1. Female infertility James N Anasti, M.D. Dept OB/GYN

2. Definition Infertility Fecundablity Fecundity

3. 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

4. What physical attribute is an important factor for infertility?

5. 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

6. 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

7. Age: Miscarriage Recognized –Age 30: 7-15% –Age 31-34: 17-21% –Age 35-39: 17-28% –Age 40: 40-52% Unrecognized: 60%

8. What is the mechanism of age that causes infertility?

9. Physiology of Aging Ovary

10. Why are older women Infertile? They less eggs develop? They ovulate less? They produce less steroids? NO

11. Chromosomes:Aneuploidy Young women 10% eggs are aneuploidic Age 40: 30% abnormal Age 43: 50 % abnormal Age 45: 100% abnormal

12. How does one check for ovarian reserve?

13. 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%

14. Who to Screen? Age >35 Family Hx POF Ovarian Surgery Smoking Poor Gonadotropin response

15. Infertility: Guiding Principles Identify the cause Provide accurate information Emotional Support; RESOLVE group Guide treatments

16. What life style behaviors decrease infertility?

17. Basic Info: Life style 62% of US have BMI > 25 25% female in US smoke: 13% infertile Mary Jane factor ETOH Caffeine??

18. Normal Reproductive Efficiency Fecundity: baboons 80% Human 20% 93% of couples pregnant in 2 years Egg 12-14 hrs, Sperm 3-5 days

19. 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

20. 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

21. History & Physical Exam G’s P’s and complicaion LNMP, Sexual Activity Surgery’s Meds, symptoms FmHX menopause, reproductive

22. Physical Exam: BMI Thyroid Skin Breast Pelvic

23. Screening Test PAP, STD Rh, Cystic Fibrosis,Rubella Varicella

24. What are the main causes of infertility?

25. Infertility: Causes

26. Infertility: KISS it Sperm in cervix Mature Oocyte Cervix must nurture sperm Capture the oocyte in tube Uterus enviroment

27. How do we screen for male infertility?

28. Male Factor

29. How do we check for ovulatory defects?

30. 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

31. 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

32. How do we check for tubal factor?

33. 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%)

34. Hydrosalpinges Myoma Normal HSG

35. Tubal Factor: Laparoscopy Chromotubation with indigo carmine –Why not methylene blue? Possibility of Treatment Tubal surgery: Is it worth it??

36. Tubal Factor: Chlamydia Antibody testing Pretest: Laparoscope or not HSG sooner than latter Not yet defined

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

38. Bicornate Polyp Early Prolif Late Prolif Mid secr

39. Endometrial Biopsy Proliferative Secretory

40. Uterine Factors: Bottom Line Congenital Malformation Leiomyomas Intrauterine Adhesions Endometrial Polyps Yes, Septum only Maybe, submucous Yes Maybe

41. 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

42. 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%

43. UI:Who should you treat? No treatment1.3-4.1% IUI3.8% Clomid5.6% Clomid & IUI8.3% Gonadotropins7.7% Gonadotropins & IUI17.1% IVF20.7%