Transcript OBgyn Week - CatsTCMNotes

OBgyn Week
Contraception, Infertility
Contraception
• Prevention of pregnancy
• Requires prevention of fertilization and/or
implantation
• Many different methods in these general
categories:
• prevent ovulation (hormonal methods)
• prevent sperm from meeting ovum (barrier methods,
female and male sterilization, spermicide, calendar)
• prevent implantation (IUD, hormonal methods)
Preg and Contracep stats
• In 2002, about 50% of the 6.4 million
pregnancies in the US were unintended
• About 18% of these pregnancies ended in
elected abortion (1.4 million)
• About 65% of these pregnancies ended in
live birth (4.14 million)
• Any sexually active fertile woman can
become pregnant
CONTRACEPTION
•
Contraceptive use in US women - 2002
– Oral contraceptives 19%
– Sterilization
• Female – 17%
• Male – 6%
– Male condom 11%
– Progestin injection 3.3%
– Withdrawal 2.5%
– IUD 1.3%%
– Periodic abstinence 0.9%%
– Implant, Lunelle, or Patch 0.8%%
– Diaphragm 0.2%%
• Not using contraception – 38%
Contraceptive Methods
• How to choose? The best option will be:
– Medically appropriate
– Used every time
– A method patient is happy with
TYPES OF CONTRACEPTION
CURRENTLY AVAILABLE
• Periodic abstinence
• Spermicides
• Barrier techniques
– Diaphragm
– Cervical cap
– Male condom
– Female condom
TYPES OF CONTRACEPTION
CURRENTLY AVAILABLE
• Hormonal contraceptives – oral, patch, ring
• Long acting hormonal contraceptive
– Injectable
– Implants
• Intrauterine devices
• Sterilization
– Tubal ligation
– Vasectomy
• Emergency contraception
Contraceptive Effectiveness
and Cost Issues
• Effectiveness rates are usually reported in the
following ways
– Typical use effectiveness (TER)
– Perfect use effectiveness (PER)
– Failure rates
• The most effective techniques provide the
greatest total cost savings
– Top 5 total savings – Copper-T IUD, vasectomy,
implant, injectable, OCPs
– Cheapest – barrier methods – condoms,
diaphragm, cervical cap, sponge, spermicides
Contraceptive Methods Periodic Abstinence
• Avoidance of sexual intercourse during fertile window
• Must avoid intercourse on all calculated fertile days
• Four techniques commonly utilized
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Calendar rhythm method
Temperature method
Cervical mucus method
Symptothermal method
CALENDAR RHYTHM METHOD
• Woman records length of cycle over several months
• Establishes fertile period by subtracting 18 days from
shortest cycle, and 11 days from longest cycle
• Couple avoids coitus during this fertile period
• Cannot be used by women with irregular menses
• Perfect use effectiveness rate 91%
• Typical use effectiveness rate 75%
TEMPERATURE AND
CERVICAL MUCUS METHODS
• Rely on measurement of either BBT or change in
cervical mucus to identify ovulation
• Coitus is avoided from onset of menses until third day
of elevated temperature in temp method
• Coitus is avoided during menses, then every other
day until ovulatory mucus is detected, then daily until
4 days after ovulatory mucus is gone
• Requires highly motivated couples and training in
techniques
• PER 97%
• TER 75%
SYMPTOTHERMAL
METHOD
• Relies on several indices to identify fertile period
– Calendar calculations and cervical mucus to establish onset
of fertile period
– Cervical mucus or BBT to estimate end of fertile period
– Coitus avoided during fertile period
– Requires significant training and motivated couples
– PER 98%
– TER 75%
PERIODIC ABSTINENCE
• Overall, typical use effectiveness rate is 75%
• Major objection of users is need to avoid
intercourse for many days each month
• Combined with barrier methods during fertile
periods may increase effectiveness rates and
decrease discontinuation rates
PERIODIC ABSTINENCE
• Home ovulation predictor kits that test
urine for hormone metabolites are now
becoming available
– Test must be done 12 days each month
– Can reduce the number of days of
abstinence required to a maximum of 7
BARRIER METHODS
• Diaphragm
