5 - Infertility

8/2/2019 5 - Infertility

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Fawaz EdrisMD, FRCSC, FACOG, RDMS, AAACS

Maternal Fetal Medicine

Reproductive Endocrinology & Infertility


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Background

Definition:y 1 yr unprotected coitus without conception

10-15% couples affected

Etiologyy Couples:

35% Tubal and pelvic pathology

35 % Male problems

15% Ovulatory dysfunction 10% Unexplained

5% unusual causes


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Background

Etiology

y Women:

40% Tubal and pelvic pathology

40% Ovulatory dysfunction 10% Unexplained Infertility

10% Unusual causes

Normal couple:

y 25-30% chance of pregnancy per ovulatory

cycle

Fertility decreases with age


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Infertility

Time of Exposure % Pregnant

3 months 60%6 months 70%

1 year 85%

18 months 90%


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Approach to Infertility

DDX

Hx

Px Tests/Inv

Dx

Rx


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Approach to Infertility

Production

Storage

Delivery


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Male Infertility

1. Production:

y Hypothalamus

yAnterior Pituitary

y Testes


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Hypothalamic-Pituitary-Gonadal Axis


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Male Infertility

1. Production

y Hypothalamus

Congenital abnormalities of hypothalamus

y e.g. Kallmans syndrome

Starvation, stress or severe illness

Tumors (craniopharyngioma, metastatic tumor)

Head injury

Inflammation (sarcoidosis) Infection (tuberculosis)

XRT

Drugs: marijuana


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Male Infertility

1. Production:y Pituitary

Endocrine: thyroid, prolactin

Tumors

Inflammation: sarcoidosis, meningitis

Infiltration

Infarction

Trauma/XRT

Drugs: anabolic steroids


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Male Infertility Production:y Testes:

Congenital: Klinefelters (XYY), developmental

disorders

Disorders of gonadal steroidgenesis

Infection: chlamydia, prostatitis, mumps orchitis

Autoimmune

Cryptorchidism

Tumors; chemo/XRT

Drugs / alcohol

Vascular: testicular torsion


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Male Infertility

2. Storage:

y Temperature

Rise in scrotal temperature

Occupation

Varicocoele


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Male Infertility

3. Delivery:y Impotence/Ejaculation

Neurogenic: medications (-blockers,methyldopa)

Endocrine: diabetes Congenital: absence vas deferens (CF)

Genetic: cystic fibrosis

Primary ciliary dyskinesia: Kartagener syndrome

Hypospadia Vasectomy


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Male Infertility

History:y Previous children

y Infections: prostatitis, STD, mumps orchitis

y Trauma to head or testiclesy Surgery to testicles or hernia

y Occupation (sitting, bio hazards, XRT)

y Chemo or Radio therapy

yEthanol or Smoking

y Medication

y Medical history (DM, HTN)

y Previous investigations


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Male Infertility

Physical

yAnatomy (meatus)

y Testicular size

y Varicocele (valsalva)

y Rectal exam (protatitis, discharge)


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Male Infertility

Investigations:

y semen analysis

Abstain 2-4 days prior

At least 2 samples over different period of

time

y If abnormal:

Blood work: FSH, LH, TSH, testosterone, PRL

Testicular U/S

Chromosomal analysis


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Male Infertility

Semen analysis:

y WHO (1992)

Volume > 2.0 mL

Sperm > 20 million/mL

Motility > 50% forward progression or

> 25% rapid progression within

60 min

Morphology > 30% normal forms

WBC < 1 million/mL


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Female Infertility

Fecundability: probability of achieving apregnancy within 1 menstrual cycle (25%)

Fecundity: ability to achieve a live birth within 1menstrual cycle (6%)


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Female Infertility

Production

Storage

Delivery


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Female Fertility

Production:

y Hypothalamus

y Pituitary

y Ovary


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Hypothalamic-Pituitary-Gonadal Axis


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Female Infertility

Hypothalamus:y Stress

y Exercise

y Eating disorders

y Psychogenic

y Congenital/genetic: Kallmans syndrome (hyposmia &

hypoplasia olfactory lobes of brain)

y Starvation/stress or severe illness

y Tumors (craniopharyngioma, metastatic tumor)

y Head injury

y Inflammation (sarcoidosis)

y Infection (tuberculosis)

y XRT

y Drugs


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Female Infertility

Pituitary:y Sheehan syndrome

y Tumors: Pituitary adenoma, metastatic

y Empty sella syndromey Inappropriate gonadal steroid feedback:

estrogen excess: obesity/ tumors

estrogen deficiency: aromatase deficiency/ ER genemutation

androgen excess: adrenal or ovarian PCOS

y Testicular feminization (46 XY) - absenceandrogen receptors


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Female Infertility

Ovary

y Gonadal dysgenesis - Turners Syndrome

45XO or mosaics 46 XX/45 XO

y Testicular feminization

y XRT / Chemo for childhood malignancies

y Premature ovarian failure


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Female Infertility

Storage (R.P.L. unless severe)

y Uterine abnormalities

y Mullerian Agenesis: Mayer-Rokitansky-

Kuster-Hauser syndrome

yAshermans syndrome

y Leiomyoma

yLuteal phase deficiency


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Female Infertility

Delivery:

y Uterine abnormalities

y Vaginal septum

y Tubal Disease

Infections/ STD/PID

Ruptured appendix

Septic abortiony Endometriosis


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Female Infertility

History:yAge

y GTPAL

y Regulatory of periody Prolactin S/S

y Thyroid S/S

y Infections, Surgeries

y Medication, Smoking, Ethanol

y Medical history

y Previous investigations


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Female Infertility

Examination:

y Thyroid

y Breast (milk)

yAbdomen (masses, scars)

y Vaginal (abnormalities)

y Bimanual (Uterus, masses)


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Investigations Blood work:y TSH

y PRL

y D3 FSH

y D3 LH

y Luteal phase Progesterone

Imaging:y

Pelvic Ultrasoundy HSG

Diagnostic

y Laparoscopy (later)


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Treatment

Treat the underlying cause

Medical

Surgical


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TreatmentAnovulation:y Clomiphene induction s IUI

y Gonadotropin s IUI

IVFy Bilateral tubal disease

y Unexplained infertility after Gonadotropin + IUI

failure.

y Failure of the above

ICSI

y Male factor

y

Unexplained infertility


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Take Home Points

DDx Hx Px Inv - Rx

Age is important factor for female

Hypothalamic-Pituitary-Gonadal axiscentral in working up both male and

female infertility

Investigations:

y Male: Sperms

y Female: Tubes (HSG) + Ovaries (FSH, LH,

PRL, TSH)


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Thank you

5 - Infertility

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