EVALUATING THE INFERTILE PATIENT-COUPLES. Stephen Thorn, MD

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1 EVALUATING THE INFERTILE PATIENT-COUPLES Stephen Thorn, MD

2 Overview The field of reproductive medicine continues to evolve rapidly by offering newer diagnostic testing and therapeutic options to improve fertility. Following pages include: Overview of current infertility evaluation Potential impact of several common gynecologic diseases

3 Peak monthly fecundity rate is 35% - while the cumulative peak pregnancy rate after one year of trying to conceive is 85% rising to 92% after 2 years 93% following 3 years Infertility affects 1 in 7 couples Generally accepted to be defined by the absence of a live birth following 1-2 years of attempting pregnancy

4 Basic Infertility Evaluation Remained constant and focused on the most common areas of abnormality 40% female factor: 40 % Ovulation dysfunction 40 % fallopian tube blockage 40% Male Factor 20% Unexplained Insurance Unpredictable insurance coverage Conscious of cost-effective, evidenced based approach

5 History 1. Female Age-Oocyte competence After 27 yrs. Infertility begins to decrease although many women become pregnant after this age Other authors feel after 33 yrs. old 2. Years of Infertility If more than 3 years, success decreases 3. Prior Live Birth Knowing can become pregnant

6 History 4. Chronic Medical Conditions and Medications PCOS Endometriosis Hypertension Thyroid Disease Hyperprolactinemia Elevated BMI 5. Coital Frequency and Timing 6. Sexual Dysfunction On demand may be difficult Use of Viagra, Cialis

7 History 7. Use of Spermicidal Lubricants 8. Complications during prior pregnancies C-Section Post-Partum Hemorrhage Necessitating D+C 9. Prior Gynecologic Surgeries Tubal Myomectomy D+C for missed or incomplete miscarriage Cervical Conizations

8 History 10. History of pelvic infections Chlamydia/Gonorrhea/PID 11. History of Salpingitis i.e Isthmic Nodosam 12. Prior Laparotomy Due to pelvic adhesions 13. Tobacco Use Including secondhand smoke

9 Physical Examination All patients should have undergone physical examination within year of considering pregnancy or treatment for infertility. Attention should be made to the following: BMI ** Extreme body weight changes have posed reproductive challenges for women, usually by impairing ovulation function Multiple studies have demonstrated decreased fertility, increased miscarriage rates, and higher pregnancy complications in women with elevated BMI Evidence of Hirsutism Endocrinologic Abnormalities Galactorrhea, weight changes, acne, frontal balding

10 TVUS In our clinic and most reproductive clinics TVUS-trans vaginal ultrasound has become part of the exam (an extension of the traditional pelvic exam) TVUS allows assessment of the ovaries for PCOS, as well as Leiomyomas within the uterus The advance of 3 and 4 D ultrasound allows a diagnosis of Mullerian anomalies and possibly the intrauterine pathology

11 Laboratory Testing FSH-LH Estradiol Progesterone Prolactin Testosterone Free-Total--?DHEAS TSH Fasting Glucose-Insulin AMH Cholesterol Many of these tests are performed during different days of the patient s cycle

12 Invasive Testing HSG Hysterosalpingogram Hysterosonogram saline Diagnostic Laparoscopy removal of endometriosis, endometriomas, adhesions, ovarian drilling] Endometrial Biopsy It was a considered basic element of any thorough infertility evaluation BUT NO LONGER serum progesterone levels. BBT recordings, monitoring LH urine secretion bx does not provide any more information

13 Medical Issues 1. Endometriosis 2. PCOS 3. Hypothyroidism 4. Uterine Anomalies 5. Other drug abuse, uncontrolled diabetes, obesity Male: Semen analysis performed to ascertain numbers, motility, morphology, wbcs, agglutination If abnormal Urological evaluation necessary

14 Treatment After thorough discussion/labs/history/physical a treatment plan will be decided upon with patient and significant other Indirect-Direct treatments with medication IUI Intrauterine insemination If indicated or no success consider IVF

15 Conclusion The MOST important issue when evaluating is honesty and communication Discuss each step in the process Realize the financial burden that this can be on a couple The entire staff involved in the care of the couple must be: Very compassionate Have patience, understanding and realize what an emotional strain this process can be on a couple

16 1. A 28 year old nulliparous woman comes to your office with her husband after trying to conceive unsuccessfully for 3 years. Over the counter ovulation predictor kits have been consistently positive at mid cycle. Her periods are every 28 days, with no dysmenorrheal. Semen analysis and hysterosalpingogram are normal. The most cost effective initial management for this couple is- A-clomiphene citrate (Clomid, Serophene) B-intrauterine insemination C-clomiphene and intrauterine insemination D-ovulation induction with gonadotropins E-in-vitro fertilization (IVF)

17 Answer: Clomiphene and intrauterine insemination Usually current management of unexplained infertility uses empiric treatments such as oral Clomid with IUI. Cost sensitivity is important. Around 30% of infertility patients have unexplained infertility. If no success after 3-6 cycles consider more invasive treatments with gonadotropins.

