The Challenge of the Miracle of Life - Infertility

Jennifer McDonald DO

Fecundability

Probability of achieving a pregnancy within one menstrual cycle

25% for normal couples

Infertility

Couple’s failure to achieve pregnancy after one year of regular,

unprotected intercourse US ~ 15% couples

Incidence has remained stable over last three decades

Primary Infertility ??

Secondary Infertility ??

Average Conception Rates

% of Couples Length of time

20% Conceive within 1 month

60% Conceive within 6 months

75% Conceive within 9 months

80% Conceive within 12 months

90% Conceive within 18 months

Causes of Infertility

Multiple factors 20% Male factors 40%

Female factors 40%Ovulatory factor 15-20%

Peritoneal factor 40%Uterine-tubal factor 30%

Cervical factor 5-10%

Unexplained infertility 20%

Aging and female infertility

As age increases follicular phase becomes shorter and estradiol

begins to rise earlier Increased rate of follicular atresia

after 37-38 Increased rate of spontaneous

miscarriage

Aging and female infertility

Age Pregnancy(1yr)

MiscarriageRate

20-25 90 9.7%

26-30 85 10%

31-35 75 11.5%

36-40 65 21.4%

>40 50 42.2%

What’s age got to do with it?

Intercourse on most fertile day

50% achieve pregnancy age 19-2640% achieve pregnancy age 27-3430% achieve pregnancy age 35-39

So what’s so hard??

Parts is Parts

Adequate numbers of healthy sperm (male factor) Mature ovum released in predictable fashion

(ovarian factor) Cervix must capture, nuture and release sperm

into uterus and tubes (cervical factor) Fallopian tubes must have a functional anatomic

relationship to facilitate ovum capture (peritoneal factor)

Fallopian tube must be patent and capable of transfer (tubal factor)

Uterus must be receptive to implantation and

supporting pregnancy (uterine factor)

Male Factor Evaluation

Physical exam Environmental/occupational exposures

Semen analysis> 20 million

Motility > 50%Volume > 2mL

Morphology > 30% normal

Endocrine evaluation if warranted

Female Factor Infertility - Peritoneal Factors

Endometriosis

Pelvic Adhesions

Pregnancy rates after treatment as high as 75%

for mild disease and as low as 30% for severe disease

Diagnosis = Laparoscopy

Hypothalamic-pituitary dysfunction Intracranial tumors

PCOS Ovarian abnormalities

Thyroid disease Androgen excess

Female Factor Infertility - Ovulatory Factors

Ovulation restored in 90% of cases due to endocrine factors. Other cases rely

on ovulation induction with medications

Evidence of Ovulation

Basal body temperature Serum progesterone (mid-luteal Day19-22)

12 - 15 ng/mL considered evidence of ovulation Ovulation predictor kits (LH surge)

Ultrasound

Basal Body Temperature

Temperature first thing in the morning Biphasic pattern suggestive of ovulation

Common to have dip the day of ovulation Temperatures rise after ovulation due to

progesterone from corpus luteum If temperatures drop late in the luteal phase don’t waste money on a pregnancy

test!

Female Factor Infertility - Uterine & Tubal Factors

Fibroids Intrauterine adhesions (Asherman’s)

Congenital malformations Tubal occlusion (PID most common)

Endometrial abnormalities

Tubal Adhesions

Mullerian Anomalies

Anomaly Frequency

Bicornuate uterus (37 percent) Arcuate uterus (15 percent)

Incomplete septum (13 percent) Uterus didelphys (11 percent)

Complete septum (9 percent) and Unicornuate uterus (4.4 percent)

Hysterosalpingogram

Radiopaque dye through the cervix under x-ray watching dye fill uterus and

spill from tubes into peritoneal cavity

Ultrasonography

Non-invasive 3D contours of uterus and

endometrium as well as ovaries

MRI

More distinct delineation of soft tissue structures

MR imaging has been shown to be both sensitive and specific and is

clearly less invasive than laparoscopy, which was considered the gold standard for diagnosis of

anomalies.

Structural abnormalities Abnormal mucous production

Female Factor Infertility - Cervical Factors

Evaluation should include post-coital test

Treatment includes intrauterine insemination

Smoking and Female Fertility

Interferes with gametogenesis, fertilization & implantation

Reduces estrogen levels Nicotine alters FSH/LH release

decreasing LH surge Nicotine stimulates cortisol secretion

Earlier menopause by 2-3 years Fertility rates lower (30%)

Smoking and Male Fertility

Impaired sperm concentration, motility & morphology

Decreased libido Combined with caffeine consumption

increases number of non-viable sperm

Assisted Reproduction

IVF (in vitro fertilization) GIFT (gamate intra-fallopian transfer) ZIFT (zygote intra-fallopian transfer)

IVF

Ovarian stimulation with gonadotropins Oocyte retrieval (36 hours after hCG)

Oocyte culture - sperm added after 4-6 hours (50,000 per oocyte)

65-80% of mature oocytes will fertilize Examined at the pro-nuclear stage

Cryopreservation of unused embryos (two thirds will survive freezing/thawing)

IVF

Embryo transfer 8-10 cell stage (72-80 hours after retrieval)

Multiple pregnancy rate 35% Rise in hCG indicates pregnancy while drops indicate a failed cycle