Male and Female

Infertility
 Goals

 Enhance comfort level with workup

 Basic Management Strategies

 TRICARE
Coveragehttp://www.rotundaivf.com/
 Definition
 12 months of unprotected intercourse

 Earlier for certain historical factors

 Older than 35
Infertility Etiology
Female Factors
 Male Factors
General Causes Meds
 Unknown: 40-50%  1° or 2°
Hypogonadism
 1° Hypogonadism: 30-
40%  Common medications
 Ketoconazole
 Altered Sperm Transport:
 Cimetidine
10-20%
 Spironolactone
 2° Hypogonadism: 1-2%
 The Scenario
 Tech: “Husband and wife can’t get
pregnant.”

 You: OB rotation was last infertility workup

 What now?
 Workup

 History is KEY

 Focused Physical Exam

 Labs and Specialized Tests

 Workup: History
 Coital Practices
 Gestational History
 PMHx/PSHx
 Meds
 Menstrual History
 Substances
 Recent High Fever
 Our Couple: History
Female Male
 G1 P0010  No previous partner
pregnancies
 No hx of STIs
 Gonorrhea hx
 Normal menses
 No meds
 Unprotected sex for 15
months  Occasional EtOH
 Workup: Physical Exam
Female Male
 Breast Formation  Infection
 Hernia
 Galactorrhea  Vas deferens
 Androgen deficiency
 Genitalia  Testicular mass
 Varicocele
 Hyperandrogenism?
 Workup: Labs
Female Male
 Ovulation problems  CBC
 FSH, Testosterone
 Ovulatory Dysfunction  GC/Chlam, UA
 Renal and Liver
 Ovarian Reserve Function
 Semen analysis
 Postejaculatory
urinalysis
 WHO Seminal Fluid
Analysis (1999)
 Volume: >2ml
 Sperm concentration: >20 million/ml
 Total Sperm Number: >40 million/ejaculate
 Sperm Motility:
 >50% motile and/or
 >25% progressively motile

 Sperm Morphology: >14% normal forms

 Workup: Special Tests
Female Male
 Transvaginal  Scrotal
Ultrasonography (TVUS) Ultrasonography

 Hysterosalpingography
(HSG)
 Transrectal
 Hysteroscopy Ultrasonography
(TRUS)
 Laparoscopy
 Our Couple: Exam,
Labs & Tests
 Normal male exam

 Normal initial labs

 Oligospermia on 2 separate semen

analyses

 TRUS and postejaculatory UA normal

 Management: General
Concepts
 41 different methods

 “Fertile window” intercourse

 “E-type” vaginal discharge

 Avoid lubricants and douches

 Management: Female
 Treat underlying cause

 Hyperprolactinemia

 PCOS

 Gonadotropin therapy
 Management: Female
 Ovulatory dysfunction (Unknown etiology)
 Clomiphene 50mg PO daily x 5 days
 Start on days 3-5

 Can increase to 100mg daily next cycle

 Results
 80% will ovulate
 Hyperstimulation and Twinning

 Higher-order multiples rare

 Management: Female
 Clomiphene Failure?

 IVF

 Injectable ovulation-inducing agents

 Management: Female
 Tubal/Pelvic/Uterine Issues
 Reparative Surgery (low success)
 IVF

 Endometriosis
 Laparoscopic ablation
 Laparotomy

 Ovulation induction +/- IUI and IVF

 Management: Male

 Hyperprolactinemia

 Surgical repair

 Fertility Specialist
 Stress and Infertility
 69% Women and 21% Men have
preexisting condition

 Greater risk for psychological stress

 No significant difference in
psychopathology
 Stress and Infertility
 Men have increased stress over time,
same as women

 Watch for normal grief vs. psychopathology

 Same rates of depression as other chronic

disease
 Stress and Infertility
 Bottom line: Not a means to improve
pregnancy rates.
 Management: Our Couple

 Male: Imipramine Mar 08

 Pregnant inhttp://www.rotundaivf.com/
June 2008!

 Separated from USAF in July 2008

Questions?