Female infertility

James N Anasti, M.D.

Dept OB/GYN
 Definition
• Infertility

• Fecundablity

• Fecundity
 Just the Facts
1790 Birth rate : 55/1000
2001 Birth rate: 14.7/1000
Fertitlity services 1982: 12% (6.6 mil)
Fertility services 1995: 15% (9.3 mil)

Services used: 53% ovulatory drugs, 1.6% ART

 What physical attribute is an
important factor for infertility?
 AGE: the Hutterites
• Peaks at age 20-24 (2.6% infertile)
• Age 30-34 decrease by 15-19 % (11% infertile)
• Age 35-39 decrease by 26-46% (33% infertile)
• Age 40-45 decrease by 95% (87% infertile)
• Data confirmed by insemination studies
 Age: IVF
• Younger than 35: 42% Live birth per embryo
• Age 35-37: 35.1% Live birth per embryo
• Age 38-40: 25% Live birth per embryo
• Age 41-42: 14.5% Live birth per embryo
• Age 43: 5.9% Live birth per embryo
• Greater than 43: 2.9% Live birth per embryo
 Age: Miscarriage
• Recognized
– Age 30: 7-15%
– Age 31-34: 17-21%
– Age 35-39: 17-28%
– Age 40: 40-52%
• Unrecognized: 60%
What is the mechanism of age
that causes infertility?
Physiology of Aging Ovary
 Why are older women Infertile?
• They less eggs develop? NO

• They ovulate less? NO

• They produce less steroids? NO

 Chromosomes:Aneuploidy
• Young women 10% eggs are aneuploidic
• Age 40: 30% abnormal
• Age 43: 50 % abnormal
• Age 45: 100% abnormal
How does one check for ovarian
reserve?
 Checking for Ovarian Reserve
• Success of IVF: the outcome
• Physiology : age related increase of FSH
– Day 3 FSH: >10-15 mIu/mL
– Day 3 Estradiol: >80 pg/mL
• Clomiphene Challenge Test (CCT)
– Day 3 & Day 10 FSH (after clomid 50mg day 5-9)
– IVF success <10%
 Who to Screen?
• Age >35
• Family Hx POF
• Ovarian Surgery
• Smoking
• Poor Gonadotropin response
 Infertility: Guiding Principles
• Identify the cause
• Provide accurate information
• Emotional Support; RESOLVE group
• Guide treatments
What life style behaviors
decrease infertility?
 Basic Info: Life style
• 62% of US have BMI > 25
• 25% female in US smoke: 13% infertile
• Mary Jane factor
• ETOH
• Caffeine??
Normal Reproductive Efficiency
• Fecundity: baboons 80% Human 20%

• 93% of couples pregnant in 2 years

• Egg 12-14 hrs, Sperm 3-5 days

 How can we help?
• Assume day before temp spike on BBT
• Peak fertility 2 days prior to ovulation
• LH detection
• But easiest: Intercourse Twice a week
 When should a work-up begin?
• Most people need no treatment
• 3 year rule
– 5% decrease per year in age
– 15-25% per year of infertile
• >35 don’t wait
• Obvious reasons
 History & Physical Exam
• G’s P’s and complicaion
• LNMP, Sexual Activity
• Surgery’s
• Meds, symptoms
• FmHX menopause, reproductive
 Physical Exam:
• BMI
• Thyroid
• Skin
• Breast
• Pelvic
 Screening Test
• PAP, STD
• Rh, Cystic Fibrosis,Rubella
• Varicella
What are the main causes of
infertility?
Infertility: Causes
 Infertility: KISS it
• Sperm in cervix
• Mature Oocyte
• Cervix must nurture sperm
• Capture the oocyte in tube
• Uterus enviroment
How do we screen for male
infertility?
Male Factor
How do we check for ovulatory
defects?
 Infertility: Ovarian Factor
• Menstrual History: 97.7% predictor
• BBT
– Thermogenic potential of progesterone (.4-.8)
– Ovulation when see rise (1-5 days after)
– 12 or more days to menses
• Progesterone 3-4 ng/mL
– 7-8 days post ovulation
– Luteal pahse function
 Ovulatory Factor
• LH excretion: Ovulation prediction (24-48 h)
– Start 2-3 days before LH Surge
– Late afternoon testing, Concentrate urine
– Day of surge and next 2
• Ultrasound
How do we check for tubal
factor?
 Tubal Factor
• Risk factors
– PID; 12%,24%,75%, Ectopic 6 fold
• HSG
– 2-5 days after menses
– 1-3 % infection rate high risk
– Increase preg rate
– False positive obstruction rate (15-30%)
 Hydrosalpinges Myoma

Normal HSG
 Tubal Factor: Laparoscopy
• Chromotubation with indigo carmine
– Why not methylene blue?

• Possibility of Treatment

• Tubal surgery: Is it worth it??

 Tubal Factor: Chlamydia Antibody
testing
• Pretest: Laparoscope or not

• HSG sooner than latter

• Not yet defined

 Uterine Factors
• Hysterosalpingography (HSG)
– HSG v Hysterscope: Sens 98%, Spec 35%
– All polyp vs submucous myomas
• Ultrasound/Sonohysterography
– SIS 75 sens, spec 90%
 Bicornate Polyp

Late Prolif Mid secr

Early Prolif
Endometrial Biopsy

Proliferative

Secretory
 Uterine Factors: Bottom Line
Congenital Malformation Yes, Septum only

Leiomyomas Maybe, submucous

Intrauterine Adhesions Yes

Endometrial Polyps Maybe

 Cervical Factor
• Postcotial test (Sims-Huhner)
Intercourse (2-12 hrs) for test
Look at: pH, Sperm, Spinnbarkeit, Ferning
Cellularity, Sperm Shaking, sperm Agglutanation
Has seen better days
 Unexplained Infertility
• Defined
• 10-30% incidence
• Laparoscope necessary:
– Canadian Study: 17% v 29% (NTT:9)
• Just slower to get pregnant 3 year data
– Spontaneous conception falls 40%
 UI:Who should you treat?
No treatment 1.3-4.1%
IUI 3.8%
Clomid 5.6%
Clomid & IUI 8.3%
Gonadotropins 7.7%
Gonadotropins & IUI 17.1%
IVF 20.7%