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Circular spring with latex rubber coating
Covers the cervix, preventing sperm from entering os
Must be fit by HCP
Woman must demonstrate ability to insert and remove
correctly during fitting
Spermicide should be used with diaphragm
Diaphragm left in place 8 hours after intercourse
Remove device within 24 hours of insertion
UTI’s higher in users vs non-users
PER 94% - TER 84%
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
BARRIER METHODS
• Cervical cap – FemCap, Lea’s Shield
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Cup shaped plastic or rubber cap
Fits around the cervix
Must be fitted by HCP
Woman must demonstrate ability to insert and remove during fitting
Can only be used by those with normal PAP
Repeat PAP 3 months after starting use of cap
Can remain in place for up to 48 hours
Spermicide recommended
No increase in UTI’s
PER parous 74% nullip 91%
TER parous 68% nullip 84%
BARRIER METHODS
• Male condom
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Latex or animal intestine sheaths that cover penis
Captures semen to prevent deposition into vagina
Must be applied tightly
Tip should extend half an inch beyond end of penis
Care must be taken to prevent spillage after ejaculation
Most effective method to prevent STD transmission (latex)
PER 98%
TER 85%
BARRIER METHODS
• Female condom
– Polyurethane vaginal pouches
– Soft, loose-fitting with two rings, one internal, one
external
– Prevents deposition of semen in vagina
– Less likely to rupture than condom
– PER 95%
– TER 79%
• Noise and distraction are major obstacles
BARRIER METHODS
• Sponge
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Made of urethane foam
Contains spermicide
Moistened with H2O, inserted into vagina
PER 91%
TER 84%
Advantages
• Can put in hours ahead of time
• Can leave in for up to 30 hours
– Disadvantages
• May be irritating or messy
BARRIER METHODS
• Barrier methods are most effective
contraceptive method to reduce
transmission of STD’s
• Contraceptive effectiveness increased
with concurrent use of spermicide
SPERMICIDE
• Made up of spermicidal chemical, either nonoxynol-9
or octoxynol combined with a base of cream, jelly,
foam, foaming tablet, film, or suppository
• No evidence of teratogenicity in several studies
• Toxic to lactobacillus
• Increased colonization with E. coli seen, may result in
bacteriuria after intercourse
• PER 82% TER 71%
ORAL CONTRACEPTIVES
• 1960 marked initial year of use in US
• Quickly became the most widely used method
of reversible contraception
• Mechanism
– Synthetic progesterone (progestin) inhibits
ovulation and thickens cervical mucus
– Synthetic estrogen maintains endometrium,
prevents abnormal bleeding, and inhibits follicular
development
OC’s
• Three major types
– Monophasic combination (fixed dose)
• Estrogen/progestin in same doses X 3 weeks
• Estrogen/progestin in same dose for 84 days
• Most widely used and most effective
– Biphasic or multiphasic combination
• Estrogen/progestin in varying doses X 3 weeks
• Lower total Est dose for possible lower SEs
– Progestin only
• Progestin same dose every day all month
• Must be taken every day, at same time (within 3 hrs)
OC’s
• All made from synthetic estrogens and/or
progestins
– Ethinyl estradiol (EE) most common estrogen
• First generation OCP’s contain > 50ug
estrogen
– Due to SE’s, these are no longer marketed in US
• Second generation OCP’s contain 20-35 ug
estrogen and older progestins
• Third generation OCP’s contain newer
progestins
– desogestrel, norgestimate, gestodene,
drospirenone, norethindrone
OC’s
• Failure of combination OC’s occurs
primarily when pill free interval is
extended
• Most important pill to take is the first
one of each cycle
• PER combined 99.9%
• PER progestin only 99.5%
• Overall TER 97%
OC’s
• Progestin only OC – AKA “mini-pill”
– Estrogen effects not seen
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Thromboembolism
Nausea
Breast tenderness
HTN
No effect on lactation
– Disadvantages
