Documente Academic
Documente Profesional
Documente Cultură
Age-Related Factors
Ability to conceive decreases as maternal age increases.
Oocyte number and quality decrease with time.
Pregnancy rates
Epidemiology
Fecundability of general population approximately 20%. In general, declines
in populations with time.
Diagnoses in infertile couples:
o
Endometriosis: 5%
Other: 4%
Unexplained: 17%
Risk Factors
Any etiology that can cause abnormalities in gamete production, gamete
transport, or embryo implantation
Infectious:
o
PID
Endometritis
Epididymitis
PID
Chemical exposure:
o
Smoking
Genetics
Genetic defects associated with infertility are primarily associated with chromosomal
abnormalities in the oocytes and embryos of women of advanced maternal age.
Maternal genetic defects include:
Turner syndrome (45 XO) or Turner mosaicism
X chromosome translocations/deletions (premature ovarian failure)
Pathophysiology
Abnormal gamete (oocyte/sperm) production
Reproductive tract defects resulting in abnormal gamete/embryo transport
Dysfunctional implantation
Associated Conditions
Iatrogenic causes of infertility with cytotoxic chemotherapy or pelvic radiation for
malignancy
Diagnosis
Signs and Symptoms
Menstrual irregularities most common. Absence of 2235 day cycles, breast
tenderness, dysmenorrhea or bloating (moliminal symptoms) suggests ovulatory
dysfunction.
History
Review of Systems
Menstrual cycle characteristics:
Moliminal symptoms, dysmenorrhea, menorrhagia, vasomotor symptoms
Abnormal nipple discharge
Dyspareunia
Male:
o
Physical Exam
Particular attention to thyroid, breasts, abdomen, and pelvis:
o BMI
Nipple discharge
Pelvic exam:
o
Male:
o
Tests
Serum progesterone:
Male factor:
o
Labs
TSH; prolactin
Semen analysis:
o
Imaging
Pelvic US and hysterosalpingogram mainstays of diagnostic imaging
Pelvic US:
Adnexal mass/endometrioma
Hydrosalpinx
Hysterosalpingogram (HSG):
o
Hysteroscopy:
o
Laparoscopy:
o
Chromopertubation:
o
Differential Diagnosis
Ovulatory dysfunction:
Anovulation/Oligo-ovulation:
o PCOS most common (70%)
P.119
Infection
Tubal disease (occlusion/adhesions):
PID/STDs
Ruptured appendix
Metabolic/Endocrine
Ovulatory dysfunction/oligo-ovulation:
o PCOS most common (70%)
Thyroid dysfunction
Hyperprolactinemia
Hypothalamic dysfunction:
o
Eating disorders
Hypothalamic hypogonadism
POF
Age-related factors
Immunologic
Ovarian insufficiency/POF
Trauma
Tubal occlusion/adhesions
Pelvic surgery
Drugs
Other/Miscellaneous
Endometriosis (tubal damage, inflammation)
Male factor (azoospermia/oligospermia)
Asherman's syndrome
Treatment
General Measures
Treatment should be centered on specific diagnosis, patient safety, and patient
preference. Adequate counseling and informed consent of vital importance.
Ovulatory Dysfunction
Weight loss (if PCOS), smoking cessation, timed intercourse
Clomiphene citrate:
o
Gonadotropin therapy:
Tubal Factor
Tubal surgery (See Fallopian Tube Surgery.):
o Adhesiolysis; fimbrioplasty; salpingotomy (hydrosalpinx); tubal
cannulation (proximal occlusion):
Endometriosis
Adhesiolysis; endometrioma resection:
Pretreatment with GnRH agonists/antagonists helpful prior to ovulation
induction
Uterine Factors
Myomectomy (abdominal/hysteroscopic):
o Success dependent on leiomyoma size; proximity to endometrium,
iatrogenic endometrial damage.
Hysteroscopic polypectomy
Male Factor
Varicocele repair
IVF intracytoplasmic sperm injection (ICSI)
Endocrinologic
Medical treatment of hyper-/hypothyroid
Hyperprolactinemia:
o
IVF
Surgery
Followup
Disposition
Issues for Referral
Referral to fertility center based on past history and current treatment, duration of
infertility, extent of possible treatment. Expedited referral:
Female age >35
History of known tubal disease including PID
Prognosis
Success rates depend on etiology of infertility and presence of coexisting
factors
Ovulatory dysfunction: 520%
Unexplained: 423%
ICSI: ~25%
Patient Monitoring
Therapy should be tailored to patient preferences, costs, and etiologic factors.
Follicle monitoring with US should be performed with ovulation induction in
addition to:
o
Treatment guidelines:
o
Clomiphene: 36 cycles
Gonadotropins: 36 cycles
Bibliography
ACOG Committee on Practice Bulletins. Management of infertility caused by
ovulatory dysfunction. Practice Bulletin No. 34. Obstet Gynecol. 2002;99:347358.
Adamson GD, et al. Subfertility: Causes, treatment, and outcome. Best Pract Res Clin
Obstet Gynaecol. 2003;17(2):169185.
Barbieri RL. Female infertility. In: Stauss JF, et al., eds. Yen and Jaffe's Reproductive
Endocrinology: Physiology, pathophysiology, and clinical management, 5th ed.
Philadelphia: Elsiver; 2004: 633668.
The Practice Committee of the American Society for Reproductive Medicine. Optimal
evaluation of the infertile female. Fertil Steril. 2006;86(Suppl 4):S264S267.
The Practice Committee of the American Society for Reproductive Medicine.
Effectiveness and treatment for unexplained infertility. Fertil Steril. 2004;82(Suppl
1):S160S163.
Miscellaneous
Abbreviations
BMIBody mass index
FSHFollicle-stimulating hormone
GnRHGonadotropin-releasing hormone
ICSIIntracytoplasmic sperm injection
IVFIn vitro fertilization
LHLuteinizing hormone
OHSSOvarian hyperstimulation syndrome
PCOSPolycystic ovarian syndrome
PIDPelvic inflammatory disease
POFPremature ovarian failure
SABSpontaneous abortion
STISexually transmitted infection
Codes
ICD9-CM
256.39 Polycystic ovaries (PCOS)
628.0 Infertility, anovulatory
628.2 Infertility, tubal origin
628.9 Infertility, unexplained origin
Patient Teaching
Smoking cessation, normal weight maintenance, limit chemical exposures
Effects of age on fertility. Preconception counseling in women >35
Attention to emotional health; counseling if needed
Prevention
STI prevention