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The Diagnosis and Treatment of Infertility

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Presentation on theme: "The Diagnosis and Treatment of Infertility"— Presentation transcript:

1 The Diagnosis and Treatment of Infertility
Ashim Kumar, M.D. Reproductive Endocrinology and Infertility Clinical Assistant Professor, UCLA School of Medicine Fertility & Surgical Associates of California, Encino & Thousand Oaks, CA

2 Infertility 1 in 8 couples affected
Definition: Failure to conceive after 1 year of regular, unprotected intercourse Earlier evaluation is recommended if: Women >35 years old Irregular menses History of Pelvic Inflammatory Disease Endometriosis Men with risk factors (e.g. testicular surgery, abnormal semen analysis)

3 Female Genital Tract

4 The Menstrual Cycle Follicular Phase Luteal Phase

5 Fertilization & Implantation

6 Causes of Infertility ? Unusual Tubal & Pelvic Male Ovulatory
Speroff and Fritz –Clinical Gynecologic Endocrinology and Infertility 2005

7 Critical Factors Affecting Fertility
Oocytes Sperm Uterus Fallopian Tubes

8 Critical Factors Affecting Fertility
Oocytes – FSH / Estradiol Ovarian Reserve Age – Quality FSH – Quantity Ovulatory Dysfunction Midluteal Progesterone – Ovulation TSH & Prolactin Sperm Uterus Fallopian Tubes

9 Evaluation of Ovulation
Basal BodyTemperature – Poor Sensitivity Urinary LH kits start 2-3 days before surge is expected ovulation is hrs later Midluteal Progesterone > 3 ng/ml shows evidence of ovulation > 10 ng/ml shows evidence of “good” ovulation 1 wk before menses is best

10 Oocyte Attrition 20 weeks in utero – 6 to 7 million Birth – 1 million
Menarche – 300,000 to 400,000 37yr – 25,000 Menopause – 1,000

11 Ovarian Reserve is the number and quality of eggs in the ovaries

12 Quantification of Ovarian Reserve
Age FSH Inhibin B, AMH Basal antral follicle count Ovarian volume Clomid challenge test FSH stimulation test Serum U/S Response to Stimulation

13 Age and Female Fertility
Peak fertility age 20-24 Decreases some until age 30-32 Declines rapidly after 435

14 Pregnancy rates, Live births rates and Singleton birth rates for ART-Fresh embryos
CDC Data, 2003

15 Age and Miscarriage Risk
<30 yr % 30-34 yr- 8-21% 35-39 yr % ≥40 yr %

16 Risk of Chromosomal Abnormality in Newborns by Maternal Age
Maternal Fetal Medicine: Practice and Principles. Creasey and Resnick 1994

17 Meiotic Nondisjunction

18 Preimplantation Genetic Diagnosis

19 Preimplantation Genetic Diagnosis

20 Preimplantation Genetic Diagnosis

21 Critical Factors Affecting Fertility
Oocytes Sperm – Semen Analysis Volume Concentration Motility Morphology Uterus Fallopian Tubes

22 Microscopic evaluation
Semen Analysis The gross examination Microscopic evaluation Appearance (opaque) Volume (2-6 mL) Viscosity (liquefaction,  1 hr) pH value (7-8) Count ( 20 million/mL) Motility (>50%) Morphology ( 30 % normal) (World Health Organization Criteria) Other Tests • Sperm Chromatin Structure Assay / TUNEL • Sperm DNA Decondensation • Sperm Penetration Tests • Postcoital Test

23 Semen Analysis Should be ordered in any couple who presents for infertility Repeat if abnormal Ideally there should be more than 10 million Normal Motile Sperm 5-20 million – insemination indicated <1 million – ICSI indicated

24 Sperm Attrition

25 Additional Male Evaluation
FSH, LH Testosterone Prolactin, TSH Karyotype Y Chromosome Microdeletion Urology referral – evaluation for varicocele (ultrasound) Freeze viable sperm if undergoing a diagnostic biopsy

26 Critical Factors Affecting Fertility
Oocytes Sperm Uterus – HSG or SHG Fibroids Polyps Synechiae Fallopian Tubes

27 Uterine Evaluation Ultrasound Sonohysterogram (saline ultrasound)
Hysterosalpingogram MRI Hysteroscopy

28 Ultrasound Evaluates uterus, adnexa and occasionally the fallopian tubes May be helpful in diagnosing uterine abnormalities

29 Sonohystogram (SHG) Concurrent saline distention of the uterine cavity and vaginal ultrasonography

30 Hysterosalpingogram (HSG)

31 Hysteroscopy Allows direct evaluation the uterine cavity
Concurrently diagnose and treat

32 Critical Factors Affecting Fertility
Oocytes Sperm Uterus Fallopian Tubes – HSG Patent vs. Occluded Proximal vs. Distal Occlusion Potential therapeutic effect

33 Hysterosalpingogram (HSG)

34 MRI In Lieu of Surgery In Preparation for Surgery
Non-surgically evaluate the uterus to differentiate between various forms of congenital anomalies In Preparation for Surgery To map fibroids prior to surgery Help diagnose adenomyosis

35 Laparoscopy Allows direct visualization of the pelvic anatomy.
Can evaluate endometriosis, adhesions, uterine abnormalities or ovarian masses Chromotubation use of a dilute solution of blue dye instilled through the cervix can demonstrate tubal patency or distal tubal occlusive disease. Surgically correct the disease process

36 Laparoscopy

37 Laparoscopy Peritubal Adhesions Lysis of Adhesions and Chromotubation

38 Laparoscopy Resection of Hydrosalpinx

39 Treatment - Oocytes Controlled Ovarian Hyperstimulation
Long Protocol Antagonist Microdose Flare Ovulation Induction Clomid hMG or FSH Clomid + FSH

40 Treatment - Sperm Intrauterine Insemination (IUI) – place the washed sperm at the top of the uterus near the opening of the fallopian tubes Intracytoplasmic Sperm Injection (ICSI) – directly inject each sperm into each egg

41 Treatment - Uterus Hormonal – estrogen supplementation to increase endometrial thickness Surgical – remove polyps, fibroids, scar tissue, septum, etc.

42 Treatment – Fallopian Tubes
Surgical – correct tubal disease, endometriosis, scar tissue OI & IUI – if unilateral tubal obstruction IVF – for bilateral tubal disease

43 Unexplained Infertility
Normal Semen analysis, evidence of ovulation, normal uterus, tubes are open Surgery-Laparoscopy-to exclude endometriosis/adhesions Consider the addition of hysteroscopy Stepwise empiric treatment of OI & IUI and IVF

44 When to Use Assisted Reproductive Technology (ART)
Neither fallopian tube is patent Severe endometriosis Severe male factor infertility Unexplained infertility After medical treatment has failed For genetic indications-PGD

45 Intracytoplasmic Sperm Injection (ICSI)

46 Embryo Development In Vitro
First Division Second Division Zygote 8-cell stage Hatching Blastocyst Morula Blastocysts

47 Embryo transfer Embryos are inserted into the uterus Embryo

48 Preimplantation Genetic Diagnosis
a procedure that allows embryos to be tested for genetic disorders before they enter the uterus and before pregnancy has begun Thornhill et al, JMD 2002

49 Donor Oocytes 10% of ivf cycles Indications

50 Live Births Rates from Own vs. Donor Eggs
CDC Data, 2003

51 2nd Opinion


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