Gynecology [INFERTILITY]

Infertility
Infertility is defined as the inability to conceive after 1 year of
attempting to conceive with reasonable frequency. AKA banging
without babies after 1 year. Most women will conceive in the 2 nd
year of attempting. However, investigation should begin after 1
year without a conception (abortions are a different disease).
Conception means a fetus is developed and implants.

There are occasions where an accelerated workup is indicated,

such as an anovulatory woman with PID or advanced maternal
age. However, for the standard patient, 1 year is when you start.

The Workup #1: Blame the Dude First

This is not some liberal propaganda. The problem is more often
with the male partner than with the female, plus evaluation is far
less invasive for the guy than for the woman. There are two main
diagnoses that are male related: erectile dysfunction and
insufficient sperm.
Erectile Dysfunction
Erectile dysfunction is evaluated with a night time tumescence Path: ♂ fault
test. If the man cannot achieve or maintain an erection there are Pt: Psychogenic or Organic
two main causes. The first is psychological which is treated with Dx: Night-Time Tumescence
counseling (erections are spontaneously achieved at night but not Tx: Psychogenic: Counseling
Organic: Sildenafil
with his partner). The second is organic which will require
f/u: Always blame the dude first
phosphodiesterase-inhibitors to overcome (there are no
spontaneous erections at night). This is discussed in detail in
subspecialty: urology.

Semen Analysis is the mainstay of evaluation of the infertile

couple. There must be sufficient number of sperm and they must Insufficient, Dysfunctional Semen
be sufficiently motile (flagellated and actually moving). Path: ♂ fault
Pt: ↓ numbers or nonmotile sperm
While frequent sex will decrease the sperm concentration, the Dx: Semen analysis
negative effect of frequent sex is negated by proper timing. Tx: ICSI
Before you touch the woman, you should rule out erectile f/u: Always blame the dude first
dysfunction and hypospermia. Then counsel them on the window
of conception; 5 days prior to ovulation through the day of
ovulation. Daily sex is recommended.

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 Gynecology [INFERTILITY]

The Workup #2: Blame the Chick Last Inhospitable Mucous

The first thing to assess is hostile mucous. Sperm is a foreign Path: Soft mucous needed
body and the uterus fights to kill the sperm. To evaluate the Pt: Inability to conceive
woman for hostile mucous, the couple should have sex and then Dx: Mucous Workup
come into the office (pun not intended). A uterine sample is taken - Smush test < 6 cm smush
and a number of tests are performed. First, if the mucous can’t - No sperm
achieve greater than 6cm on a smush test, it’s inhospitable - No fern sign
Tx: Estrogen
(hostile mucous breaks at short distances, hospitable mucous can
Bypass = Artificial Insemination
extend quite far). Then you actually look at the uterine secretions.
If you see fern sign or sperm, the mucous is hospitable. The
Ovulation Issues
absence of fern sign or semen is indicative of a hostile mucous. Path: ♀ fault
Treat this with estrogen (to soften the mucous) or simply bypass Pt: Inability to conceive
with ICSI. Normal mucous workup
Dx: Basal Temp rises 1o on ovulation
If she has a normal uterine mucous, it’s time to assess for Endometrial biopsy day 14-28 = secretory uterus
anovulation. This can be done a number of ways and these Progesterone levels at day 22
methods are often employed by couples looking to conceive by Hx… anovulatory = h/o irregular menses
choosing the “ideal” time to copulate. Look for a 1o rise of basal Tx: Clomiphene
temperature as a sign of ovulation. More specific tests include Pergonal
an endometrial biopsy between day 14 and 28, ensuring there’s
a secretory uterus. Finally, a blood test can be used. Look at Anatomic Issues
progesterone level on day 22; it should be elevated. If a woman Path: ♀ fault
has a history of irregular menses, it’s a potential clue that she may Fibroids (implantation), Stricture, PID (tubes)
be anovulatory. If the woman is anovulatory, treat her with Pt: Inability to conceive
clomiphene or pergonal to stimulate ovulation. Note that this Normal mucous, normal ovulation
runs the risk of multiple pregnancies as multiple eggs are Dx: Hysterosalpingogram
Tx: ICSI, in vitro fertilization, Surrogate
released.
Tuboplasty
If she has regular ovulation, assess her anatomy. Do this with a
Hysterosalpingogram (this can also be achieved with Endometriosis
Ultrasound or MRI). Look for anatomic defects such as fibroids, Path: ♀ fault
tubal strictures, or a bicornate uterus. Tuboplasty, ICSI, or other Retrograde Flow
Pt: Abdominal pain, dyspareunia
surgical maneuver can be employed. Care must be made to
Dx: Ex-Lap with Laser Ablation
protect the uterus to allow for implantation.
Tx: Laser Ablation
At the very end of the workup, go after endometriosis. The last
step is to do a diagnostic scope with laser ablation. If a Idiopathic
All other tests have failed to find a cause
chocolates cyst is found, ablate it and hope that works. It’s a long
Adoption
shot and you’re hoping to find something.
Surrogate, ICSI
If all else fails, it’s unexplained fertility. The only treatment is
adoption.

Treatment

Adoption is always an option.

Clomiphene is used when anovulatory. Look for PCOS

Estrogen is used for a hostile mucous

ICSI (artificial insemination) is used when the problem is with

the dude’s sperm

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