INFERTILITY

dr. Amelia Wahyuni, SpOG

Quick Time and a

Micros oft Video Utility decompres sor
are needed to s ee this picture.
Definition
Infertility
Inability to conceive after one year of unprotected
intercourse
Fertility
Ability to conceive
Fecundity
Ability to carry to delivery
Incidence
80% conceive within 1 year of unprotected
intercourse
~14-20% of US couples are infertile by
definition
Origin:
Female factor ~40%
Male factor ~30%
Combined ~30%
Etiologies
Sperm disorders 30.6%
Anovulation/oligoovulation 30%
Tubal disease 16%
Unexplained 13.4%
Cx factors 5.2%
Peritoneal factors 4.8%
Male infertility
Associated Factors
PID
Endometriosis
Ovarian aging
Spermatic varicocoele
Toxins
Previous abdominal surgery (adhesions)
Cervical/uterine abnormalities
Cervical/uterine surgery
Fibroids
Overview of Evaluation
Female
Ovary
Tube
Corpus
Cervix
Peritoneum
Male
Sperm count and function
Ejaculate characteristics, immunology
Anatomic anomalies
The Most Important Factor in the
Evaluation of the Infertile Couple
Is:

HISTORY
History-General
Both couples should be present
Age
Previous pregnancies by each partner
Length of time without pregnancy
Sexual history
Frequency and timing of intercourse
Use of lubricants
Impotence, anorgasmia, dyspareunia
Contraceptive history
History-Male
History of pelvic infection
Radiation, toxic exposures (include drugs)
Mumps
Testicular surgery/injury
Excessive heat exposure (spermicidal)
History-Female

