCN Probably OK

– Most Anticonvulsants Impair Efficacy of Hormonal Contraceptives

* may affect lactation before milk flow established

Summary

• Barrier Methods Tend to Have Higher Failure Rates than Hormonal Methods and the IUD
• The IUD is Underutilized
• All Methods have Risks and May Not be Appropriate for all Patients

Thank you!