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Infertility definition (3)

Inability to conceive after 1 yr of trying (regular sexual intercourse without birth control)

Or 6months if the woman is 35yrs old or older

Women who are able to conceive but unable to maintain pregnancy may also be infertile

Secondary infertility

Couples have conceived a child before but are unable to conceive again

Normal fertility stats

Normal fertile couple in mid 20s having regular intercourse have a 1/5-6 chance of conceiving each month with no contraception

Rates re: infertility causes (5)

Male factors 35%
Tuboperitoneal 35%
Ovulatory 15%
Unexplained 10%
Other-unusual 5%

Couples may have multiple causes

Normal Semen Analysis (10)

Best specimen after 2-3 days of abstinence
By masturbation to avoid loss of ejaculate- must bring to lab within 1hr
If Test abnormal- repeat in a month or so

Volume >2ml
pH 7-8
Sperm concentration > 20 million/ml
Liquefaction 30minutes
60% or > forward motility progression
30% or > wnl forms
White Cells <1million/ml

Male Factors that impair the # and motility of sperm (5)

Abnormal hormonal levels for sperm production

Illness, mumps, cirrhosis, renal failure

Infections of the genital tract

Anatomic abnormalities, varicocele, obstructed ducts that carry sperm in penis

*Sperm resides and matures for 70-90 days before ejaculation

More factors that impair # and motility of sperm (5)

Exposure to toxins, lead, pesticides, chemicals

Chemotherapy, Radiation for CA

Excessive alcohol use, marijuana, cocaine

Elevated scrotal temperature, febrile illness, saunas, hot tubs, excessive exercise

Autoimmune response by the male upon himself or by the woman causing damage to the sperm

Varicocele (4)

A varicocele is a widening of the veins along the cord that holds up a man's testicles. Swelling

Most do not impair testicular function

Impaired sperm production via elevated testicular temperature

Repair may have improvement in semen quality

Abnormal Erection & causes (5)

Reduces the mans ability to deposit sperm in the womans upper vagina.

Caused by:
CNS dysfunction: drugs, psychiatric disturbance, or chronic illness

Surgery to the spinal cord

Peripheral Vascular Disease, Diabetes


Antihypertensive drugs

Abnormal Ejaculation & problems (3)

Prevents deposit of sperm at base of the cervix

Retrograde ejaculation: backward release of semen into the bladder

Hypospadias, urethral opening on the underside

Excessive alcohol intake or illicit drugs, smoking and use of anabolic steroids

Abnormal Seminal Fluid (2) & how it causes infertility

Seminal fluid nourishes, protects and carries sperm into the vagina until they enter the cervix

Normally semen coagulates immediately after ejaculation but liquefies within 30min facilitating forward movement of sperm

Semen remains thick and traps the sperm

Womens supply of ova (4)

Women receive their entire lifetime supply of ova prior to their birth and begin the steady process of losing them

at Birth- 7 million eggs

At Puberty: 300,000 eggs

Late 30s- a few thousand

Ova are vulnerable to cumulative toxic effects (4)


Abused Drugs

Excessive alcohol

Cigarette smoking

Normal ovulation (4)

-Communication between HYPOTHALAMUS, PITUITARY AND OVARY to release mature ovum

Hypothalamus secretes gonadotropin-releasing hormone (GnRH)
-GnRH stimulates pituitary to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

Hypothalamus > GnRH > Pituitary > FSH & LH

Normal Ovulations continued (4)


As follicles mature, ovary secretes ESTROGEN, TO THICKEN ENDOMETRIUM

24-36hrs prior to ovulation LH increases, which STIMULATES FINAL MATURATION AND RELEASE OF OVUM

The collapsed follicle from which the ovum was released, called the CORPUS LUTEUM, produces PROGESTERONE AND ESTROGEN which further prepares the endometrium for implantation

Anovulation/Oligovulation (3)

Abnormal hormonal levels: GnRH, FSH, LH, Estrogen, Progesterone

Majority of women who fail to ovulate (anovulation) have pituitary gland which is functional and plenty of eggs in their ovaries

Common finding is lack of FSH to keep follicles from developing to maturity

Ovulation occurs (2)

14 days BEFORE day 1 of menses (of the next cycle)

This fact is what makes birth control and conception a difficulty, can only predict ovulation in retrospect

Polycystic Ovary Syndrome (PCOS) (6)

Condition of unexplained hyperandrogenic chronic anovulations
accumulation of cysts on ovaries
Etiology unknown
Tx: symptom based and empirical

PCOS has substantial metabolic sequelae (abnormal condition
Risk of DM and cardiovascular disease

Clinical features of PCOS (6)

Menstrual irregularities =
-Impaired fertility r/t lack of regular ovulation
-Irregular periods and may have heavy bleeding
-May have amennorrhea

Higher risk for miscarriage and complications during pg-GDM & G-HTN

Hair and skin problems (acne)
-Testosterone production is excessive

Tx of ovulation Disorders:
Clomid, how does it work, dosage and how to take

Classified as an anti-estrogen, therefore blocks the effects of estrogen, so....

