Managing unwanted Managing unwanted childlessnesschildlessnessDr Jodie SemmlerDr Jodie Semmler

fertility fertility SASA

Dr Louise HullDr Louise Hull

Senior lecturer in reproductive medicineSenior lecturer in reproductive medicine

WCH, University of Adelaide andWCH, University of Adelaide and

fertilityfertility SASA

‘‘For unflagging For unflagging interest and interest and enjoyment,enjoyment,

all other forms of all other forms of success lose their success lose their importance in importance in comparison to a comparison to a household of household of children’children’

Theodore RooseveltTheodore Roosevelt

Age makes a differenceAge makes a difference

Lifestyle AdviceLifestyle Advice

• Intercourse every 2-3 days optimises conceptionIntercourse every 2-3 days optimises conception• Fertile times of the cycleFertile times of the cycle• Moderate alcohol intake (no binges)Moderate alcohol intake (no binges)• Stop smokingStop smoking• Optimal BMI between 19 and 25Optimal BMI between 19 and 25• Avoid DrugsAvoid Drugs• Avoid occupational exposures to solvents etcAvoid occupational exposures to solvents etc• Folic acid, Vit B 6 and 12 supplements, Omega 3Folic acid, Vit B 6 and 12 supplements, Omega 3• Vitamin supplementation (Vit E and Selenium)Vitamin supplementation (Vit E and Selenium)

Causes of difficulty conceivingCauses of difficulty conceiving

EggsEggs

SpermSperm

Need to meetNeed to meet

EGGS!EGGS!

Assessing OvulationAssessing Ovulation• Are your cycles regular?Are your cycles regular?

• Mid luteal prog – day 21 if Mid luteal prog – day 21 if day 28 cycle, day 28 if 35 day day 28 cycle, day 28 if 35 day cycle (timing critical)cycle (timing critical)

• Basal body temperature Basal body temperature

• LH kitsLH kits

• Cycle trackingCycle tracking

Ovarian ReserveOvarian ReserveOvarian reserve may be reduced evenOvarian reserve may be reduced even if ovulatoryif ovulatory

Assess with egg timer test day 3-5Assess with egg timer test day 3-5FSHFSHAMH AMH ovarian volume and antral follicle countovarian volume and antral follicle count

If low ovarian reserve If low ovarian reserve ––prompt referral for fertility advice.prompt referral for fertility advice.Associated with poor response to gonadotrophins, Associated with poor response to gonadotrophins,

possibly poor oocyte and embryo quality if possibly poor oocyte and embryo quality if markedly reduced, ?increased miscarriagemarkedly reduced, ?increased miscarriage

AnovulationAnovulation

• Hypothalamic dysfunction (normal FSH/LH)Hypothalamic dysfunction (normal FSH/LH)• Hypogonadotrophic hypogonadism (low FSH/LH)Hypogonadotrophic hypogonadism (low FSH/LH)• Premature menopause (high FSH/LH) Premature menopause (high FSH/LH)

• Hyperprolactinaemia (high PRL)Hyperprolactinaemia (high PRL)• Abnormal thyroid function (high TSH)Abnormal thyroid function (high TSH)

• Polycystic ovarian syndromePolycystic ovarian syndrome

• Tests- day 3 FSH, LH, PRL, TSH, androgens if Tests- day 3 FSH, LH, PRL, TSH, androgens if suspect PCOSsuspect PCOS

• USS pelvis –ovarian reserve, PCOSUSS pelvis –ovarian reserve, PCOS

Hypothalamic DysfunctionHypothalamic Dysfunction• Simple Environmental CausesSimple Environmental Causes• Exam/ other stressExam/ other stress• TravelTravel• PerimenarchalPerimenarchal

• Weight related CausesWeight related Causes• Anorexia/malnutritianAnorexia/malnutritian• Exercise induced amenorrhoeaExercise induced amenorrhoea

• PsychiatricPsychiatric• DepressionDepression

• Organic Causes (pan hypopit)Organic Causes (pan hypopit)• Brain tumors –need MRIBrain tumors –need MRI• Endocrine disordersEndocrine disorders