• Abnormal bleeding
• Amenorrhea
• Slightly less effective than COC’s
SIDE EFFECTS OF OC’s
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SE’s from estrogen component
– Nausea
– Breast tenderness
– Headache
– Fluid retention
– Decreased B-complex vitamins, vitamin C, and increased vit A
– Melasma
– Breakthrough bleeding
– Possibly mood changes/depression
– Thrombosis
– Increases in some coagulation factors and angiotensinogen
– HTN
– Neoplastic effects
• Small increase in current and recent users- -probable small
promoting effect with breast cancer
• Cervical cancer – may be cocarcinogen
• Protective effect on endometrial and ovarian cancer
SIDE EFFECTS OF OC’s
• SE’s from progestin components
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Weight gain
Acne
Mood changes
Amenorrhea
Increased insulin, decreased glucose tolerance
Increased LDL, decreased TC, HDL, TG’s
Headache
Breast tenderness
CONTRAINDICATIONS TO OC’s
• Absolute contraindications
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Hx vascular disease
Hx SLE, DM with nephropathy or retinopathy
Cigarette smoking > 35 yrs of age
Uncontrolled HTN
Breast or endometrial CA
Pregnancy
Functional heart disease
Active liver disease
CONTRAINDICATIONS TO OC’s
• Relative contraindications
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Heavy cigarette smoking under 35 years of age
Migraine headaches
Undiagnosed amenorrhea
Prolactin secreting macroadenoma
• Prior to prescribing, screen for diabetes,
lipids, liver disease if patient has personal or
family history
OCs
– Protect against:
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Ovarian cancer
Uterine cancer
Follicular ovarian cysts
PID from STI (thickened cervical mucus)
– May increase risk for:
• Breast cancer
• Heart disease
– Deplete levels of (need supplementation:
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Folic acid
B 12
B6 (pyridoxine)
B2 (riboflavin)
Vitamin C
Zinc
FOLLOW-UP
• Monitor for side effects
• Follow-up in 3 months
– Hx, BP
• If patient on medications, check for
interactions
• If no SE’s and BP OK, see patient
annually
The Patch
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Ortho Evra
Synthetic Estrogen and progestin
Patch changed weekly X 3 weeks
PER >99%
TER 92%
Simple, convenient
Same contraindications, disadvantages and
possible SE’s as OC’s
The Ring
• NuvaRing
• Synthetic estrogen and progestin on plastic ring
– Ethylene vinyl acetate
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Inserted into vagina, left X 3 weeks
PER >99%
TER 92%
Simple, convenient
Same contraindications, disadvantages and possible
SEs as OCs
POTENTIAL BENEFITS OF
HORMONAL CONTRACEPTIVES
• Reduced endometrial and ovarian cancer
• Reduced menorrhagia, intermenstrual, and
irregular menses
• Reduced benign breast disease
• Reduced PMS and dysmenorrhea
• Reduced PID
• Reduced bone loss
LONG ACTING
CONTRACEPTIVE STEROIDS
• Injectable
– Two types
• Monthly (Lunelle), q 3 months (Depo-Provera)
– PER 97.7% TER 97.7%
– Adverse effects
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Amenorrhea or irregular menses
Weight gain
Headache
Mood changes
Increased LDL, decreased HDL
– Potential benefits
• Decreased endometrial cancer
LONG ACTING
CONTRACEPTIVE STEROIDS
• Subdermal implants
– Levonorgestrel in a silastic capsule, implanted under the
dermis
– PER 97.7% TER 97.7%
• NORPLANT NO LONGER AVAILABLE, BUT SOME
WOMEN STILL HAVE THEM IN THEIR SKIN
• Implanon approved by FDA July 2006
• Adverse effects
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Irregular bleeding
Infection or local irritation
Headache
Weight gain
Acne
Mastalgia
Mood changes
INTRAUTERINE DEVICES
• Devices implanted into uterus
• Creates inflammatory reaction and acts as
spermicide, may also prevent implantation
• Two primary types
– ParaGard (Copper T-380A)
• PER 99.4% TER 99.2%
• Good for 12 years
– Mirena (Levonorgestrel)
• PER 99.9% TER 99.9%
• Good for 5 years
IUD’s
• Advantages
