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Female infertility

Female infertility. James N Anasti, M.D. Dept OB/GYN. Definition. Infertility Fecundablity Fecundity. Just the Facts. 55/1000. 1790 Birth rate :. 2001 Birth rate:. 14.7/1000. Fertitlity services 1982: . 12% (6.6 mil). Fertility services 1995:. 15% (9.3 mil).

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Female infertility

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  1. Female infertility James N Anasti, M.D. Dept OB/GYN

  2. Definition • Infertility • Fecundablity • Fecundity

  3. Just the Facts 55/1000 1790 Birth rate : 2001 Birth rate: 14.7/1000 Fertitlity services 1982: 12% (6.6 mil) Fertility services 1995: 15% (9.3 mil) Services used: 53% ovulatory drugs, 1.6% ART

  4. What physical attribute is an important factor for infertility?

  5. AGE: the Hutterites • Peaks at age 20-24 (2.6% infertile) • Age 30-34 decrease by 15-19 % (11% infertile) • Age 35-39 decrease by 26-46% (33% infertile) • Age 40-45 decrease by 95% (87% infertile) • Data confirmed by insemination studies

  6. Age: IVF • Younger than 35: 42% Live birth per embryo • Age 35-37: 35.1% Live birth per embryo • Age 38-40: 25% Live birth per embryo • Age 41-42: 14.5% Live birth per embryo • Age 43: 5.9% Live birth per embryo • Greater than 43: 2.9% Live birth per embryo

  7. Age: Miscarriage • Recognized • Age 30: 7-15% • Age 31-34: 17-21% • Age 35-39: 17-28% • Age 40: 40-52% • Unrecognized: 60%

  8. What is the mechanism of age that causes infertility?

  9. Physiology of Aging Ovary

  10. Why are older women Infertile? • They less eggs develop? • They ovulate less? • They produce less steroids? NO NO NO

  11. Chromosomes:Aneuploidy • Young women 10% eggs are aneuploidic • Age 40: 30% abnormal • Age 43: 50 % abnormal • Age 45: 100% abnormal

  12. How does one check for ovarian reserve?

  13. Checking for Ovarian Reserve • Success of IVF: the outcome • Physiology : age related increase of FSH • Day 3 FSH: >10-15 mIu/mL • Day 3 Estradiol: >80 pg/mL • Clomiphene Challenge Test (CCT) • Day 3 & Day 10 FSH (after clomid 50mg day 5-9) • IVF success <10%

  14. Who to Screen? • Age >35 • Family Hx POF • Ovarian Surgery • Smoking • Poor Gonadotropin response

  15. Infertility: Guiding Principles • Identify the cause • Provide accurate information • Emotional Support; RESOLVE group • Guide treatments

  16. What life style behaviors decrease infertility?

  17. Basic Info: Life style • 62% of US have BMI > 25 • 25% female in US smoke: 13% infertile • Mary Jane factor • ETOH • Caffeine??

  18. Normal Reproductive Efficiency • Fecundity: baboons 80% Human 20% • 93% of couples pregnant in 2 years • Egg 12-14 hrs, Sperm 3-5 days

  19. How can we help? • Assume day before temp spike on BBT • Peak fertility 2 days prior to ovulation • LH detection • But easiest: Intercourse Twice a week

  20. When should a work-up begin? • Most people need no treatment • 3 year rule • 5% decrease per year in age • 15-25% per year of infertile • >35 don’t wait • Obvious reasons

  21. History & Physical Exam • G’s P’s and complicaion • LNMP, Sexual Activity • Surgery’s • Meds, symptoms • FmHX menopause, reproductive

  22. Physical Exam: • BMI • Thyroid • Skin • Breast • Pelvic

  23. Screening Test • PAP, STD • Rh, Cystic Fibrosis,Rubella • Varicella

  24. What are the main causes of infertility?

  25. Infertility: Causes

  26. Infertility: KISS it • Sperm in cervix • Mature Oocyte • Cervix must nurture sperm • Capture the oocyte in tube • Uterus enviroment

  27. How do we screen for male infertility?

  28. Male Factor

  29. How do we check for ovulatory defects?

  30. Infertility: Ovarian Factor • Menstrual History: 97.7% predictor • BBT • Thermogenic potential of progesterone (.4-.8) • Ovulation when see rise (1-5 days after) • 12 or more days to menses • Progesterone 3-4 ng/mL • 7-8 days post ovulation • Luteal pahse function

  31. Ovulatory Factor • LH excretion: Ovulation prediction (24-48 h) • Start 2-3 days before LH Surge • Late afternoon testing, Concentrate urine • Day of surge and next 2 • Ultrasound

  32. How do we check for tubal factor?

  33. Tubal Factor • Risk factors • PID; 12%,24%,75%, Ectopic 6 fold • HSG • 2-5 days after menses • 1-3 % infection rate high risk • Increase preg rate • False positive obstruction rate (15-30%)

  34. Hydrosalpinges Myoma Normal HSG

  35. Tubal Factor: Laparoscopy • Chromotubation with indigo carmine • Why not methylene blue? • Possibility of Treatment • Tubal surgery: Is it worth it??

  36. Tubal Factor: Chlamydia Antibody testing • Pretest: Laparoscope or not • HSG sooner than latter • Not yet defined

  37. Uterine Factors • Hysterosalpingography (HSG) • HSG v Hysterscope: Sens 98%, Spec 35% • All polyp vs submucous myomas • Ultrasound/Sonohysterography • SIS 75 sens, spec 90%

  38. Polyp Bicornate Mid secr Late Prolif Early Prolif

  39. Endometrial Biopsy Proliferative Secretory

  40. Uterine Factors: Bottom Line Congenital Malformation Leiomyomas Intrauterine Adhesions Endometrial Polyps Yes, Septum only Maybe, submucous Yes Maybe

  41. Cervical Factor • Postcotial test (Sims-Huhner) Intercourse (2-12 hrs) for test Look at: pH, Sperm, Spinnbarkeit, Ferning Cellularity, Sperm Shaking, sperm Agglutanation Has seen better days

  42. Unexplained Infertility • Defined • 10-30% incidence • Laparoscope necessary: • Canadian Study: 17% v 29% (NTT:9) • Just slower to get pregnant 3 year data • Spontaneous conception falls 40%

  43. UI:Who should you treat?

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