Ovarian FailureOvarian Failurehigh FSH and LH and low E2,high FSH and LH and low E2,normal prolactin and thyroidnormal prolactin and thyroid

Further Investigations may include:Further Investigations may include:chromosomeschromosomesautoantibody screenautoantibody screenbone massbone masslipidslipids

Treatment – Treatment – donor oocyte programmedonor oocyte programme estrogen replacement therapyestrogen replacement therapy counsellingcounselling

ProlactinProlactin

• Elevated prolactin on 2 Elevated prolactin on 2 occasions occasions

• Galactorrhoea, breast Galactorrhoea, breast discomfort, visual field discomfort, visual field abnormalitiesabnormalities

• MRI/CT pituitaryMRI/CT pituitary

• Treat with Carbergoline Treat with Carbergoline (0.5mg weekly)(0.5mg weekly)

Thyroid disordersThyroid disorders

TSH to screenTSH to screen• SymptomsSymptoms• Goitre/thyroid Goitre/thyroid

enlargementenlargement• Referral to Referral to

endocrinologist/surgeon endocrinologist/surgeon for treatment and for treatment and ongoing care.ongoing care.

Polycystic ovarian syndromePolycystic ovarian syndrome

2 out of 3 of:2 out of 3 of:

• Oligo/ammenorrhoeaOligo/ammenorrhoea• Clinical and/or biochemical signs of hyperandrogenismClinical and/or biochemical signs of hyperandrogenism• Ultrasound Ultrasound

• And exclude other causes of anovulationAnd exclude other causes of anovulationPCOS consensus agreement

ESHRE/ASRM (Rotterdam) 2003

Hum. Reprod, (2004) 19,1:41-47

PCOS InvestigationsPCOS Investigations

Investigations: Investigations:

Insulin resistance (blood glucose) Insulin resistance (blood glucose)

LipidsLipids

Endometrial thicknessEndometrial thickness

PCOS fertility PCOS fertility treatmenttreatment

• Weight lossWeight loss

• Clomiphene Clomiphene

• MetforminMetformin

• Ovulation Induction with FSHOvulation Induction with FSH

• Ovarian drillingOvarian drilling

• IVF –risk of OHSSIVF –risk of OHSS

Ovulation InductionOvulation Induction

Sperm

Male Factor DisorderMale Factor Disorder• HistoryHistory

– Previous surgery/traumaPrevious surgery/trauma– Congenital problemsCongenital problems– Infections (mumps orchitis/STDs)Infections (mumps orchitis/STDs)– Other illnesses (cancer/chemotherapy)Other illnesses (cancer/chemotherapy)– Smoking, drinking, drugsSmoking, drinking, drugs– Occupational exposuresOccupational exposures

Semen AnalysisSemen Analysis

More than 1 semen Analysis usually More than 1 semen Analysis usually required (3 months apart)required (3 months apart)

• Normal SA Normal SA • >20 million per ml>20 million per ml• >50% forward motility>50% forward motility• >3% normal morphology >3% normal morphology

(WHO strict criteria)(WHO strict criteria)

Other sperm defectsOther sperm defects• Kruger et al 1986 (strict morphological criteria) Kruger et al 1986 (strict morphological criteria) • <15% normal morphology (old criteria) associated with <15% normal morphology (old criteria) associated with

reduced IVF fertilisation even with normal counts. No reduced IVF fertilisation even with normal counts. No data yet with new reference ranges, 4% normal shapes is data yet with new reference ranges, 4% normal shapes is 55thth centile, may be fertilisation issue if less than eg 8% centile, may be fertilisation issue if less than eg 8%

• ICSI restored fertilisation ratesICSI restored fertilisation rates

Investigation of an abnormal Investigation of an abnormal semen Analysissemen Analysis

• If semen Analysis abnormalIf semen Analysis abnormal

- repeat S.A.- repeat S.A.

