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Babies Without a Test-Tube DanMartinMD/bmhwbwtt.htm

Babies Without a Test-Tube Dan C. Martin, M.D. University of Tennessee Health Science Center Memphis, Tennessee. Babies Without a Test-Tube www. DanMartinMD.com/bmhwbwtt.htm. Learning Objectives. Following the presentation “Babies With Test Tube” participants should be able to:

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Babies Without a Test-Tube DanMartinMD/bmhwbwtt.htm

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  1. Babies Without a Test-TubeDan C. Martin, M.D.University of Tennessee Health Science CenterMemphis, Tennessee

  2. Babies Without a Test-Tubewww.DanMartinMD.com/bmhwbwtt.htm

  3. Learning Objectives Following the presentation “Babies With Test Tube” participants should be able to: • Understand initial infertility evaluation. • Clarify evaluation and therapy with: • Normal History and Physical • Irregular Menses • Dysmenorrhea

  4. Patients • Irregular Menses • Dysmenorrhea • Normal History and Physical

  5. Patients • Irregular Menses  PCOS • Dysmenorrhea  Endometriosis • Normal History and Physical

  6. Evaluation • Months • 6 Months • 12 Months • 36 Months • Available Resources • Age • 28 • 38 • 45

  7. Disclosure • None

  8. Off-Label Discussion • Clomiphene Citrate • Oral hypoglycemics • Estradiol • Progestins

  9. One healthy baby Twins can be a major complication. Triplets are often a major complication. Goals

  10. Evaluation • History • Physical • General Lab • Pregnancy Test, Pap Smear, GC and Chlamydia • CBC, TSH, prolactin, rubella, vitamin D* • Fertility Lab • Semen Analysis • Luteal Progesterone * Vitamin D deficiency is associated with pre-eclampsia and C-section for small pelvis

  11. Evaluation • Day 3 FSH and E2 if age ≥38 (≥35) • HIV, RPR, fasting glucose, Type and Rh,free testosterone, testosterone, DHEAS, 17 OHP (follicular) • Sonogram • Sonohysterogram • Hysterosalpingogram (HSG) • Hysteroscopy • Diagnostic Laparoscopy

  12. General • Prenatal Vitamins • Pregnancy test before any medication • Clomiphene Class X • Includes neural tube defects.Day 18 to 30 after ovulationUse folic acid up to 5 mg dailyStart 96 hours to 6 months before pregnant • Femara Class X

  13. Aging

  14. Windows of Opportunity Cervix (Tube) - Sex Endometrium -Implantation Ampulla - Fertilization

  15. Windows of Opportunity • Cervical sperm survival – 2 to 8 days • Tubal sperm survival – 2 to 8 days? • Ampullary fertilization of egg – 6 to 7 hours • Implantation in endometrium – 6 to 7 days after LH surge

  16. Windows of Opportunity • Cervix – 2 to 8 daysTubal Sperm also? • Ampullary Egg – 6 to 7 hours • Implantation – 6 to 7 days Estrogenized Tubal Environment Egg Release Estrogen proliferation and Progestin maturation of Endometrium Estrogenized Cervical Mucus

  17. Basics • Sperm • An adequate number of spermatozoa must be deposited at or near the cervix at or near the time of ovulation, ascend into the fallopian tubes, and fertilize an ovum.

  18. Basics • Ovary • A mature ovum must be released from the ovaries, ideally on a regular, predictable, cyclic basis.

  19. Basics • Cervix • The cervix must capture, nurture, and release spermatozoa into the uterus that then travel into the fallopian tubes.

  20. Basics • Peritoneum • The fallopian tubes must have a functional anatomic relationship with the adjacent ovaries to facilitate travel and capture.

  21. Basics • Tubes • The fallopian tubes must be patent and also capable of timely transport of an embryo to the uterine cavity.

  22. Basics • Uterus • The uterus must be receptive to embryo implantation and capable of supporting subsequent normal growth and development.

