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Infertility

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					INFERTILITY
   Anna Mae Smith, MPAS, PA-C
Definition
 Infertility is one year of unprotected coitus
  without conception
 The term "primary infertility" is applied to
  the couple who has never achieved a
  pregnancy
 "secondary infertility" implies that at least
  one previous conception has taken place
Tx Goals
     – To identify the cause of the infertility
     – To provide a basis for potentially
       successful treatment options
     – To provide a realistic prognosis
     – To offer emotional support
Fecundability
 20-25% of couples will conceive/cycle
 50% should conceive after 3-4mos
 95% should conceive after 1 yr
Major Causes
        Female Infertility Etiologies
Unexplained               10%
Cervical/mucus            2-3%
Endometrial/uterine       2-3%
                          5-10%
Pelvic/peritoneal
                          30-50%
Tubal
                          40%
Central (CNS)
Other Etiologies
   PID
   Cx conization/cautery
   Smoking
   DES exposure
   IUD
   Endometriosis
   PCOF
Others
 Age - fertility decreases after the age of 30!
     Even if severely low sperm count present …the
      female prior to the age of 30 may compensate
      by her fertility!
 Maximum fecundity is around 25
First visit
   Have both come to all visits!!
   Get a complete history
   Sexual history!!
   Educate!!
Manly Questions
   Infertility duration
   Prior fertility in relationship(s)
   Medical & surgical history
   Meds (anabolic steroids, cancer chemotherapy,
    sulfasalazine, nitrofurantoin)
   Alcohol, drugs, pot
   Occupational exposures
   Sexual dysfunction
   Tight fitting underwear/pants
   Previous testing
Womanly Questions
   Infertility duration
   Detailed menstrual history
   Prior pregnancies
   Fertility in other relationships
   IUD’s, OCP’s, Depo
   Frequency of intercourse/sexual dysfunction
Womanly Questions
 Gynecologic history (PID, endometriosis,
  fibroids, cervical dysplasia)
 DES exposure
 Medical and surgical history
 Medications
 Previous tests and therapy
DRUGS

 Cause hyperprolactinemia:
     Neuroleptic, antidepressant, and hypotensive
      drugs and drugs for gastrointestinal symptoms
 Recreational drugs such as marijuana and
  cocaine
 Spontaneous galactorrhoea must be
  ascertained and further investigated for
  suspected hyperprolactinemia
TESTS
 Thyroid
 Midcycle progesterone level &/or luteal phase
  progesterone level
 FSH/ LH
 Cortisol
 Hystersalpingogram
 Laporoscopy
 Postcoital Test
Treatment
   Education
   BBT’s/menstrual calendar
   Clomiphene
   Pergonal
   Artificial insemination
   IVF
Male Infertility
 Sperm production… idiopathic or certain
  known entities such as mumps, endocrine
  disorders & immunological disorders
 Anatomical abnormalities that obstruct the
  genital tract…varicocele.
Sperm Count
 Fresh sample (to lab within 30 mins.) –most sperm
  in initial ejaculate
 Male should be abstinent for 48 to 72 hours
      sperm concentration > 20 million per ml
      total count > 60 million
      ejaculate volume > 1.5 ml
      total motile count > 30 million
      viable sperm > 50%
      normal shapes (morphology) > 60%
    Sperm Terms
 Normozoospermia    Normal ejaculate
 Normal ejaculate   Sperm concentration <20 ×
                      106 /ml
 Asthenozoospermia  <50% spermatozoa with
                      forward progression

 Teratozoospermia
                       <30% spermatozoa with
                        normal morphology
 Azoospermia          No spermatozoa in the
                        ejaculate
 Aspermia             No ejaculate
Male/Female Infertility
 Endocrine - gonadotropins, bromocriptine
 Surgery to repair anatomical conditions
 Artificial insemination
     IVF - in vitro fertilization (ET embryo transfer)
     ZIFT – zygote (embryo) intra-fallopian transfer
     GIFT - gamete intra fallopian transfer
     ICSI – Intracytoplasmic sperm injection
       • microsurgical fertilization
Environmental changes
   Vitamins
   Baggy shorts
   Sex not every nite…every other
   Diet changes
   Stop smoking