Bunt - Male and Female Infertility USAFP 2009-v2 (PPTminimizer).ppt
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Transcript of Bunt - Male and Female Infertility USAFP 2009-v2 (PPTminimizer).ppt
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Male and Female
Infertility
Capt. Christopher W. Bunt, MDEhrling Bergquist Family Medicine Residency
Offutt AFB, NE
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Goals
Enhance comfort level with workup
Basic Management Strategies
TRICARE Coverage
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Demographics
80-168 million people worldwide
2.1 million couples in the US
9.3 million US women
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Definition
12 months of unprotected intercourse
Earlier for certain historical factors
Older than 35
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Infertility Etiology
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Female Factors
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Male Factors
General Causes
Unknown: 40-50%
1 Hypogonadism: 30-
40%
Altered SpermTransport: 10-20%
2 Hypogonadism: 1-2%
Meds
1 or 2
Hypogonadism
Common medications
Ketoconazole
Cimetidine Spironolactone
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The Scenario
Tech: Husband and wife cant get
pregnant.
You: OB rotation was last infertility workup
What now?A. Refer
B. Google
C. Use online EBM resources
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Online EBM Resources
www.aafp.org/afp
American Family Physician
March 2007: Jose-Miller, Boyden and Frey.
www.infopoems.com
Cochrane Systematic reviews
Original research
http://www.aafp.org/afphttp://www.infopoems.com/http://www.infopoems.com/http://www.aafp.org/afp -
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Workup
History is KEY
Focused Physical Exam
Labs and Specialized Tests
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Workup: History
Coital Practices
Gestational History
PMHx/PSHx
Meds
Menstrual History
Substances
Recent High Fever
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Our Couple: History
Female
G1 P0010
No hx of STIs
Normal menses
Unprotected sex for
15 months
Male
No previous partner
pregnancies
Gonorrhea hx
No meds
Occasional EtOH
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Workup: Physical Exam
Male
Infection
Hernia
Vas deferens
Androgen deficiency
Testicular mass
Varicocele
Female
Breast Formation
Galactorrhea
Genitalia
Hyperandrogenism?
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Workup: Labs
Female
Ovulation problems
Ovulatory Dysfunction
Ovarian Reserve
Male
CBC
FSH, Testosterone
GC/Chlam, UA
Renal and Liver
Function
Semen analysis
Postejaculatory
urinalysis
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WHO Seminal Fluid
Analysis (1999)
Volume: >2ml
Sperm concentration: >20 million/ml
Total Sperm Number: >40 million/ejaculate Sperm Motility:
>50% motile and/or
>25% progressively motile Sperm Morphology: >14% normal forms
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Workup: Special Tests
Female
Transvaginal
Ultrasonography
(TVUS)
Hysterosalpingography
(HSG)
Hysteroscopy
Laparoscopy
Male
Scrotal
Ultrasonography
Transrectal
Ultrasonography(TRUS)
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Our Couple: Exam,
Labs & Tests Normal male exam
Normal initial labs
Oligospermia on 2 separate semen
analyses
TRUS and postejaculatory UA normal
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Management: General
Concepts 41 different methods
Fertile window intercourse
E-type vaginal discharge
Avoid lubricants and douches
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Management: Female
Treat underlying cause
Hyperprolactinemia
PCOS
Gonadotropin therapy
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Management: Female
Ovulatory dysfunction (Unknown etiology)
Clomiphene 50mg PO daily x 5 days
Start on days 3-5
Can increase to 100mg daily next cycle
Results
80% will ovulate
Hyperstimulation and Twinning Higher-order multiples rare
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Management: Female
Clomiphene Failure?
IVF
Injectable ovulation-inducing agents
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Management: Female
Tubal/Pelvic/Uterine Issues
Reparative Surgery (low success)
IVF
Endometriosis
Laparoscopic ablation
Laparotomy
Ovulation induction +/- IUI and IVF
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Management: Male
Hyperprolactinemia
Surgical repair
Fertility Specialist
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Stress and Infertility
69% Women and 21% Men have
preexisting condition
Greater risk for psychological stress
No significant difference inpsychopathology
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Stress and Infertility
Men have increased stress over time,
same as women
Watch for normal grief vs. psychopathology
Same rates of depression as other chronicdisease
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Stress and Infertility
Bottom line: Not a means to improve
pregnancy rates.
Websites and Organizations:
American Society for Reproductive Medicine
www.asrm.org
American Fertility Association www.theafa.org
RESOLVE: The National Infertility Association
www.resolve.org
http://www.asrm.org/http://www.theafa.org/http://www.resolve.org/http://www.resolve.org/http://www.theafa.org/http://www.asrm.org/ -
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Management: Our Couple
Male: Imipramine Mar 08
Pregnant in June 2008!
Separated from USAF in July 2008
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TRICARE Coverage
Will cover diagnostic tests, workup and
treatment of physical conditions
Will cover some fertility drug prescriptions
May require pre-authorization
Will cover any pregnancy issues once
pregnant
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TRICARE Coverage
Exceptions
Artificial methods of reproduction:
Artificial insemination
IVF
Gamete intrafallopian transfer (GIFT)
ICSI
Reversal of prior surgical sterilization
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Military Infertility Specialists
All 3 Services have treatment centers
Many can be accessed throughPermissive TAD/TDYs or Leave
(Command-dependent)
Some are restricted to locally assigned
members only
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USA Options
Walter Reed (DC)
IVF, ICSI (Intracytoplasmic Sperm Injection),Assisted Hatching (AH)
Tripler (HI) IVF, IUI (Intra Uterine Insemination)
Womack (NC)
IVF, ICSI, IUI, AH, Frozen Embryo Transfer(FET)
Madigan (WA)
IVF, ICSI, AH, FET
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USN Options
San Diego
IVF, IUI, AH, ICSI
Portsmouth
IUI only
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USAF Options
Wilford Hall (TX)
IVF, ICSI, AH
Wright-Patterson (OH)
Locally stationed military only
IUI only
Keesler (MS)
IUI only
Hope to start IVF program soon
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Review
Comfort level
Demographics
Workup and Management
TRICARE options
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Questions?