Male and Female Male and Female InfertilityInfertility

GoalsGoals

Enhance comfort level with workupEnhance comfort level with workup

Basic Management StrategiesBasic Management Strategies

TRICARE TRICARE www.rotunda.co.inwww.rotunda.co.in

DefinitionDefinition 12 months of unprotected intercourse12 months of unprotected intercourse

Earlier for certain historical factorsEarlier for certain historical factors

Older than 35Older than 35

Infertility EtiologyInfertility Etiology

Female FactorsFemale Factors

Male FactorsMale Factors

General CausesGeneral Causes Unknown: 40-50%Unknown: 40-50%

1° Hypogonadism: 30-1° Hypogonadism: 30-40%40%

Altered Sperm Transport: Altered Sperm Transport: 10-20%10-20%

2° Hypogonadism: 1-2%2° Hypogonadism: 1-2%

MedsMeds 1° or 2° 1° or 2°

HypogonadismHypogonadism

Common medicationsCommon medications KetoconazoleKetoconazole CimetidineCimetidine SpironolactoneSpironolactone

The ScenarioThe Scenario Tech: “Husband and wife can’t get Tech: “Husband and wife can’t get

pregnant.”pregnant.”

You: OB rotation was last infertility workupYou: OB rotation was last infertility workup

What now?What now?

WorkupWorkup

History is KEYHistory is KEY

Focused Physical ExamFocused Physical Exam

Labs and Specialized TestsLabs and Specialized Tests

Workup: HistoryWorkup: History Coital PracticesCoital Practices Gestational HistoryGestational History PMHx/PSHxPMHx/PSHx MedsMeds Menstrual HistoryMenstrual History SubstancesSubstances Recent High FeverRecent High Fever

Our Couple: HistoryOur Couple: History

FemaleFemale G1 P0010G1 P0010

No hx of STIsNo hx of STIs

Normal mensesNormal menses

Unprotected sex for 15 Unprotected sex for 15 monthsmonths

MaleMale No previous partner No previous partner

pregnancies pregnancies

Gonorrhea hxGonorrhea hx

No medsNo meds

Occasional EtOHOccasional EtOH

Workup: Physical ExamWorkup: Physical Exam

MaleMale InfectionInfection HerniaHernia Vas deferensVas deferens Androgen deficiencyAndrogen deficiency Testicular massTesticular mass VaricoceleVaricocele

FemaleFemale Breast FormationBreast Formation

GalactorrheaGalactorrhea

GenitaliaGenitalia

Hyperandrogenism?Hyperandrogenism?

Workup: LabsWorkup: Labs

FemaleFemale Ovulation problemsOvulation problems

Ovulatory DysfunctionOvulatory Dysfunction

Ovarian ReserveOvarian Reserve

MaleMale CBCCBC FSH, TestosteroneFSH, Testosterone GC/Chlam, UAGC/Chlam, UA Renal and Liver Renal and Liver

FunctionFunction Semen analysis Semen analysis Postejaculatory Postejaculatory

urinalysisurinalysis

WHO Seminal Fluid WHO Seminal Fluid Analysis (1999)Analysis (1999)

Volume: >2mlVolume: >2ml Sperm concentration: >20 million/mlSperm concentration: >20 million/ml Total Sperm Number: >40 million/ejaculateTotal Sperm Number: >40 million/ejaculate Sperm Motility:Sperm Motility:

>50% motile and/or>50% motile and/or >25% progressively motile>25% progressively motile

Sperm Morphology: >14% normal formsSperm Morphology: >14% normal forms

Workup: Special TestsWorkup: Special Tests

FemaleFemale Transvaginal Transvaginal

Ultrasonography (TVUS)Ultrasonography (TVUS)

Hysterosalpingography Hysterosalpingography (HSG)(HSG)

HysteroscopyHysteroscopy

LaparoscopyLaparoscopy

MaleMale Scrotal Scrotal

UltrasonographyUltrasonography

Transrectal Transrectal Ultrasonography Ultrasonography (TRUS)(TRUS)

Our Couple: Exam, Our Couple: Exam, Labs & TestsLabs & Tests

Normal male examNormal male exam

Normal initial labsNormal initial labs

Oligospermia on 2 separate semen Oligospermia on 2 separate semen analysesanalyses

TRUS and postejaculatory UA normalTRUS and postejaculatory UA normal

Management: General Management: General ConceptsConcepts

41 different methods41 different methods

““Fertile window” intercourseFertile window” intercourse

““E-type” vaginal dischargeE-type” vaginal discharge

Avoid lubricants and douchesAvoid lubricants and douches

Management: FemaleManagement: Female Treat underlying causeTreat underlying cause

HyperprolactinemiaHyperprolactinemia

PCOS PCOS

Gonadotropin therapyGonadotropin therapy

Management: FemaleManagement: Female Ovulatory dysfunction (Unknown etiology)Ovulatory dysfunction (Unknown etiology)

Clomiphene 50mg PO daily x 5 daysClomiphene 50mg PO daily x 5 days Start on days 3-5Start on days 3-5 Can increase to 100mg daily next cycleCan increase to 100mg daily next cycle ResultsResults

80% will ovulate80% will ovulate Hyperstimulation and TwinningHyperstimulation and Twinning Higher-order multiples rareHigher-order multiples rare

Management: FemaleManagement: Female Clomiphene Failure?Clomiphene Failure?

IVFIVF

Injectable ovulation-inducing agentsInjectable ovulation-inducing agents

Management: FemaleManagement: Female Tubal/Pelvic/Uterine IssuesTubal/Pelvic/Uterine Issues

Reparative Surgery (low success)Reparative Surgery (low success) IVFIVF

EndometriosisEndometriosis Laparoscopic ablationLaparoscopic ablation LaparotomyLaparotomy Ovulation induction +/- IUI and IVFOvulation induction +/- IUI and IVF

Management: MaleManagement: Male

HyperprolactinemiaHyperprolactinemia

Surgical repairSurgical repair

Fertility SpecialistFertility Specialist

Stress and InfertilityStress and Infertility 69% Women and 21% Men have 69% Women and 21% Men have

preexisting conditionpreexisting condition

Greater risk for psychological stressGreater risk for psychological stress

No significant difference in No significant difference in psychopathologypsychopathology

Stress and InfertilityStress and Infertility Men have increased stress over time, Men have increased stress over time,

same as womensame as women

Watch for normal grief vs. psychopathologyWatch for normal grief vs. psychopathology

Same rates of depression as other chronic Same rates of depression as other chronic diseasedisease

Stress and InfertilityStress and Infertility Bottom line: Not a means to improve Bottom line: Not a means to improve

pregnancy rates.pregnancy rates.

Management: Our CoupleManagement: Our Couple

Male: Imipramine Mar 08Male: Imipramine Mar 08

Pregnant in www.rotunda.co.in June Pregnant in www.rotunda.co.in June 2008!2008!

Separated from USAF in July 2008Separated from USAF in July 2008

Questions?Questions?