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Highly effective and cost-effective
Convenient, no compliance or perfect use issues
Long lasting, easily reversible
Minimally invasive
Safe during lactation
• Disadvantages
– Must be inserted and removed by health care
provider
– Does not protect against STDs
IUD’s
• Adverse effects
– Menorrhagia or intermenstrual bleeding
• Usually diminishes with time
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Expulsion of device - occasional
Perforation of uterus - rare
Complications related to pregnancy - rare
Infection - rare
Does not protest against STD’s
IUD’s
• Contraindications
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Pregnancy
Acute or hx PID
Postpartum endometritis
Known or suspected uterine or cervical malignancy
Genital bleeding of unknown origin
IUD previously inserted and still in place
Vaginitis, cervicitis, STD, TB (current)
Allergy to copper or Wilson’s dz (ParaGard)
Liver disease (Mirena)
STERILIZATION
• Most common method of non-hormonal contraception used
by couples in US
• Female
– No-Incision Method (Essure) – metallic coils placed into
fallopian tubes via vagina, cx, uterus
– Tubal ligation – Tubes ligated via mini-laparotomy or
laparotomy
– PER 99.6% TER 99.6%
– Slight surgical risk with ligation
– Coils can be expelled or perforate rarely
semi non-surgical – go in through vagina/cervix/uterus
– Reversal procedure 75% successful
• Risk of ectopic pregnancy
• expensive
STERILIZATION
• Male – vasectomy
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Require local anesthesia and office setting
Excision of portion of vas deferens
PER 99.9% TER 99.9%
Sperm still present for up to 3 weeks
Slight surgical risk, no reduction in sexual
performance
– Reversal procedure 50% successful, expensive
EMERGENCY
CONTRACEPTION
• Emergency contraception pills
– Combined E/P
• Preven
• Regular OCP’s (certain brands only)
• Reduces risk of pregnancy 75%
– Progestin only
• Plan B
• Reduces risk of pregnancy 89%
• Take first dose within 72 hours, second dose 12 hours
later
• Stops ovulation, fertilization, or implantation
– May cause nausea and vomiting
– Don’t use if pregnant
EMERGENCY
CONTRACEPTION
• Emergency IUD insertion
– ParaGard (Copper T 380A)
– Inserted within 5 days
– Can be left in for up to 12 years, or
removed after next menses
– Not recommended for women at HR of
STD, including rape victims
– Reduces risk of pregnancy 99.9%
EMERGENCY
CONTRACEPTION
• Where to get EC
– Available OTC to those >18 yo
– EC hotline - 1-888-NOT-2-LATE
– Planned Parenthood
• 1-800-230-PLAN
INDUCED ABORTION
• One of the most common gynecologic
procedures performed in the US and many
other countries
• 90% performed in the first trimester
• Two primary methods
• Vacuum aspiration methods
– Manual vacuum aspiration
– Dilation and suction curetttage (D&C)
• Medication methods
– Mifepristone (RU 486) or methotrexate followed
by misoprostol
INDUCED ABORTION
• Vacuum aspiration abortion
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Procedures take about 10 minutes
May have cramps and clots for 10 days
May bleed for up to 2 weeks
>99% effective
• Medication abortion
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Entire process may take from 1-2 weeks
May bleed for up to 4 weeks
May have cramps, N&V, diarrhea
90-97% effective
INDUCED ABORTION
• Safety issues
– Risk of death from abortion: 0.7 per
100,000 abortions
– Risk of death from pregnancy: 7-8 per
100,000 live births
– Performed in outpatient clinics, general
anesthesia not required
INDUCED ABORTION
• Risks
• Allergic reactions
• Infection
• Incomplete abortion
• Bleeding
• Injured organ – vacuum aspiration only
Key Concepts
• Major categories of contraception are:
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Periodic abstinence
Barrier methods
Oral contraceptives
Long acting contraceptive steroids
IUD’s
Emergency contraception
Sterilization
• Which are most effective?
• What are some pros/cons of each?
• Which help prevent STD transmission?
