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Infertility: the role of the family doctor. Carroll Haymon, M.D. January 7, 2002. Definitions . Infertility = Inability of a couple practicing frequent intercourse and not using contraception to fail to conceive a child within one year.

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infertility the role of the family doctor

Infertility: the role of the family doctor

Carroll Haymon, M.D.

January 7, 2002

definitions
Definitions
  • Infertility = Inability of a couple practicing frequent intercourse and not using contraception to fail to conceive a child within one year.
  • Infertility affects 15-20% of couples, or 11 million reproductive age people in the U.S.
causes of infertility
Causes of infertility
  • Tubal pathology 35%
  • Male factor 35%
  • Ovulatory dysfunction 15%
  • Unexplained 10%
  • Cervical/other 5%
counsel patience
Counsel patience!
  • In normal young couples:
    • 25% conceive after one month
    • 70% conceive after six months
    • 90% conceive by one year
  • Only an additional 5% will conceive in an additional 6-12 months
fecundity and age
Fecundity and Age
  • In a federal survey:
    • Impaired fertility in women < 25y is 11.7%
    • Impaired fertility in women > 35y is 42.1%
  • In another study:
    • 74% of women < 31y conceived in one year.
    • 54% of women >35y conceived in one year.
  • Our challenge: presenting data in a supportive, non-judgmental manner
tubal pelvic pathology
Congenital anomalies

Tubal occlusion

Evaluated by:

hysterosalpingogram

laparoscopy

hysteroscopy

May occur as sequelae of

PID

endometriosis

abdominal/pelvic surgery

peritonitis

Tubal/ Pelvic pathology
male factor
Male factor
  • Male partner should be evaluated simultaneously with female
  • Causes of male infertility:
    • reversible conditions (varicocele, obstructive azoospermia)
    • not reversible, but viable sperm available (ejaculatorydysfunction, inoperative obstructive azoospermia)
    • not reversible, no viable sperm (hypogonadism)
    • genetic abnormalities
    • testicular or pituitary cancer
ovulatory dysfunction
Ovulatory dysfunction
  • Causes 15% of infertility
  • Diagnosed by menstrual irregularities, basal body temperature charting, ovulation prediction kits, serum progesterone levels.
ovulatory dysfunction 2
Ovulatory Dysfunction - 2
  • Causes of ovulatory dysfunction:
    • polycystic ovary syndrome
    • hypothalamic anovulation
    • hyperprolactinemia
    • premature and age-related ovarian failure
    • luteal phase defect (theoretical)
polycystic ovarian syndrome
Polycystic Ovarian Syndrome
  • Oligomenorrhea/amenorrhea and hyperandrogenism
  • Prevalence: 5%. Among women with O.D., 70% have PCOS.
  • Clinical evidence: hirsutism, acne, obesity
  • Lab evidence: elevated testosterone, elevated DHEA-S.
  • “Polycystic ovaries” supportive, not diagnostic
pcos treatment approach
PCOS: Treatment Approach
  • Weight loss if BMI>30
  • Clomiphene to induce ovulation
  • If DHEA-S >2, clomiphene + glucocorticoid (dexamethasone)
  • If clomiphene alone unsuccessful, try metformin + clomiphene.
    • Source: ACOG Bulletin, #34, “Management of Infertility caused by Ovulatory Dysfunction” Feb 2002.
hypothalamic anovulation
Hypothalamic Anovulation
  • Low levels of GnRH, low of normal levels of FSH/ LH, low levels of endogenous estrogen.
  • Associated factors: low BMI (< 20), high-intensity exercise, extreme diets, stress.
  • Treatment: lifestyle modification.
hyperprolactinemia
Hyperprolactinemia
  • Causes: pituitary adenoma, psych meds.
  • Test for: pregnancy, thyroid disease.
  • Imaging: MRI for macro vs microadenoma
  • Treament: Bromocriptine (dopamine agonist). After correction, 80% of women will ovulate, 80% will get pregnant.
  • Discontinue treatment once pregnancy established.
what can i do

What Can I Do?