HYPOTHALAMUS- perceives only low levels of estrogen and secretes more GnRH WHICH STIMULATES THE PITUITARY TO INCREASE FSH & LH which induce ovulation of possible >1 ovum

PO- Start 50mg/day for 5 days on cycle days 3, 4 or 5. May increase to 250mg each day

Intercourse every other day for 1wk starting 5 days after last dose

Increased risk of twins by 10%

Fallopian Tube Problems (7)

Requires at least 1 tube for natural conception
Causes of Tubal Obstruction
-Reproductive tract infections (Chlamydia, Gonorrhea)
-Scarring from PID, surgery, peritonitis
-Ovarian cysts
-Congenital anomalies

Partial fallopian tube obstruction may result in ectopic pg

Other factors for woman infertility (6)

Anatomic Abnormalities
-Malformation, previous surgery, scarring


-Age 30 has 20% chance of getting pg, Age 40 has 5%)

Lifestyle Factors
-Stress, smoking, ETOH, certain drugs
-Obesity, anorexia
-Athletic Training

Female infertility tests (8)

Ovulation Prediction
-BBT, cervical mucous, serum progesterone levels

US pelvic organs- also sonohysterography

Postcoital test
-evaluates cervical mucous and sperm function

Endocrine tests
-FSH, LH, estrogen, progesterone, prolactin, TSH

Hysterosalpingography (HSG)
-use contrast medium to determine patency of fallopian tubes

Endometrial biopsy



Patient teaching BBT (Basal Body temperature) (7)

BBT may drop just slightly before ovulation*

Best time to conceive 48hrs before ovulation*
BBT remains higher if conception occurs
BBT falls 2-4 days before mestruation

No longer recommended, doesnt help achieve pg, just stresses out the mom
Have to use a special BBT thermometer, range is smaller 96-100, each degree is divided into 10ths
BBT is the lowest or resting temp of the body, probably the influence of progesterone

BBT influencing factors (8)


Restless or inadequate sleep

Waking later than usual

Traveling across time zone

Electric blanket

Heated water bed

Activity before taking Temp

ETOH intake evening prior

Cervical Mucus reflects

womans hormonal status

Spinnbarheit: Cervical mucous

how much the mucus can be stretch between fingers or slide/cover slip

Cervical mucus before and after ovulation (2)

Mucus is scant, thick, sticky and opaque

Stretches <6cm

Cervicul mucus prior and for 2-3 days after ovulation (3)

Mucus is thin, slippery and clear, like egg white

Stretches 6+ cm

Best time to conceive

Influencing factors on cervical mucus (6)


Vaginal Infection

Contraceptive foams

Sexual arousal



Ovulation kits (2)

90% accurate, best method

OTC 20$ a month

Intrauterine Insemination (IUI) (8)

Best results are achieved when insemination is coupled with ovulation stimulating drugs

-Drug tx to encourage ovulation/follicle growth
-Hormone levels are closely monitored
-US to evaluate follicles (goal is 2-3)
-Semen sample is obtained and washed
---Semen is usually obtained from male parner (THI) but may be therapeutic donor insemination (TDI)
-Semen is inserted through the cervix and placed high in the uterus (washed & concentrated)

Used to be called artificial insemination

In Vitro Fertilization (IVF), why used it and what is done before implant (3)

Bypasses blocked or absent fallopian tubes, mucus abnormalities, male infertility, unexplained infertility, immunologic infertility and cervical factors

Ova is removed by laparoscope or US guided transvaginal retrieval

Sperm from partner/donor is mixed with ova ( can retrieve sperm surgically from the testes (TESA) or the epididymis (MESA)

IVF continued (2)

About 2 days later, 2-5 embryos are returned to the uterus, 12-24 hrs rest for the mom and Rx progesterone supplementation

Unused embryos may be frozen

IVF issues of concern (4)

Success rate
Multiple conceptions
Higher complication rates for mom during pg, and for children
Couple may be asked to decide on selective reduction

Gamete Intrafallopian Transfer (GIFT) (5)

Requires 1 functioning fallopian tube

Retrieve multiple ova similar to IVF

Obtain sperm

Ova are drawn into a catheter along with prepared sperm

Inserted into fallopian tube through a laparoscope, in which fertilization may occur (acceptable to Catholic Church)

ZIFT (2)

Zygote intra-fallopian transfer, also called TET tubal embryo transfer

Women must have a functional faloplian tube, done in 24 hrs of fertilization

Which fertilization technology is most widely used?

IVF = Still the most used technology
-Less expensive
-Success similar in comparison to other technologies

Oocyte Donation - what is it and who are the donors?

Oocytes provided by a donor for invitro fertilization

Donors may be known or unknown to the recipient

In the US usually are young women who are paid for hteir donation

Oocyte Donation - who are the recipients? (3)

-Women with diminished ovarian reserve
-Advanced maternal age
-Used to avoid transmitting genetic illnesses

Sperm Donation - what is it and who are the donors?

Sperm provided by a donor for conception

Donors may be known or unknown to recipient

Usually are young men who are paid for their donation

Sperm Donation - who are the recipients? (3)

-Men with inadequate or abnormal sperm
-Used to avoid transmitting a genetic illness
-No male partner, lesbian, or single female parent

How do you react to people with infertility?

Be a human. You cant fix everything. Listen to their concerns, dont change the subject. Dont tell them you know how they feel.

Be nice!

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