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2. Infertility

3. Thomas A. Klein, MD Professor, OB-GYN Has disclosed the following commercial relationships in relation to this content: Nothing to Disclose Questions: thomas.klein@jefferson.edu

4. Objectives Review the various female and male factors which may result in the inability to conceive Review the diagnostic approaches to establish the etiology of infertility Review the therapeutic methods currently available to assist the infertile couple

5. Causes of Infertility in U.S. Cause Couples Women Tubal, pelvic disorders 35 % 40 % Ovulatory disorders 15 40 Male disorders 35 N/A Unexplained 10 10 Other 5 10

6. Infertility is defined as: 1.The inability to conceive within 1 year of unprotected intercourse 2.The inability to conceive within 1 year of unprotected intercourse at least once weekly 3.The inability to deliver a living child within one year of unprotected intercourse 4.The inability to conceive within 1 year of intercourse at least once weekly 5.The inability to conceive within 1 year of marriage

7. A 38-year-old women, G1P0010, has been unable to conceive despite unprotected intercourse for 8 months. Her pelvic examination is normal. What would you recommend? 1. Keep trying for an additional 4 months and then return 2. Have intercourse daily 3. Refer for in vitro fertilization 4. Begin evaluation for infertility 5. Order MRI of uterus

8. The preceding patient has regular monthly menses, she has no history of STD and her partner has fathered 3 children. What would you evaluate first? 1. Ovulatory status 2. Male factor 3. Tubal patency 4. Ovarian reserve 5. Thyroid status

9. Which of the following statements concerning diminished ovarian reserve is correct? 1. It is a feature of menopause 2. It results in low rates of fertility but normal rates of spontaneous abortion 3. It results in low fertility rates and increased risk of spontaneous abortion 4. It develops only after age 40 5. The only valid test for it requires a pelvic ultrasound

10. A 24-year-old G1P0010 has been unable to conceive after 18 months of unprotected intercourse. Her menses have always been infrequent, every 2-4 months. Her physical exam is normal except for moderate acne. Which of the following is correct: 1. She has polycystic ovary syndrome (PCOS) 2. She should have a pelvic ultrasound examination 3. She has less than 10% probability of conception after appropriate therapy 4. She will probably require surgery to conceive 5. She is at increased risk for endometriosis

11. Which of the following is one of the “Rotterdam Criteria” for PCOS? 1.Obesity 2.Infertility 3.Insulin resistance 4.Ovarian cyst > 5 cm 5.Irregular menstrual cycles

12. Polycystic Ovary Syndrome

13. Polycystic Ovary Syndrome: What Is It? Anovulation E B F Hirsutism A C D G Enlarged multicystic ovaries

14. PCOS: Definition Rotterdam Conference, 2003 Two of the following three features: ● Oligo- or anovulation ● Hyperandrogenism Clinical or biochemical evidence ● Polycystic ovaries Ultrasound or histologic evidence Fertil Steril 2004;81:19-25

15. For the preceding patient, assuming no other causes of her infertility, which of the following is the most appropriate initial therapy? 1. Metformin 2. Clomiphene 3. Recommend adoption 4. Artificial insemination 5. In vitro fertilization-embryo transfer

16. A 26-year-old nulligravida has been trying to conceive for 3 years. She has severe dysmenorrhea. Her PCP suspects endometriosis and has referred her to you. You tell her that: 1. The diagnosis of endometriosis can only be made surgically 2. Endometriosis is caused by a virus 3. If she has endometriosis, she will require in vitro fertilization in order to become pregnant 4. Endometriosis causes infertility by interfering with ovulation 5. If she has endometriosis, her symptoms suggest that it will be severe

17. A 28-year-old G1P1001 has been trying to conceive her second child with the same partner for 2 years. She has regular menses preceded by breast tenderness. Her friend conceived using clomiphene and she wants to try it. You tell her that: 1. Clomiphene significantly increases her risk of multiple gestation 2. Clomiphene is very expensive 3. Clomiphene is unlikely to help her 4. Clomiphene may cause dangerous side effects 5. Clomiphene is the only oral drug shown to correct ovulatory disorders

18. Endometriosis: Peritoneal Implants

19. Endometriosis and Infertility Suggested theories – Peritoneal macrophage activation – Peritoneal fluid prostaglandin effects – Luteinized unruptured follicles – Ovulatory disorder – Hyperprolactinemia – Subclinical abortion – Immune rejection of blastocyst In mild-stage endometriosis, expectant management is as effective as active treatment

20. The preceding patient is convinced that she may have an ovulatory disorder and wants testing. You tell her that ovulation would be strongly suggested by: 1. A monophasic basal body temperature chart 2. An endometrial biopsy taken on day 24 of her cycle, showing proliferative features 3. A positive urinary LH test on day 13 of her cycle 4. Multiple ovarian follicular cysts on ultrasound 5. Serum progesterone level of 2 ng/ml on day 22 of her cycle

21. Basal Body Temperature

22. A 25-year-old nulligravida has been trying to conceive for 3 years. A hysterosalpingogram shows bilateral hydrosalpinges. Assuming no other causes for infertility, which of the following is most likely to result in a live birth? 1. Clomiphene 2. Tubal surgery 3. Artificial insemination 4. Ovarian hyperstimulation 5. In vitro fertilization-embryo transfer

23. Hysterosalpingogram Normal Hydrosalpinges

24. Hydrosalpinges

25. In Vitro Fertilization-Embryo Transfer