• If mild/ moderate oligozoospermic (majority)If mild/ moderate oligozoospermic (majority)

- IUI/IVF/ICSI- IUI/IVF/ICSI

• If azoospermic/severe oligozoospermia If azoospermic/severe oligozoospermia

-further investigations-further investigations

Investigations of Severe Semen Investigations of Severe Semen DefectsDefects

FSH/LH/testosterone/PRL/TSHFSH/LH/testosterone/PRL/TSHIf abnormal then MRI pituitary If abnormal then MRI pituitary

USS testes (tumour)USS testes (tumour)

Chromosomes/CF mutations/Y chromosome Chromosomes/CF mutations/Y chromosome deletionsdeletions

ManagementManagement

Hypogonadotrophic hypogonadism Hypogonadotrophic hypogonadism -FSH treatment-FSH treatment

Mild sperm defects -Mild sperm defects -IUIIUI

Testicular failure -Testicular failure -ICSI/TESA/donor spermICSI/TESA/donor sperm

Obstructive azoospermia Obstructive azoospermia -PESA/TESA-PESA/TESA

Intrauterine InseminationIntrauterine Insemination

15-40% chance of pregnancy 15-40% chance of pregnancy over 3 cycles (very dependent over 3 cycles (very dependent on patient selection)on patient selection)

FSH Injections to ensure 1 or 2 FSH Injections to ensure 1 or 2 eggs present at inseminationeggs present at insemination

Need patent fallopian tubesNeed patent fallopian tubes

Risk of multiple pregnancyRisk of multiple pregnancy

Low sperm morphology , Low sperm morphology , unexplained and endometriosis unexplained and endometriosis patients do poorlypatients do poorly

PESA/TESAPESA/TESA

ICSIICSI

IVF+/- ICSI approx 50% chance of pregnancy in 1 IVF+/- ICSI approx 50% chance of pregnancy in 1 cycle if < 38yrscycle if < 38yrs

Meeting upMeeting up

Assessing Sexual dysfunction Assessing Sexual dysfunction (5%)(5%)

• Male history importantMale history important– How often do you make love?How often do you make love?– Do you get erections?Do you get erections?– Can you penetrate your partner deeply?Can you penetrate your partner deeply?– Do you reach orgasm?Do you reach orgasm?– Do you ejaculate?Do you ejaculate?

Assessing Tubal Damage Assessing Tubal Damage

• Have you had tubal surgery, endometriosis, painful Have you had tubal surgery, endometriosis, painful periods, appendicitis or infections like chlamydia?periods, appendicitis or infections like chlamydia?

• If no- HSG (reliable indicator of tubal patency not If no- HSG (reliable indicator of tubal patency not obstruction)obstruction)

• If yes- consider laparoscopy and dyeIf yes- consider laparoscopy and dye

• History of Tubal ligation/reversal History of Tubal ligation/reversal – – high high chance tubal issueschance tubal issues

• Congenital anomalies -Congenital anomalies - best assessed by MRI, best assessed by MRI, 3D ultrasound, Hy Cosi or saline sonogram. HSG 3D ultrasound, Hy Cosi or saline sonogram. HSG not as accurate for thisnot as accurate for this

EndometriosisEndometriosis

Tubal damage, Tubal damage, Oxidative damage to oocytes/embryosOxidative damage to oocytes/embryosEutopic endometrial changes (implantation problems)Eutopic endometrial changes (implantation problems)Painful intercoursePainful intercourse

Management: Surgery, GnRH agonists before IVFManagement: Surgery, GnRH agonists before IVF

Unexplained Unexplained

Failed FertilisationFailed Fertilisation (5-10% IVF cycles) (5-10% IVF cycles)

Implantation FailureImplantation Failure

Recurrent MiscarriageRecurrent Miscarriage

Other causesOther causes

IVFIVF

Who needs referral?Who needs referral?

Referral to Fertility ServicesReferral to Fertility Services

• All couples concerned about fertility should All couples concerned about fertility should be offered a consultationbe offered a consultation

• Further investigation should be offered after Further investigation should be offered after 1 year of failing to conceive1 year of failing to conceive

• Earlier investigation should be offered to:Earlier investigation should be offered to:– Women >35 yearsWomen >35 years– History suggestive of anovulation, tubal History suggestive of anovulation, tubal

disease, pelvic surgery, endometriosis or male disease, pelvic surgery, endometriosis or male factor problemsfactor problems

– Family history of early menopauseFamily history of early menopause

The goal of treatmentThe goal of treatment

A single A single healthy baby healthy baby born at termborn at term