Lecture 39: Infertility
 Objectives
1. Define Infertility
2. Differentiate the causes of female infertility
3. Utilize the patient’s clinical history to determine the most appropriate evaluation method and management of
infertility
 Infertility
 “Inability to conceive after 12 months of unprotected intercourse” or “6 months if prior pregnancy or 35
years old”
 Fertility
So Why Does it Happen?
 Reproductive Physiology
 Ovulation (egg release)
 Egg pick-up by tube
 Timed intercourse, sperm placed in the vagina
 Sperm must travel to end of tube
 Fertilization of egg (now called an embryo)
 Transport of the embryo to the uterus through the tube
 Implantation of embryo into the uterine lining
 Implantation
 Embryo must be transported to the uterine cavity
 Blastocyst must break out of zona (hatch)
 Cells from the embryo must invade the endometrium
 Absolute Requirements
 Ovulation (release of egg)
 Adequate numbers of motile, normal sperm
 Patent (open) fallopian tube(s)
 Normal, receptive uterus
 Initial Infertility Workup
 Evaluate ovulatory status
 Basal body temperature charts
 Ovulation predictors kits
 Mid-luteal phase Progesterone levels
 Ultrasound monitoring
 Evaluate male factor (semen analysis)
 Evaluate tubal patency
 Hysterosalpingogram (HSG)
 Laparoscopy (out-patient surgery)
 Ovulatory Status
 Age and Female Fertility
 Fertility peaks in late teens to late twenties and then gradual decline after age 30
 20-30% fecundity rate
 Rapid decline in fertility after age 40
 Age 35: 15% fecundity rate
 Age 40: 5-10% fecundity rate
 Age 43: <5% fecundity rate
 Increase risk for miscarriages
 Increase risk for genetic abnormalities (Down’s Syndrome, Turner’s Syndrome)
 Ovulation Induction
 Clomiphene Citrate (Clomid, Serophene)
 Tamoxifen
 Letrozole (Femara)
 All of the above increase Follicle Stimulating Hormone (FSH) levels from the brain to stimulate the ovaries
 Gonadotropins (Injectable medications) FSH
 Repronex, Bravelle, Menopur, Gonal-F, Follistim
 Metformin (Glucophage): Polycystic Ovarian Syndrome (PCOS) - decreases insulin and androgen levels
 Male Factor
 Accounts for up to 40% of infertility
 A previous pregnancy does not equal a normal semen analysis
 A normal semen analysis does not equal fertility
 Remember: Less than 0.1% of sperm ever make to the end of the tube
 Semen analysis
 Volume: 1-5 cc
 Sperm count: >20 million per cc
 Motility: 50% or more
 Morphology: 30% or more normal forms or >10% normal forms by Kruger’s Strict Criteria
 Example: 2cc, 25 million/cc, 50% motility, 10% normal forms (strict criteria) = 2.5 million, motile normal sperm
 <2500 sperm will make it to the tubes
 Male Treatment
 Vitamin supplements (Multi-vitamins, Anti-oxidants, Fertile One, Fertility Blend, Proxeed )
 Discontinue or decrease tobacco, alcohol, drug use
 Urology consult, varicocele repair if present (controversial)
 Clomiphene citrate (controversial)
 Artificial insemination - intrauterine insemination (IUI)
 Assisted reproduction (ART)
 IVF
 ICSI- intracytoplasmic sperm injection
 Donor sperm insemination
 Tubal Factor
 Hysterosalpingography (HSG)
 Laparoscopy
 Treatment - Tubal disease
 Surgery
 Assisted Reproduction Technologies ART; In Vitro Fertilization (IVF)
 “So what is IVF and how does it work?”
 IVF – In Vitro Fertilization:
 Stimulation of ovaries to develop multiple follicles (egg sacs) by gonadotropins
 Retrieval of eggs by vaginal ultrasound
 Fertilization of eggs by sperm in lab
 Growth and development of embryos in the lab for 3-6 days
 Transfer of several embryos (1–3) into the uterus through small catheter
 “How good are we”
 Clinical Pregnancy Rates:
 Presence of a fetal heartbeat at 6-7 weeks by ultrasound
 Live Birth Rate:
 “Take Home Baby” rate
 “Comparisons of individual IVF clinics pregnancy success rates may not be meaningful as patient medical
characteristics and treatment approaches may vary from clinic to clinic”
“So what are the chances for success with infertility treatments?”
 Infertility Treatments (Pregnancy rate/treatment cycle)
 No treatment: <5%
 Ovulation induction (Clomid, Femara): 5-12%
 Costs: $100-300/cycle
 Ovulation induction and IUI: 8-15%
 Costs: $400-800/cycle
 Gonadotropins and IUI: 10-25%
 Cost: $3,000/cycle
 In-vitro fertilization (IVF): 50% (15-65%)
 Costs: $12-14,000/cycle (including medications)
 Donor egg IVF: 60% (50-70%)
 Costs: $19,500/cycle (excluding medications)
“So What can we do to improve your IVF Success Rates?”
 Factors that Can Affect Pregnancy and ART Success
1. Smoking:
 Female smokers have an earlier onset age of
menopause
 Decrease in ovarian reserve
 IVF and smoking:
 Higher day 3 basal FSH levels
 Decrease numbers of oocytes retrieved
 50% reduction in pregnancy rates as compared
to non-smokers
 Women with partners who smoke had an increase in
IVF pregnancy losses
2. Body Mass Index (BMI):
 Association between extremes of body weight and reproductive dysfunction has been well established by
many investigators
 Increased use of ovulation induction agents:
 Increased risk of multiple pregnancies
 Increased risk of ovarian hyperstimulation syndrome (OHSS)
 Obstetrical outcomes are also well established for these groups:
 Increase in preterm delivery, IUGR in underweight gravidas
 Increase in miscarriages, gestational diabetes and C-section with resultant morbidity for obese gravidas
3. Stress:
 Does Infertility Cause Stress? ..OR.. Does Stress Cause Infertility?
 Effects of Stress:
 Stress can cause release of hormones such as cortisol,
epinephrine, norepinephrine and others
 Classic “Fight or Flight” response
 Increase in heart rate, blood pressure, respiratory rate
insulin levels and other metabolic hormones
 Shunts blood and nutrients away from abdominal and
pelvic organs
 Chronic stress can cause depression and adverse
changes in the immune system and sleep patterns
 Chronic stresses can cause a elevated baseline of these
above responses
 So how can we deal with our stress?
 Get rid of or lessen certain stressors
 Become more informed, involved with your treatment process
 Psychological counseling (individual, couple or group)
 Acupuncture
 Acupuncture has been used as an infertility
treatment in Eastern medicine for >3000 years
 Health is the balance between Yin (hot) and Yang
(cold)
 Imbalances causes disease and health problems
 “Qi” is the energy flow through the body that needs
to flow freely to allow a healthy state and balance
 Acupuncture is use of need of small needles placed
in specific points or meridians that “unblocks” this
flow
 Stimulates release of endorphins and enkephalins
 Increases blood flow to reproductive organs,
improving fertility
 Decreases stress levels
 Hypnosis
 Massage therapy
 Exercise, Yoga, Pilates
 Meditation, relaxation techniques, breathing exercises
 Imagery, positive thinking, inner focusing
 “Helping the mind help the body”