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The Challenge of the Miracle of Life - Infertility

The Challenge of the Miracle of Life - Infertility. Jennifer McDonald DO. Fecundability. Probability of achieving a pregnancy within one menstrual cycle 25% for normal couples. Infertility. Couple’s failure to achieve pregnancy after one year of regular, unprotected intercourse

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The Challenge of the Miracle of Life - Infertility

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  1. The Challenge of the Miracle of Life - Infertility Jennifer McDonald DO

  2. Fecundability Probability of achieving a pregnancy within one menstrual cycle 25% for normal couples

  3. Infertility • Couple’s failure to achieve pregnancy after one year of regular, unprotected intercourse • US ~ 15% couples • Incidence has remained stable over last three decades Primary Infertility ?? Secondary Infertility ??

  4. Average Conception Rates

  5. Causes of Infertility • Multiple factors 20% • Male factors 40% • Female factors 40% Ovulatory factor 15-20% Peritoneal factor 40% Uterine-tubal factor 30% Cervical factor 5-10% • Unexplained infertility 20%

  6. Aging and female infertility • As age increases follicular phase becomes shorter and estradiol begins to rise earlier • Increased rate of follicular atresia after 37-38 • Increased rate of spontaneous miscarriage

  7. Aging and female infertility

  8. What’s age got to do with it? Intercourse on most fertile day 50% achieve pregnancy age 19-26 40% achieve pregnancy age 27-34 30% achieve pregnancy age 35-39

  9. So what’s so hard??

  10. Parts is Parts • Adequate numbers of healthy sperm (male factor) • Mature ovum released in predictable fashion (ovarian factor) • Cervix must capture, nuture and release sperm into uterus and tubes (cervical factor) • Fallopian tubes must have a functional anatomic relationship to facilitate ovum capture (peritoneal factor) • Fallopian tube must be patent and capable of transfer (tubal factor) • Uterus must be receptive to implantation and supporting pregnancy (uterine factor)

  11. Male Factor Evaluation • Physical exam • Environmental/occupational exposures • Semen analysis > 20 million Motility > 50% Volume > 2mL Morphology > 30% normal • Endocrine evaluation if warranted

  12. Female Factor Infertility - Peritoneal Factors Endometriosis Pelvic Adhesions Pregnancy rates after treatment as high as 75% for mild disease and as low as 30% for severe disease Diagnosis = Laparoscopy

  13. Female Factor Infertility - Ovulatory Factors • Hypothalamic-pituitary dysfunction • Intracranial tumors • PCOS • Ovarian abnormalities • Thyroid disease • Androgen excess Ovulation restored in 90% of cases due to endocrine factors. Other cases rely on ovulation induction with medications

  14. Evidence of Ovulation • Basal body temperature • Serum progesterone (mid-luteal Day19-22) • 12 - 15 ng/mL considered evidence of ovulation • Ovulation predictor kits (LH surge) • Ultrasound

  15. Basal Body Temperature • Temperature first thing in the morning • Biphasic pattern suggestive of ovulation • Common to have dip the day of ovulation • Temperatures rise after ovulation due to progesterone from corpus luteum • If temperatures drop late in the luteal phase don’t waste money on a pregnancy test!

  16. Female Factor Infertility - Uterine & Tubal Factors • Fibroids • Intrauterine adhesions (Asherman’s) • Congenital malformations • Tubal occlusion (PID most common) • Endometrial abnormalities

  17. Tubal Adhesions

  18. Mullerian Anomalies

  19. Anomaly Frequency • Bicornuate uterus (37 percent) • Arcuate uterus (15 percent) • Incomplete septum (13 percent) • Uterus didelphys (11 percent) • Complete septum (9 percent) and • Unicornuate uterus (4.4 percent)

  20. Hysterosalpingogram • Radiopaque dye through the cervix under x-ray watching dye fill uterus and spill from tubes into peritoneal cavity

  21. Ultrasonography • Non-invasive • 3D contours of uterus and endometrium as well as ovaries

  22. MRI • More distinct delineation of soft tissue structures • MR imaging has been shown to be both sensitive and specific and is clearly less invasive than laparoscopy, which was considered the gold standard for diagnosis of anomalies.

  23. Female Factor Infertility - Cervical Factors • Structural abnormalities • Abnormal mucous production Evaluation should include post-coital test Treatment includes intrauterine insemination

  24. Smoking and Female Fertility • Interferes with gametogenesis, fertilization & implantation • Reduces estrogen levels • Nicotine alters FSH/LH release decreasing LH surge • Nicotine stimulates cortisol secretion • Earlier menopause by 2-3 years • Fertility rates lower (30%)

  25. Smoking and Male Fertility • Impaired sperm concentration, motility & morphology • Decreased libido • Combined with caffeine consumption increases number of non-viable sperm

  26. Assisted Reproduction • IVF (in vitro fertilization) • GIFT (gamate intra-fallopian transfer) • ZIFT (zygote intra-fallopian transfer)

  27. IVF • Ovarian stimulation with gonadotropins • Oocyte retrieval (36 hours after hCG) • Oocyte culture - sperm added after 4-6 hours (50,000 per oocyte) • 65-80% of mature oocytes will fertilize • Examined at the pro-nuclear stage • Cryopreservation of unused embryos (two thirds will survive freezing/thawing)

  28. IVF • Embryo transfer 8-10 cell stage (72-80 hours after retrieval) • Multiple pregnancy rate 35% • Rise in hCG indicates pregnancy while drops indicate a failed cycle

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