MANAGEMENT OF THE INFERTILE COUPLE IN A PRIMARY CARE SETTING

PART TWOMILIE NWOYE MD

SHAPE ARMY MEDICAL CLINIC

MARCH 27TH 2014

MILIE.NWOYE@GMAIL.COM

INFERTILITY MANAGEMENT

• Timed intercourse

• Ovulation induction

• Intrauterine insemination (+/- ovulation induction)

• In-vitro fertilization (IVF)

• Intracytoplasmic sperm injection (ICSI)

TIMED INTERCOURSE

• DEFINITION: SEXUAL INTERCOURSE AT THE FERTILE PERIOD OF THE MENSTRUAL CYCLE, WITHOUT OVULATION INDUCTION

• INDICATION: UNEXPLAINED INFERTILITY- INFERTILE COUPLE (NO CONCEPTION AFTER 1 YEAR OF TRYING), WITH NORMAL FERTILITY TESTS, <35

• PREGNANCY RATE: 3.4% PER CYCLE*

* Fertil steril 1991 jul 56 (1)

TIMED INTERCOURSE- PROCESS

• STEP 1: RULE OUT PREGNANCY AND CONFIRM EARLY FOLLICULAR PHASE

• HCG TESTS (URINE OR BLOOD)

• FSH AND ESTRADIOL BLOOD TESTS (IDEALLY <10 IU/L AND <80PG/ML RESPECTIVELY) OR OBTAIN GOOD MENSTRUAL HISTORY

• STEP 2: DETERMINE LH RISE

• LH KIT TESTS

• OR BLOOD LH TESTING

• STEP 3: SEXUAL INTERCOURSE THE EVENING OF LH RISE AND THE NEXT EVENING

• STEP 4: PREGNANCY TEST

• 10 DAYS AFTER SEXUAL INTERCOURSE IS NO PERIOD

OVULATION INDUCTION• DEFINITION: USING MEDICATIONS TO INDUCE OVULATION TO INITIATE OVULATION OR TO INCREASE THE NUMBER

OF OVULATORY FOLLICLES

• INDICATION:

• UNEXPLAINED INFERTILITY

• OVULATION DYSFUNCTION

• LUTEAL PHASE DEFECT

• FAILED TIMED INTERCOURSE

• FEMALE > 35 UNDERGOING HER FIRST TREATMENT AND NORMAL FERTILITY TESTS

• CONTRAINDICATION:

• SEVERE PCOS

• ALLERGY OR SEVERE REACTION TO OVULATION INDUCTION AGENT

• PREGNANCY RATES:

• CC+TI 2.7%/CYCLE*

• FSH+TI 8.2%/CYCLE*

*Zollner et al; J Reprod Med , 2013

OVULATION INDUCTION AGENTS

• CLOMIPHENE CITRATE (50-150MG):

• INCREASE IN ENDOGENOUS FSH BY ER ANTAGONISM AND REMOVING CENTRAL NEGATIVE FEEDBACK*

• 8% CHANCE OF MULTIPLES**

• LETROZOLE

• INCREASES ENDOGENOUS FSH BY DECREASING PERIPHERAL ESTROGEN*

• FSH

• INCREASE IN EXOGENOUS FSH

• 20% CHANCE OF MULTIPLES****Speroff** ASRM practice bulletin*** Check et al; J Perinat Med 1993

CLOMIPHENE CITRATE- PROCESS

• STEP 1: RULE OUT PREGNANCY AND CONFIRM EARLY FOLLICULAR PHASE

• STEP 2: START CC AT LOWEST DOSE ON DAY 2 OF CYCLE AND CONTINUE FOR 5 DAYS

• STEP 3: CHECK FOLLICULAR RESPONSE

• STEP 4: LH SURGE (SPONTANEOUS OR AFTER HCG TRIGGER)

• STEP 5: SEXUAL INTERCOURSE THE EVENING OF LH SURGE AND THE NEXT EVENING OR 36 HOURS AFTER HCG TRIGGER OR IUI IN 24 HOURS

• STEP 6: PREGNANCY TEST

• IF NO PERIOD AFTER 10 DAYS

FSH INDUCTION- PROCESS

• STEP 1: RULE OUT PREGNANCY AND CONFIRM EARLY FOLLICULAR PHASE

• STEP 2: START FSH AT LOWEST DOSE ON DAY 2 OF CYCLE AND CONTINUE UNTIL ADEQUATE FOLLICULAR RESPONSE

• STEP 3: ADMINISTER HCG FOR OVULATION TRIGGER

• STEP 4: SEXUAL INTERCOURSE THE EVENING OF LH SURGE AND THE NEXT EVENING OR 36 HOURS AFTER HCG TRIGGER OR IUI IN 24 HOURS

• STEP 5: PREGNANCY TEST

• IF NO PERIOD AFTER 10 DAYS

INTRAUTERINE INSEMINATION (IUI)

• DEFINITION: PLACEMENT OF PREPARED SPERMS IN THE UTERINE CAVITY AT TIME OF OVULATION

• INDICATION:

• UNEXPLAINED INFERTILITY

• MILD MALE FACTOR

• CERVICAL FACTOR

• FAILED TIMED INTERCOURSE

• UNAVAILABLE MALE

• CONTRAINDICATION

• CERVICAL STENOSIS

• SEVERE MALE FACTOR

• PREGNANCY RATE

• CC+IUI 10.3%/CYCLE*

• FSH+IUI 15.5%/CYCLE*

*Zollner et al; J Reprod Med , 2013

INTRAUTERINE INSEMINATION- PROCESS

• WASHED SPERM INTRODUCED INTO UTERINE CAVITY WITH A CATHETER 36 HOURS AFTER HCG TRIGGER

• CHECK PREGNANCY TEST 10 DAYS AFTER IUI IF NO PERIOD

IN-VITRO FERTILIZATION (IVF)• DEFINITION: A PROCESS OF CONTROLLED OVARIAN STIMULATION, OVULATION TRIGGER, OOCYTE

ASPIRATION, SPERM PREPARATION, IN-VITRO FERTILIZATION, EMBRYO TRANSFER

• INDICATION:

• UNEXPLAINED INFERTILITY

• TUBAL FACTOR INFERTILITY

• FAILED INTRAUTERINE INSEMINATION

• OTHER EG. NEED FOR PRE-GENETIC DIAGNOSIS (PGD)

• CONTRAINDICATION:

• SEVERE PCOS

• ALLERGY OR SEVERE REACTION TO OVULATION INDUCTION AGENT

• PREGNANCY RATES:

• 35.5% PER EMBRYO TRANSFER (EUROPE 2010)*

*www.eshre.eu

OVARIAN STIMULATION PROTOCOLS

GNRH AGONIST GNRH ANTAGONIST

INTRACYTOPLASMIC SPERM INDUCTION (ICSI)

• DEFINITION: SIMILAR TO IVF EXCEPT THAT THE SPERM IS DIRECTLY INJECTED INTO THE OOCYTE

• INDICATION:

• SAME AS IVF

• FAILED IVF

• TESTICULAR SPERM

• CONTRAINDICATION:

• SEVERE PCOS

• ALLERGY OR SEVERE REACTION TO AGENTS

• PREGNANCY RATES:

• 32.1% PER EMBRYO TRANSFER- EUROPE 2010*

*www.eshre.eu

IN-VITRO MATURATION

• IN-VITRO MATURATION (IVM): LIGHT OVARIAN STIMULATION, ASPIRATION OF IMMATURE OOCYTE, AND OOCYTE MATURATION IN-VITRO