Reproductive Testing: Less is More G. Wright Bates, Jr., M.D. Professor and Director Reproductive Endocrinology and Infertility Objectives

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1 Reproductive Testing: Less is More G. Wright Bates, Jr., M.D. Professor and Director Reproductive Endocrinology and Infertility Objectives 1. Review definition of infertility and impact of age 2. Stress evidence based approach to the diagnosis of infertility 3. Highlight unnecessary and potentially harmful test and interventions The speaker has no conflict of interest or relevant disclosures Infertility Definition and Evaluation Failure to achieve a successful pregnancy after 12 months of unprotected appropriately timed intercourse Evaluation is warranted after 6 months in a woman over 35 years of age Evaluation is warranted earlier if medical history or physical exam indicated abnormality Ovulatory dysfunction / Endocrinopathy Pelvic pain Male factor ASRM Practice Committee Statement Fertil Steril 2013;99:63. 1

2 WHAT TEST SHOULD WE DO?!?!?! HSG Basal Body Temp Semen Analysis Immunologic Hysteroscopy Testing TSH CCCT Laparoscopy Prolactin Vitaminsi DHEAS Post coital Test 17-OH Progesterone Antisperm Antibodies Testosterone Hamster Penetration Assay Estrogen FSH AMH Chromosome Analysis Inhibin MIS Ovarian Reserve Testing Amenorrhea failure to menstruate by age 15 in the presence of normal secondary sexual development within five years after breast development if that occurs before age 10 (Failure to initiate breast development by age 13) No menses for 3 months if history of regular cycles No menses for 9 months if cycles irregular 10% will have POI Irregular or short cycles > 35 years of age 2008 and 2015 ACOG Committee Opinion Age and Fertility 2

3 Ovarian Reserve Testing Clomiphene Citrate Challenge Test Day 3 FSH, Estradiol CC 100 mg days 5 9 Day 10 FSH, Estradiol Day 3 FSH PLUS Estradiol Gonadotropin Stimulation Test Basal Antral Follicle Count** Inhibin B AMH Gonadotropin Stimulation 2008; 2015 ACOG Committee Opinion Aims to promote conversations between clinicians and patients by helping patients choose care that is: Supported by evidence Not duplicative of other tests or procedures already received Free from harm Truly necessary 1/24/16 Prolactin in ovulatory women org 1/22/16 Unless Galactorrhea Ovulatory Dysfunction Recurrent Pregnancy Loss Measure twice If elevated MRI Don t forget IGF1 3

4 Ovulation Confirmation Menstrual history Predictable, Cyclic, Confounders LH surge Done correctly Kept in perspective Luteal progesterone Highly accurate but retrospective Basal Body Temperature Endometrial biopsy Ultrasound assessment Cervical mucous changes Mittelschmerz Recent technologies (Skin and Saliva) Advantages Low Cost Accessibility Establishes a pattern of ovulation Disadvantages Accuracy (predict the LH surge to the day at 18.3% 30%; 30%; within 1 day at 56.7% 70%) 70%) Added Stress Brezina, PR, et.al., F&S 95(6)1867, 2011 Urinary LH Testing Begin testing based on shortest cycle in last 6 months 28 day cycle begin day (21 begin 5 7, 35 begin 16 18) 18) Optimum time for testing is late afternoon Ovulation follows in hours Approximately 10% false positive, 20% false negative Product variability Delay testing until 3 days after CC ASRM Practice Committee. Diagnostic Evaluation of Infertile female, 2012 Brezina, PR, et.al., F&S 95(6)1867,

5 Post Coital Testing Invasive on many levels Endometrial biopsy Unless symptoms, age, obesity, anovulation, endometrial thickness warrant Bx Post Coital Test Four board certified REI evaluated PCT Agreement 39% sperm number and motility 11% cellularity 14% spinnbarkeit 14% overall test impression (kappa statistic 0.13 (poor) 0.51 (fair) Glatstein, et al, ACOG, 1995 Possible exception: coital concerns Endometrial Biopsy 847 subjects NIH RMN Biopsies early (21 22) and late (26 27) after LH surge Out of phase biopsy greater 2 day discrepancy Out of phase biopsies Early: fertile: 49.4%, infertile: 43.2% late luteal phase: fertile: 35.3%, infertile 23.0% Coutifaris, Diamond, et al, Fert Steril

6 Routine diagnostic laparoscopy org 1/22/16 History / Exam Pain dysmenorrhea, dyspareunia, dyschezia Surgery appendectomy, tubal surgery Infection PID, chlamydia, GC If L/S all infertile patients: NNT 40 Advanced spermatozoa function Hemizona assay Hamster Penetration Assay Sperm DNA testing Immunologic testing Thrombophilia Testing MTHFR Limited testing (APAS) for recurrent pregnancy loss 6

7 Do NOT perform the following test: FSH to determine menopausal transition as a cause of abnormal uterine bleeding Karyotype for initial evaluation of secondary amenorrhea Do NOT administer: Any form of testosterone or androgens to men who might pursue fertility Vitamin D Vitamin D deficiency suggested as an etiology of Infertility PCOS Ovarian Reserve Uterine fibroids Success with IVF Deficiency Excess No effect No evidence of improved outcomes with Supplementation or Replacement Irani M and Merhi Z, Fertil Steril, August 2014 Recommendations Infertility Evaluation Thyroid Confirm Ovulation Consider Ovarian Reserve Anatomic Evaluation Semen Analysis Avoid Unnecessary Test CHOOSE WISELY 7

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