Download evaluating the intertile patient-couples - Mercy Medical Center

EVALUATING THE INFERTILE
PATIENT-COUPLES
Stephen Thorn, MD
Overview
• The field of reproductive medicine continues
to evolve rapidly by offering newer
diagnostic testing and therapeutic options to
improve fertility.
• Following pages include:
▫ Overview of current infertility evaluation
▫ Potential impact of several common gynecologic
diseases
• Peak monthly fecundity rate is 35% - while
the cumulative peak pregnancy rate after
one year of trying to conceive is 85%
 rising to 92% after 2 years
 93% following 3 years
• Infertility affects 1 in 7 couples
▫ Generally accepted to be defined by the
absence of a live birth following 1-2
years of attempting pregnancy
Basic Infertility Evaluation
• Remained constant and focused on the most
common areas of abnormality
▫ 40% female factor:
 40 % Ovulation dysfunction
 40 % fallopian tube blockage
▫ 40% Male Factor
▫ 20% Unexplained
• Insurance
▫ Unpredictable insurance coverage
▫ Conscious of cost-effective, evidenced based
approach
History
1. Female Age-Oocyte competence
 After 27 yrs. Infertility begins to decrease –
although many women become pregnant after
this age
 Other authors feel after 33 yrs. old
2. Years of Infertility
 If more than 3 years, success decreases
3. Prior Live Birth
 Knowing can become pregnant
History
4. Chronic Medical Conditions and Medications




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
PCOS
Endometriosis
Hypertension
Thyroid Disease
Hyperprolactinemia
Elevated BMI
5. Coital Frequency and Timing
6. Sexual Dysfunction
 On demand may be difficult
 Use of Viagra, Cialis
History
7. Use of Spermicidal Lubricants
8. Complications during prior pregnancies



C-Section
Post-Partum Hemorrhage
Necessitating D+C
9. Prior Gynecologic Surgeries