  23. Ovulation Predictor Kits

  24. Ovulation • An LH (luteinizing hormone) surge begins 24 to 36 hours prior to ovulation and peaks 12 to 24 hours before ovulation. • Follicular rupture = It is the ovary’s job to make a cyst and rupture it. • Progesterone is increasingly produced after the LH surge • Secretory changes occur in the endometrium due to progesterone.

  25. Ovulation • Pregnancy is absolute proof of ovulation. • Serum progesterones are 99%+ • 8 days after a positive ovulation test • 7 days after ovulation on a monitor • Day 21 and 24 if ovulation day is uncertain.

  26. Patients • Irregular Menses • Dysmenorrhea • Normal History and Physical

  27. Ovulation Disorders • PCOS • Hypothyroidism • Hyperprolactinemia • Weight Loss / Weight Gain

  28. PCOS

  29. PCOS • Diagnosis is more clinical than lab. • Androgenism (hirsute, acne, central obesity) • Oligo-anovulatory • PCOM – polycystic morphology • > 12 follicles at 2 - 9 mm in at least 1 ovary • Volume > 10cc • Does not apply if on BCPs • If a follicle is >10mm, repeat scan next cycle • Elevated androgens • Androgens decrease with age • Decreased HDL and SHBG

  30. PCOS • Treatment • Weight loss and exercise • Clomid (clomiphene citrate) (3 months) • Femara (aromatase inhibitor) (3 months) • Metformin (6 months) • Note that the combination of Metformin and Clomid are more productive at months 4-6 compared with months 1-3 . • Gonadotropins

  31. PCOS • Weight loss • Poor results if BMI > 50 • Requires a dedicated program of diet and exercise • Use dieticians who work with diabetics • Liposuction of cutaneous fat is not the same as loss of visceral weight

  32. Yee 2003

  33. Letrozole and ClomipheneBirth Defects • There is no increase in birth defects for letrozole or clomiphene if used when not pregnant. • Letrozole associated with fewer birth defects than clomiphene but this is not statistically significant. Tulandi T. Fertil Steril 85:1761, 2006

  34. Clomiphene • Four ovarian responses to clomiphene • Ovulatory response • Anovulatory response • Ovulatory dysfunction • Luteinized unruptured follicle (LUF) • Ultrasound characteristics of ovulation

  35. Ovulation Monitoring • Basal body temperature charting (BBTC) • Mid luteal phase serum progesterone • Urine LH hormone detection (ovulation kits) • Serial ultrasounds for follicular growth and collapse.

  36. Sonographic Collapse • Collapse at 24 mm maximum or 21 mm mean with no stimulation –2 to 3 mm larger with clomiphene • Scan 1 to 2 days after collapse

  37. Luteinized Unruptured Follicle • No Collapse • May respond to 10,000 to 20,000 IU HCG

  38. Clomiphene Citratefor PCOS • Ovulatory rate - 80% • Pregnancy rate - 40% • Multiple rate • Twins - 5% • Triplets - < 1% • 80% of pregnancies occur in 4 cycles • 85% at 3 months if IUI

  39. Patients • Irregular Menses • Dysmenorrhea • Normal History and Physical

  40. Endometriosis Minimum Maximum Theoretical 1% 99% Family Practice 1% 15% Gyn Practice 30% 72%

  41. Powder Burn? 1) Infiltrating dark and scarred or 2) Surface vesicles and hemosiderin. These lesions have different histology and behavior.

  42. Theories • Retrograde Menstruation - Implantation • Mullerian Tissue Present at Birth • Coelomic Metaplasia • Vascular Metastasis • Lymphatic Metastasis

  43. Theories Implantation Nisolle 1997 Nisolle 1997

  44. Theories • Retrograde Menstruation • Pelvis • Bowel • Bladder • Appendix • Vagina • Sciatic Nerve • Diaphragm (Lungs)

  45. Natural Progressioni f P r o g r e s s i n g • Implantation • Clear Blisters • Red Polypoid Blisters • Scarring and Blood Trapping • Collection of Old Blood • More Scar • Deep Infiltration

  46. Histological Diagnosis

  47. Histological Diagnosis

  48. Histological Diagnosis Stroma  Glandular Epithelium  Old Blood  Fibromuscular Scar 

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