Work-up of the Infertile Couple Flashcards
Is infertility common?
YES. 1 in 7 of every couple will have fertility challenges.
What is infertility?
- after trying for 12 months for a woman less than age 35.
- after trying for 6 months for a woman over age 35.
What are the causes of infertility?
- female= 40%
- male= 40%
- 10%= combined
- 10%= unexplained
What does an infertility evaluation involve?
- detailed pt history
- semen analysis
- HSG
- ovarian function testing
What are some things to rule out in women for infertility?
- length of trying to conceive.
- menstrual hx
- hyperthyroidism
- smoking, alcohol, drugs
- gyn problems
- surgical hx (adhesions..)
- family hx of birth defects
What are some things to rule out in men for infertility?
- fathered child previously
- urological problems
- varicocele
- difficulty with erections or ejaculation.
- stress
- frequency of ejaculation
- smoking, alcohol, drugs
- recent fever or illness
- DM or CAD
- antacids, antibiotics…
- sauna, hot tub or jacuzzi
After taking a history, what do we do next in evaluating the female?
Screening of ovarian reserve:
- age
- day 3 of menstrual cycle blood work for FSH (goal less than 10 IU/L) and anti-mullerian hormone (AMH; goal greater than 1).
- antral follicle count via ultrasound.
** So what do FSH and AMH really tell us, respectively?
- FSH= better test for egg QUALITY.
- AMH= better test for egg QUANTITY.
How do we assess anatomy for infertility?
- transvaginal pelvic ultrasound= size and shape of ovaries, fibroids (leiomyomas), endometriomas, and size of uterus.
- HSG= fluoroscopic procedure that looks to see if tubes are open.
- sonohysterogram (saline sonogram)- if indicated.
- laparoscopy- if indicated.
- hysteroscopy- if indicated.
Why can fibroids (leiomyomas) or endometrial polyps cause problems?
- blocks sperm transport
- can cause improper implantation
When do we do a laparoscopy?
only if pathology is suspected, such as endometriosis (which can be ablated) or adhesions that are affecting transport.
What is a hysteroscopy?
- procedure that utilizes a thin, lighted tube with a magnifying glass that is inserted into the cervix and inside of the uterus
What follows the history for the male?
- semen analysis
What is evaluated in a semen analysis?
- volume
- sperm concentration (normal= 15 million per mL).
- motility (normal= 50%)
- morphology
What percent of sperm are considered abnormal in a single ejaculate?
95%
*this has nothing to do with birth defects, sexuality or health. It only means optimal efficiency of penetration and fertilization!
Where is the nucleus of the sperm?
in the head
Where is the mitochondria within the sperm?
- in the mid-piece
If a semen analysis is poor, what do we do?
- repeat another one in 3 months because sperm can be affected for 3 months from drinking, smoking, or drugs. So have the guy chill on his boozing for 3 months.
What pre-pregnancy screening labs do we do for the woman?
- CBC (MCV)
- TSH
- prolactin
- vit D
- evidence of rubella and varicella immunity.
- infectious disease blood work.
- genetic screening
- targeted blood work based on hx (androgens..)
What treatment options are available?
- medical management (thyroid, clomiphene…).
- surgical management (fibroids, polyps, adhesions…).
- intrauterine insemination (partner or donor sperm).
- in-vitro fertilization (IVF)= own eggs or donor eggs.