Tubal
Myomectomy
D+C for missed or incomplete miscarriage
Cervical Conizations
History
10.
History of pelvic infections
 Chlamydia/Gonorrhea/PID
11. History of Salpingitis –
 i.e Isthmic Nodosam
12. Prior Laparotomy
 Due to pelvic adhesions
13. Tobacco Use
 Including secondhand smoke
Physical Examination
• All patients should have undergone physical examination
within year of considering pregnancy or treatment for
infertility.
• Attention should be made to the following:
▫ BMI
 ** Extreme body weight changes have posed reproductive
challenges for women, usually by impairing ovulation
function
 Multiple studies have demonstrated decreased fertility,
increased miscarriage rates, and higher pregnancy
complications in women with elevated BMI
▫ Evidence of Hirsutism
▫ Endocrinologic Abnormalities
 Galactorrhea, weight changes, acne, frontal balding
TVUS
• In our clinic – and most reproductive clinics –
TVUS-trans vaginal ultrasound – has become part
of the exam (an extension of the traditional
pelvic exam)
• TVUS – allows assessment of the ovaries for
PCOS, as well as Leiomyomas within the uterus
▫ The advance of 3 and 4 D ultrasound allows a
diagnosis of Mullerian anomalies and possibly the
intrauterine pathology
Laboratory Testing
•
•
•
•
•
•
•
•
•
FSH-LH
Estradiol
Progesterone
Prolactin
Testosterone –Free-Total-?DHEAS
TSH
Fasting Glucose-Insulin
AMH
Cholesterol
Many of these
tests are
performed
during different
days of the
patient’s cycle
Invasive Testing
• HSG – Hysterosalpingogram
• Hysterosonogram – saline
• Diagnostic Laparoscopy
▫ removal of endometriosis, endometriomas, adhesions,
ovarian drilling]
• Endometrial Biopsy
▫ It was a considered basic element of any thorough
infertility evaluation – BUT NO LONGER – serum
progesterone levels. BBT recordings, monitoring LH
urine secretion—bx does not provide any more
information
Medical Issues
1.
2.
3.
4.
5.
Endometriosis
PCOS
Hypothyroidism
Uterine Anomalies
Other – drug abuse, uncontrolled diabetes,
obesity
Male: Semen analysis performed to ascertain
numbers, motility, morphology, wbcs,
agglutination
▫ If abnormal – Urological evaluation necessary
Treatment
• After thorough
discussion/labs/history/physical – a
treatment plan will be decided upon with
patient and significant other
• Indirect-Direct treatments with
medication
• IUI – Intrauterine insemination
• If indicated or no success – consider IVF
Conclusion
• The MOST important issue when evaluating is
honesty and communication
▫ Discuss each step in the process
▫ Realize the financial burden that this can be on a
couple
• The entire staff involved in the care of the
couple must be:
▫ Very compassionate
▫ Have patience, understanding and realize what an
emotional strain this process can be on a couple
1. A 28 year old nulliparous woman comes to your
office with her husband after trying to conceive
unsuccessfully for 3 years. Over the counter ovulation
predictor kits have been consistently positive at mid
cycle. Her periods are every 28 days, with no
dysmenorrheal. Semen analysis and
hysterosalpingogram are normal. The most cost
effective initial management for this couple is-
A-clomiphene citrate (Clomid, Serophene)
B-intrauterine insemination
C-clomiphene and intrauterine insemination
D-ovulation induction with gonadotropins
E-in-vitro fertilization (IVF)
Answer: Clomiphene and intrauterine
insemination
• Usually current management of unexplained
infertility uses empiric treatments such as
oral Clomid with IUI. Cost sensitivity is
important.
• Around 30% of infertility patients have
unexplained infertility. If no success after 36 cycles consider more invasive treatments
with gonadotropins.
2. A 33 year old infertile woman underwent
gastric bypass surgery has lost weight and
continues to do so. The best recommendation
patient can be given her regarding a future
pregnancy is that she should try to achieve
conception
A - immediately
B - in six months
C - in 12 months
D - in 18 months
Answer: in 12 Months
• These operations are associated with
postoperative complications-including
vomiting, dumping syndrome, and
malnutrition(i.e. deficiencies in iron,
vitamin B12, folate, calcium, and vitamin
D)-It takes about 12 months for a patient to
stabilize her body weight and nutritional
status.
3. A 35 year old female on Hysterosalingogram is
noted to have bilateral Hydrosalpinges and no
tubal patency. Her husband has a normal semen
analysis. For the best chance of conceiving over
the next year, the next step isA - perform a neosalingostomy procedure on
both tubes
B - perform a unilateral neosalpingostomy on
the small diameter hydrosalpinx
C – In vitro fertilization-embryo transfer-(IVF)
D - Bilateral salingectomy before an IVF
procedure
E - transvaginal aspiration of hydrosalpinx
Answer: Bilateral Salingectomy before
an IVF Procedure
• Numerous studies have shown that the
presence of a hydrosalpinx has an adverse
outcome on IVF cycles. Patients have about
½ the pregnancy rate with IVF if a
hydrosalpinx is noted. A bilateral
salpingectomy or clip placement near
cornua of uterus was noted to improve
pregnancy rates.
4. A 33 year nulligravid married woman receives a
diagnosis of breast cancer. She is scheduled to have a
mastectomy and subsequent chemotherapy for 12
weeks with a regimen that includes an alkylating agent.
The therapy or intervention that might improve her
ability to deliver a child after chemotherapy for breast
cancer is-
A - use of oral contraceptives during the
chemotherapy
B - use of a gonadotropin-releasing hormone
(GnRH) agonist during her chemotherapy
C - obtain ovarian tissue and cryoperserve
before chemotherapy
D - perform in vitro fertilization (IVF) and
cryopreserve embryos before chemotherapy
Answer: perform in vitro fertilization (IVF)
and cryopreserve embryos before
chemotherapy
• Chemotherapeutic agents damage rapidly dividing
cells and specifically injure the structure and
function of ovarian granulosa cells. This ultimately
leads to premature oocyte depletion and eventual
ovarian failure.
• It appears that alkylating agents cause significant
oocyte depletion. The extent of damage appears
to be age related - women older than 40 have
increased sensitivity to chemotherapeutic agents.
5. A 25 year old nulligravid woman has a history of irregular
cycles and mid-luteal serum progesterones that are consistent
with annovulation. A hysterosalpingogram and semen analysis are
normal. Treatment with clomiphene citrate (Clomid, Serophene)
50mg was administered days 5-9 of the menstrual cycle. A
luteinizing hormone (LH) surge was detected by urinary
monitoring on day 15 of the cycle. The most appropriate timing
for intercourse and ovulation to provide the best chance for
pregnancy, relative to the day of the LH surge is-
A - the same day
B – 1 day later
C - 2 days later
D - 3 days later
E - 1 week later
Answer: The Same Day
• Ovulation with follicle rupture occurs
approximately 36-40 hours after the onset of the
LH surge and 24 hours after the peak. It is
suggested that the fertile period occurs before
ovulation and then declines rapidly.
• The egg survives for no more than 24-36 hours
after ovulation. Sperm has been noted to survive
in the reproductive tract 3-5 days and to retain
the ability to fertilize an ovum even before
ovulation occurs.
6. A 32 year old nulligravid female with infertility is
found to have a 8-cm posterior uterine fibroid on
transvaginal ultrasound. A hysterosalgingogram shows
uterine cavity distortion from a submucosal location. In
discussing complications of abdominal myomectomy,
you inform her that the most likely risk is-
A - conversion to hysterectomy
B - uterine rupture with labor
C - pelvic adhesions
D - blood transfusions
E - intrauterine synechiae
Answer: Pelvic Adhesions
• Fibroids in the submucosal position can cause
heavy periods, pain, and infertility. Before a
myomectomy is performed all risks should be
discussed—i.e.-operative risks, anesthesia,
infection, adhesions, increased likelihood for
cesarean section, small risk of uterine rupture,
and recovery time.
• Interceed did decrease incidence of adhesions.
Hysterectomy conversion is rare with experienced
surgeon.
7. A 31 year old woman has a history of a prior cesarean
delivery with an associated Pomeroy tubal ligation. The patient
had endometritis after her delivery that was treated with
antibiotics. She has recently remarried. Her husband has not
fathered a child but does have a normal semen analysis. She
desires information regarding tubal reanastomosis versus in vitro
fertilization (IVF) to help her conceive another child. The factor
that best predicts the success rate for pregnancy and delivery
after a tubal reanatomosis versus IVF is-
A - age of woman requesting treatment
B - prior history of an cesarean section
C - type of tubal ligation performed
D - history of endometritis
E - absence of any prior conception with the
husband’s sperm
Answer: Age of woman requesting treatment
• Data shows that difference between IVF and Tubal
reanatomosis, 52% and 59.5% respectively, but
when age of woman considered a significant
difference was noted-Age less than 37-Surgical
versus IVF-72.2-52.4 %-respectively. More than 37
years the advantage of reanastomosis was lost—
Surgical versus IVF-36% 51.4 respectively.