Top IVF Clinic India,IVF Infertility Clinic,IVF Fertility Center,In Vitro fertilization
Post on 30-Mar-2016
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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?
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