18 2. A 33 year old infertile woman underwent gastric bypass surgery has lost weight and continues to do so. The best recommendation patient can be given her regarding a future pregnancy is that she should try to achieve conception A - immediately B - in six months C - in 12 months D - in 18 months

19 Answer: in 12 Months These operations are associated with postoperative complications-including vomiting, dumping syndrome, and malnutrition(i.e. deficiencies in iron, vitamin B12, folate, calcium, and vitamin D)-It takes about 12 months for a patient to stabilize her body weight and nutritional status.

20 3. A 35 year old female on Hysterosalingogram is noted to have bilateral Hydrosalpinges and no tubal patency. Her husband has a normal semen analysis. For the best chance of conceiving over the next year, the next step is- A - perform a neosalingostomy procedure on both tubes B - perform a unilateral neosalpingostomy on the small diameter hydrosalpinx C In vitro fertilization-embryo transfer-(ivf) D - Bilateral salingectomy before an IVF procedure E - transvaginal aspiration of hydrosalpinx

21 Answer: Bilateral Salingectomy before an IVF Procedure Numerous studies have shown that the presence of a hydrosalpinx has an adverse outcome on IVF cycles. Patients have about ½ the pregnancy rate with IVF if a hydrosalpinx is noted. A bilateral salpingectomy or clip placement near cornua of uterus was noted to improve pregnancy rates.

22 4. A 33 year nulligravid married woman receives a diagnosis of breast cancer. She is scheduled to have a mastectomy and subsequent chemotherapy for 12 weeks with a regimen that includes an alkylating agent. The therapy or intervention that might improve her ability to deliver a child after chemotherapy for breast cancer is- A - use of oral contraceptives during the chemotherapy B - use of a gonadotropin-releasing hormone (GnRH) agonist during her chemotherapy C - obtain ovarian tissue and cryoperserve before chemotherapy D - perform in vitro fertilization (IVF) and cryopreserve embryos before chemotherapy

23 Answer: perform in vitro fertilization (IVF) and cryopreserve embryos before chemotherapy Chemotherapeutic agents damage rapidly dividing cells and specifically injure the structure and function of ovarian granulosa cells. This ultimately leads to premature oocyte depletion and eventual ovarian failure. It appears that alkylating agents cause significant oocyte depletion. The extent of damage appears to be age related - women older than 40 have increased sensitivity to chemotherapeutic agents.

24 5. A 25 year old nulligravid woman has a history of irregular cycles and mid-luteal serum progesterones that are consistent with annovulation. A hysterosalpingogram and semen analysis are normal. Treatment with clomiphene citrate (Clomid, Serophene) 50mg was administered days 5-9 of the menstrual cycle. A luteinizing hormone (LH) surge was detected by urinary monitoring on day 15 of the cycle. The most appropriate timing for intercourse and ovulation to provide the best chance for pregnancy, relative to the day of the LH surge is- A - the same day B 1 day later C - 2 days later D - 3 days later E - 1 week later

25 Answer: The Same Day Ovulation with follicle rupture occurs approximately hours after the onset of the LH surge and 24 hours after the peak. It is suggested that the fertile period occurs before ovulation and then declines rapidly. The egg survives for no more than hours after ovulation. Sperm has been noted to survive in the reproductive tract 3-5 days and to retain the ability to fertilize an ovum even before ovulation occurs.

26 6. A 32 year old nulligravid female with infertility is found to have a 8-cm posterior uterine fibroid on transvaginal ultrasound. A hysterosalgingogram shows uterine cavity distortion from a submucosal location. In discussing complications of abdominal myomectomy, you inform her that the most likely risk is- A - conversion to hysterectomy B - uterine rupture with labor C - pelvic adhesions D - blood transfusions E - intrauterine synechiae

27 Answer: Pelvic Adhesions Fibroids in the submucosal position can cause heavy periods, pain, and infertility. Before a myomectomy is performed all risks should be discussed i.e.-operative risks, anesthesia, infection, adhesions, increased likelihood for cesarean section, small risk of uterine rupture, and recovery time. Interceed did decrease incidence of adhesions. Hysterectomy conversion is rare with experienced surgeon.

28 7. A 31 year old woman has a history of a prior cesarean delivery with an associated Pomeroy tubal ligation. The patient had endometritis after her delivery that was treated with antibiotics. She has recently remarried. Her husband has not fathered a child but does have a normal semen analysis. She desires information regarding tubal reanastomosis versus in vitro fertilization (IVF) to help her conceive another child. The factor that best predicts the success rate for pregnancy and delivery after a tubal reanatomosis versus IVF is- A - age of woman requesting treatment B - prior history of an cesarean section C - type of tubal ligation performed D - history of endometritis E - absence of any prior conception with the husband s sperm

29 Answer: Age of woman requesting treatment Data shows that difference between IVF and Tubal reanatomosis, 52% and 59.5% respectively, but when age of woman considered a significant difference was noted-age less than 37-Surgical versus IVF %-respectively. More than 37 years the advantage of reanastomosis was lost Surgical versus IVF-36% 51.4 respectively.

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