Monday, May 29, 2017

A Brief Introduction to Infertility

Definition of Infertility:

A. Primary infertility
1. Female partner has never been pregnant
2. Couple unable to conceive after unprotected intercourse for at least 1 year
B. Secondary infertility
1. Female partner has had at least one prior conception
2. Couple unable to conceive after unprotected intercourse for at least 1 year

Scope of Problem:
Approximately 15% of couples are unable to achieve a pregnancy within 1 year of attempting conception.Fertility declines are evident at least a decade prior to the menopausal transition.

Evaluation of the Infertile Couple:
A. History and physical
1. Menstrual cycle frequency and length
2. Gravidity, parity, pregnancy outcomes
3. Coital frequency and sexual dysfunction
4. Duration of infertility
5. Surgical history, particularly pelvic/abdominal
6. Medications, allergies
7. Tobacco, alcohol, drug history
8. History of sexually transmitted diseases
9. Family history of birth defects, reproductive difficulties, spontaneous abortions, early menopause, mental retardation
10. Symptoms of thyroid disease, pelvic pain, galactorrhea, hirsutism, dyspareunia
11. Physical examination includes weight, body mass index (BMI), thyroid and breast examinations, signs of hyperandrogenism/hirsutism, pelvic tenderness, and vaginal/uterine/cervical abnormalities.

B. Male infertility evaluation—semen analysis
1. Volume: 15–5.0 mL
2. pH: >7.2
3. Concentration: >20 million sperm/mL
4. Percent motility: at least 50%
5. Morphology by strict criteria: at least 4% normal
6. Physical examination looking for varicocele, hypospadias, cryptorchidism, testicular volume, penile length, extent of virilization

C. Female infertility evaluation

1. Hysterosalpingogram to evaluate the uterus and tubal patency
2. Cycle day 3 FSH and LH level to evaluate ovarian reserve
a. Released by anterior pituitary
b. >10 mIU/mL abnormal
c. Elevated levels indicate diminished ovarian reserve and predict poorer response to treatment, increased spontaneous abortion rate, lower fecundity
3. Confirmation of ovulation
a. Mid-luteal (cycle day 21) progesterone level >30nmol/L confirms ovulation
b. Basal body temperature rises by approximately 1°F above baseline at ovulation; temperature best taken prior to any morning activity
c. LH surge: best indicator of ovulation; occurs around day 13–14 in a 28-day menstrual cycle; lasts 48–50 hours; ovulation occurs 10–12 hours after peak LH levels achieved
4. Thyroid-stimulating hormone (TSH) and prolactin levels (released by anterior pituitary)
5. Ultrasound to rule out uterine (i.e., fibroids) and ovarian pathologies (i.e., cysts, endometriomas)
6. Laparoscopy if pelvic pain, endometrioma, or suspicion for endometriosis or pelvic adhesions (no longer performed as part of routine infertility evaluation)

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