Infertility

Question 1

What is the definition of infertility?

Answer 1

The inability to conceive after one year of unprotected intercourse

Question 2

What female factors affect infertility?

Answer 2

Ovarian
Tubal
Uterine
Cervical 
Peritoneal

Question 3

What male factors affect infertility?

Answer 3

Sperm quantity and quality

Question 4

What are the expected conception rates?

Answer 4

25% conceive within the first month
60-70% conceive after six months
80-85% conceive after 12 months
93%conceive after 24 months

Question 5

What are some common factors that affect the sperm quantity and quality for male infertility?

Answer 5

Varicocoele
Testicular dysfunction
Obstruction
hyperthermia of the sperm (tight underwear, saunas, hot tubs)

Question 6

What is required for to rule out male infertility as the cause?

Answer 6

semen analysis.

Volume 2-6 ml
Concentration > 20 million/ml
Motility > 50 %
Morphology > 14% normal (Kruger)

Question 7

When should basic eval of infertility be done?

Answer 7

After one year of unprotected intercourse (~85% of couples should be pregnant)

After 6 months for women > 35 years old.

As soon as pregnancy is desired if:
Known problems such as oligomenorrhea
Known or suspected tubal disease
Known past history of infertility for patient or male partner.

Question 8

What is important to gather from the history of the patient?

Answer 8

• Pregnancy history for patient and prior paternity for male partner
• Time without using contraception
• Menstrual cycle pattern
• Risk factors for tubal disease (STI, surgery)
• Prior infertility evaluation and treatment
• Family history of genetic disease
• Medications and habits
• Sexual function

Question 9

What is expected from menstrual cycles?

Answer 9

Most ovulatory cycles are 21-35 days. Women may state “irregular cycles” even if cycles vary by only a couple of days (e.g. 28-31 days).

Menses may occur even in the absence of ovulation, but unpredictable.

If cycles are irregular (skipping months) or without symptoms, ovulation is not occurring or is infrequent

Question 10

After a thorough history and exam, what is necessary to establish in regards to female infertility possibilities?

Answer 10

MUST DETERMINE IF OVULATION IS TAKING PLACE

• Careful menstrual history (day 1 to day 1)
• Ovulation predictor kit
• Progesterone > 3ng/mL mid-luteal
• Transvaginal ultrasound follicle monitoring if uncertain or if undergoing treatment
• Basal body temperature charting (BBT) not routinely recommended.

Question 11

If you suspect anovulation, what other tests are indicated?

Answer 11

Thyroid stimulating hormone (TSH)
Prolactin
FSH and estradiol
If PCOS is suspected or hirsutism present:
-Testosterone
-Fasting glucose and insulin and/or 2 hr GLT
-Follicular phase 17 OHP

Question 12

What is the Ovarian Reserve?

Answer 12

Reproductive potential with respect to ovarian follicle number (oocyte supply) and oocyte quality.

Question 13

what occurs in regards to age with the ovarian reserve?

Answer 13

Effects of aging:

• Ovarian reserve declines
• Decreased quality regardless of supply
• Does not affect fertility potential equally

Cycles may remain regular even for women with markedly decreased ovarian reserve.

Question 14

Who should be tested for ovarian reserve?

Answer 14

1. All women > 35 with infertility (but many fertility programs test all women
2. Unexplained infertility or recurrent miscarriage
3. Risk factors for diminished ovarian reserve (endometriosis, smoking, family history of early menopause, ovarian surgery, severe adhesive disease)