Previous female pelvic surgery

PID
Appendicitis
IUD use
Ectopic pregnancy history
Endometriosis
History-Female
Irregular menses, amenorrhea, detailed
menstrual history
Vasomotor symptoms
Stress
Weight changes
Exercise
Cervical and uterine surgery
Physical Exam-Male
Size of testicles
Testicular descent
Varicocoele
Outflow abnormalities (hypospadias, etc)
Physical Exam-Female
Pelvic masses
Uterosacral nodularity
Abdominopelvic tenderness
Uterine enlargement
Thyroid exam
Uterine mobility
Cervical abnormalities
Work-up by Organ Unit
Female
Ovary
Tube
Corpus
Cervix
Peritoneum
Ovarian Function
Document ovulation:
BBT
Luteal phase progesterone
LH surge
If POF suspected, perform FSH
TSH, PRL, adrenal functions if indicated
The only convincing proof of ovulation is
pregnancy
Ovarian Function
Three main types of dysfunction
Hypogonadotrophic, hypoestrogenic (central)
Normogonadotrophic, normoestrogenic (e.g.
PCOS)
Hypergonadotrophic, hypoestrogenic (POF)
Siklus Haid
BBT
Cheap and easy, but
Inconsistent results
Provides evidence after the fact (like the old story
about the barn door and the horse)
May delay timely diagnosis and treatment
98% of women will ovulate within 3 days of the
nadir
BBT
Luteal Phase Progesterone
Pulsatile release, thus single level may not be
useful unless elevated
Performed 7 days after presumptive ovulation
Done properly, >15 ng/ml consistent with
ovulation
Urinary LH Kits
Very sensitive and accurate
Positive test precedes ovulation by ~24 hours,
so useful for timing intercourse
Downside: price, obsession with timing of
intercourse
LH Surge
Endometrial Biopsy
Invasive
Pregnancy loss rate <1%
Perform around 2 days before expected
menstruation (= day 28 by definition)
Endometrial Biopsy
Tubal Function
Evaluate tubal patency whenever there is a
history of PID, endometriosis or other
adhesiogenic condition
Kartageners syndrome can be associated with
decreased tubal motility
Tests
HSG
Laparoscopy
Falloposcopy (not widely available)
Hysterosalpingography (HSG)
Radiologic procedure requiring contrast
Performed optimally in early proliferative
phase (avoids pregnancy)
Low risk of PID except if previous history
of PID (give prophylactic doxycycline or
consider laparoscopy)
Oil-based contrast
Higher risk of anaphylaxis than H2O-based
May be associated with fertility rates
HSG
HSG
Laparoscopy
Invasive; requires OR or office setting
Can offer diagnosis and treatment in one
sitting
Not necessary in all patients
Uses (examples):
Lysis of adhesions
Diagnosis and excision of endometriosis
Myomectomy
Tubal reconstructive surgery
Laparoscopy
Laparoscopy
Corpus
Asherman Syndrome
Diagnosis by HSG or hysteroscopy
Usually s/p D+C, myomectomy, other
intrauterine surgery
Associated with hypo/amenorrhea, recurrent
miscarriage
Fibroids, Uterine Anomalies
Rarely associated with infertility
Work-up:
Ultrasound
Hysteroscopy
Laparoscopy
Hysteroscopy
Hysteroscopy
Cervical Function
Infection
Ureaplasma suspected
Stenosis
Immunologic Factors
Sperm-mucus interaction
Male Factors
Male Factors
Serum FSH, PRL levels
Semen analysis
Testicular biopsy
Sperm penetration assay (SPA)
 Male Factors-Semen Analysis
Collected after 48 hour of abstinence
Evaluated within one hour of ejaculation
If abnormal parameters, repeat twice, 2 weeks
apart
 Normal Semen Analysis
Quality Normal Value
Volume >1 cc
Concentration >2 x 106/cc
Initial Forward >50%
Motility
Normal Morphology >60%
Sperm Penetration Assay
Dynamic test of fertilization capacity of sperm
Failure to penetrate at least 10% of zona-free
ova consistent with male factor
False positives and negatives exist
Treatment Options
Ovarian Disorders
Anovulation
Clomiphene Citrate hCG
hMG
Induction + IUI (often done but unjustified)
PRL
Bromocriptine
macroadenoma
POF
?high-dose hMG (not very effective)
Ovarian Disorders
Central amenorrhea
CC first, then hMG
Pulsatile GnRH
LPD
Progesterone suppositories during luteal phase
CC hCG
Ovulation Induction
CC
70% induction rate, ~40% pregnancy rate
Patients should typically be normoestrogenic
Induce menses and start on day 5
With dosages, antiestrogen effects dominate
Multifetal rates 5-10%
Corpus
Asherman syndrome
Hysteroscopic lysis of adhesions (scissor)
Postop Abx, E2
Fibroids (rarely need treatment)
Myomectomy(hysteroscopic, laparoscopic, open)
??UAE
Uterine anomalies (rarely need treatment)
metroplasty
Cervix
Repeat test to rule out inaccurate timing of
test
If cervicitis Abx
If scant mucus low-dose estrogen
Sperm motility issues (? Antisperm ABs)
Steroids?
IUI
Peritoneum (Endometriosis)
From a fertility standpoint, excision beats
medical management
Lysis of adhesions
GnRH-a (not a cure and has side effects,
expense)
Danazol (side effects, cost)

Chances of pregnancy highest within 6

mos-1 year after treatment
Male Factor
Hypogonadotrophism
GnRH
CC, hCG results poor
Varicocoele
Ligation? (no definitive data yet)
Male Factor
Idiopathic oligospermia
No effective treatment
?IVF
donor insemination
 Unexplained Infertility
5-10% of couples
Consider PRL, laparoscopy, other hormonal
tests, cultures, ASA testing, SPA if not done
Review previous tests for validity
Empiric treatment:
Ovulation induction
Abx
IUI
Consider IVF and its variants
Adoption
 Summary
Infertility is a common problem
Infertility is a disease of couples
Evaluation must be thorough, but
individualized
Treatment is available, including IVF, but can
be expensive, invasive, and of limited efficacy
in some cases
Thank you!