Infertility Evaluation

for the Family Doctor

history and physical female
History

menarche, puberty

menstrual hx

preganancies, abortions, birth control

dysparenunia, dysmenorrhea

STD’s, abdominal surg, galactorrhea

Weight loss/gain

Stress, exercise, drugs, alcohol, psychological

Physical

weight/BMI

thyroid

skin (striae? Acanthosis nigracans?)

pelvic (vaginal mucosa, masses, pain)

rectal (uterosacral nodularity)

History and Physical - Female
history and physical male
History

prior fertility

medications

h/o diabetes, mumps, undescended testes

genital surgery, trauma, infections

ED

drug/alcohol use, stress

underwear, hot tubs, frequent coitus

Physical

habitus, gynecomastia

sexual development

testicular volume (5x3 cm)

epididymis, vas, prostate by palpation

check for varicocele

History and Physical - Male
trouble in paradise
Trouble in Paradise
  • Don’t wait a year if:
    • irregular menses; intermenstrual bleeding
    • h/o PID
    • h/o appy with rupture
    • h/o abdominal surgery
    • dyspareunia
    • age > 35
    • male factors
on your first visit
On your first visit:
  • Semen analysis
  • Confirm ovulation
    • basal body temperature charting
    • ovulation predictor kits (detect LH surge)
    • consider serum progesterone on day 21
  • Labs:
    • TSH and prolactin. DHEA-S if concern for PCOS.
    • FSH & estradiol on cycle day 3 if >35y.
    • Cervical cultures prn.
three months later
Three months later
  • Hysterosalpingogram
    • evaluates tubal patency and uterine cavity shape
    • noninvasive but involves a tenaculum
    • performed by radiology with gynecology supervision
    • diagnostic and therapeutic
sorry no data for
Sorry, no data for...
  • Postcoital test
  • endometrial biopsy
  • immune testing for antisperm antibodies
  • routine cervical cultures
clomiphene citrate
Clomiphene citrate
  • Effective for anovulatory patients.
    • Also used in unexplained fertility, but no data to support.
    • Most effective for women with nomal FSH and estrogen, least effective in hypothalamic amenorrhea or elevated FSH.
  • Induces ovulation by unknown mechanism
  • Most pregnancies occur in first 3 cycles. 80% will ovulate, 40% will become pregnant in 3 cycles.
clomiphene complications
Clomiphene - complications
  • 7% twin gestations, 0.3% triplet gestations
  • Miscarriage rate = 15%
  • Birth defect rate unchanged from controls
  • Side effects: hot flashes, adnexal tenderness, nausea, headache, blurry vision
  • Contraindications: pregnancy, ovarian cysts.
clomiphene administration
Clomiphene - Administration
  • 50 mg po qd, cycle day 3 through 7. Induce bleeding first with progesterone if amenorrheic.
  • Intercourse QOD cycle days 12 - 17.
  • Track ovulation with BBT or ovulation detection kits.
  • Increase dose to 100 qd, then 150, if no ovulation occurs.
bibliography
Bibliography
  • Bradshaw, Karen. Evaluation and Management of the Infertile Couple. Ob/Gyn vol 5, chapter 50, 1998.
  • Penzias, Alan. Infertility:Contemporary office-based evaluation and treatment. Obstet& Gynecol Clinics, vol 27, no 3, Sept 2000.
  • ACOG Practice Bulletin. Management of Infertility Caused by Ovulatory Dysfunction. Number 34, February 2002.
  • Royal College of Obstetricians and Gynecologists, The Management of Infertility in Secondary Care: National Evidence-Based Clinical Guidelines. www.rcog.org.uk.
case 1
Case 1
  • A 24 year old couple comes to see you. They have been trying to get pregnant for 8 months.
    • What questions do you ask?
case 126
Case 1
  • The woman tells you she has never been pregnant. She has a regular 28 day cycle and bleeds for 4 days each month. Her medical history is unremarkable except she “got really sick” when she was 16 and had “nasty stuff coming from down there”
    • what do you do next?
case 2
Case 2
  • A 35 year old woman and her 31 year old male partner come to see you. They have been trying to get pregnant for 6 months.
    • What do you ask?
case 228
Case 2
  • She says her periods have been irregular since she went off the pill a year ago. She has never been pregnant. He has fathered a child by another woman several years ago.
    • What do you look for on exam?
    • What lab tests do you order today?
    • Do you give them homework?
case 229
Case 2
  • They come back 3 months later with BBT charts showing no discernable pattern. Lab tests, including semen analysis, were all normal.
    • What is the diagnosis?
    • What do you do next?
case 230
Case 2
  • You begin discussion of clomiphene. They want to know the side effects, and if this means they’ll have sextuplets and get a free house like the folks on TV.
    • What do you tell them?
    • How do you administer the clomiphene?
case 231
Case 2
  • They come back in one month. She feels “like a total bitch - excuse me, doctor” on the clomiphene. She is not pregnant. BBT charting shows a mid-cycle temperature rise.
    • What happens next?