The Challenge of the Miracle of Life - Infertility Jennifer McDonald DO
Jan 02, 2016
The Challenge of the Miracle of Life - Infertility
Jennifer McDonald DO
Fecundability
Probability of achieving a pregnancy within one menstrual cycle
25% for normal couples
Infertility
Couple’s failure to achieve pregnancy after one year of regular,
unprotected intercourse US ~ 15% couples
Incidence has remained stable over last three decades
Primary Infertility ??
Secondary Infertility ??
Average Conception Rates
% of Couples Length of time
20% Conceive within 1 month
60% Conceive within 6 months
75% Conceive within 9 months
80% Conceive within 12 months
90% Conceive within 18 months
Causes of Infertility
Multiple factors 20% Male factors 40%
Female factors 40%Ovulatory factor 15-20%
Peritoneal factor 40%Uterine-tubal factor 30%
Cervical factor 5-10%
Unexplained infertility 20%
Aging and female infertility
As age increases follicular phase becomes shorter and estradiol
begins to rise earlier Increased rate of follicular atresia
after 37-38 Increased rate of spontaneous
miscarriage
Aging and female infertility
Age Pregnancy(1yr)
MiscarriageRate
20-25 90 9.7%
26-30 85 10%
31-35 75 11.5%
36-40 65 21.4%
>40 50 42.2%
What’s age got to do with it?
Intercourse on most fertile day
50% achieve pregnancy age 19-2640% achieve pregnancy age 27-3430% achieve pregnancy age 35-39
So what’s so hard??
Parts is Parts
Adequate numbers of healthy sperm (male factor) Mature ovum released in predictable fashion
(ovarian factor) Cervix must capture, nuture and release sperm
into uterus and tubes (cervical factor) Fallopian tubes must have a functional anatomic
relationship to facilitate ovum capture (peritoneal factor)
Fallopian tube must be patent and capable of transfer (tubal factor)
Uterus must be receptive to implantation and
supporting pregnancy (uterine factor)
Male Factor Evaluation
Physical exam Environmental/occupational exposures
Semen analysis> 20 million
Motility > 50%Volume > 2mL
Morphology > 30% normal
Endocrine evaluation if warranted
Female Factor Infertility - Peritoneal Factors
Endometriosis
Pelvic Adhesions
Pregnancy rates after treatment as high as 75%
for mild disease and as low as 30% for severe disease
Diagnosis = Laparoscopy
Hypothalamic-pituitary dysfunction Intracranial tumors
PCOS Ovarian abnormalities
Thyroid disease Androgen excess
Female Factor Infertility - Ovulatory Factors
Ovulation restored in 90% of cases due to endocrine factors. Other cases rely
on ovulation induction with medications
Evidence of Ovulation
Basal body temperature Serum progesterone (mid-luteal Day19-22)
12 - 15 ng/mL considered evidence of ovulation Ovulation predictor kits (LH surge)
Ultrasound
Basal Body Temperature
Temperature first thing in the morning Biphasic pattern suggestive of ovulation
Common to have dip the day of ovulation Temperatures rise after ovulation due to
progesterone from corpus luteum If temperatures drop late in the luteal phase don’t waste money on a pregnancy
test!
Female Factor Infertility - Uterine & Tubal Factors
Fibroids Intrauterine adhesions (Asherman’s)
Congenital malformations Tubal occlusion (PID most common)
Endometrial abnormalities
Tubal Adhesions
Mullerian Anomalies
Anomaly Frequency
Bicornuate uterus (37 percent) Arcuate uterus (15 percent)
Incomplete septum (13 percent) Uterus didelphys (11 percent)
Complete septum (9 percent) and Unicornuate uterus (4.4 percent)
Hysterosalpingogram
Radiopaque dye through the cervix under x-ray watching dye fill uterus and
spill from tubes into peritoneal cavity
Ultrasonography
Non-invasive 3D contours of uterus and
endometrium as well as ovaries
MRI
More distinct delineation of soft tissue structures
MR imaging has been shown to be both sensitive and specific and is
clearly less invasive than laparoscopy, which was considered the gold standard for diagnosis of
anomalies.
Structural abnormalities Abnormal mucous production
Female Factor Infertility - Cervical Factors
Evaluation should include post-coital test
Treatment includes intrauterine insemination
Smoking and Female Fertility
Interferes with gametogenesis, fertilization & implantation
Reduces estrogen levels Nicotine alters FSH/LH release
decreasing LH surge Nicotine stimulates cortisol secretion
Earlier menopause by 2-3 years Fertility rates lower (30%)
Smoking and Male Fertility
Impaired sperm concentration, motility & morphology
Decreased libido Combined with caffeine consumption
increases number of non-viable sperm
Assisted Reproduction
IVF (in vitro fertilization) GIFT (gamate intra-fallopian transfer) ZIFT (zygote intra-fallopian transfer)
IVF
Ovarian stimulation with gonadotropins Oocyte retrieval (36 hours after hCG)
Oocyte culture - sperm added after 4-6 hours (50,000 per oocyte)
65-80% of mature oocytes will fertilize Examined at the pro-nuclear stage
Cryopreservation of unused embryos (two thirds will survive freezing/thawing)
IVF
Embryo transfer 8-10 cell stage (72-80 hours after retrieval)
Multiple pregnancy rate 35% Rise in hCG indicates pregnancy while drops indicate a failed cycle