Infertility
• Defined as the reduced capacity to conceive
as compared with the mean capacity of the
general population
• Inability of couples of reproductive age to
establish a pregnancy by having unprotected
sexual intercourse within a certain period of
time (usu. 1 year)
– Primary: woman has never been pregnant
– Secondary: infertility after one or more
pregnancies
Infertility
• Fecundability (monthly conception rate) in
normal, fertile females is about 20%
– Half of the couples who try to conceive do so
within the first 3 months
– Three fourths will conceive within 6 months
– 90% will conceive within 1 year
• Two categories of infertility:
– Hypofertile – couples have low fecundability
• Woman with mild endometriosis
• Male with low sperm count (oligospermia)
– Sterile – couples who are never able to conceive
without therapy
• Woman with complete occlusion of Fallopian tubes
Infertility and Age
• Fertility decreases with age
– Failure to conceive within 1 year steadily
increases from ages 25-44
– About 1 in 7 couples are infertile if the
woman is 30-34 years
– 1 in 5 if woman is between 35-40 years old
– 1 in 4 if woman is between 40-44
– Monthly ovulation decreases greatly after
age 45
Causes of Infertility
– 10-15% annovulation
– 10-15% abnormal sperm-mucus penetration
– 30-40% abnormalities in the male repro tract
• Oligozoospermia, high semen viscosity, low motility of
sperm, low semen volume
– 30-40% pelvic factors
• Tubal occlusion
• Endometriosis adhesions
– Idiopathic or unexplained infertility
• Tend to be hypofertile and eventually able to conceive
without treatment
Anovulation
• Anovulation may be due to:
– Physiologic (pregnancy, postpartum, menopause)
– Extreme exercise
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Low body fat
Too much stimulation of breasts may elevate prolactin
– Psychogenic
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Acute physical or emotional stress
Traveling, lifestyle changes
Chronic stress
Anorexia nervosa (amenorrhea a likely early symptom)
Anovulation
• May be due to hormone imbalance
– Decreased progesterone production (or problem
with progesterone receptors)
– Estrogen deficiency
– Hyperprolactinemia (endocrine tumors, breast
feeding, hypothyroidism)
– Insufficient function of hypothalamus/ pituitary
– Ovarian insufficiency (cysts, tumors, insulin
resistance, autoimmune)
Annovulation/
Hormone Imbalance
• Systemic diseases:
– Hypothyroidism (elevated TSH associated
with elevated prolactin)
– Adrenal abnormalities (Cushings, Addisons:
heavy irregular menses; adrenal
insufficiency/ burnout)
– Diabetes, Anemia
– Malnutrition
Infertility
General Counseling
• Timing
– Best chance for conception the day prior to
ovulation
– Sperm has ability to fertilize 5-7 days
– Ova viable for only about 24 hrs.
– Daily intercourse for 3 consecutive days
midcycle
Infertility
General Counseling
• Stop smoking
– Lowers sperm count, higher proportion of
malformed sperm
– Worse response to fertility treatment
– Lengthens time to conceive
– Women who smoke are twice as likely to be
infertile
Infertility
General Counseling
• Avoid coffee
– Coffee drinking during pregnancy is
associated w >2x inc risk of miscarriage
– Risk of not conceiving for 12 months is:
55% higher for women drinking 1 cup/ day
100% higher for 1.5-3 cups/day
176% higher for 3 or more cups/ day
Infertility
General Counseling
• Avoid alcohol
• Alcohol consumption by the woman 1 week
prior to IVF treatment reduces success nearly
3 times
• Alcohol consumption by the man the month
before IVF reduces success rate 2.5 times; 8
times if the week prior
• Alcohol consumption by either partner the
week prior to conception associated with
increased risk of miscarriage
Infertility
General Counseling
• Avoid marijuana
– Males: decreases sperm count
– Lowers testosterone
• Males: avoid increase in pelvic temperature:
– Hot tubs, laptop on lap for extended periods
• Sperm motility may be decreased by keeping
cell phone in front pocket
• Avoid pesticide and chemical exposure
• Manage stress well
Infertility
General Counseling
– Avoid douches
– Avoid use of saliva or petroleum-based
lubricants
– Even some water-based lubricants may
interfere with sperm motility and integrity
• FemGlide, Replens, and Astroglide (laboratory
study)
• KY had lowest negative effect on sperm
Infertility
and Body Weight
• Small amounts of weight loss (5-10%)
may dramatically improve ovulation and
pregnancy rates in overweight women
(BMI> 25)
• Sperm counts lower in both over- (21%)
and underweight (28%) men
Diagnostic Evaluation:
• Documentation of ovulation
– Regular menstrual cycles
– Serum progesterone level in midluteal phase
(should be above 10ng/ml to indicate adequate
luteal function)
– BBT
• Semen analysis: volume, viscosity, sperm
density, sperm morphology, sperm motility
– Male partner should abstain from ejaculation 2-3
days prior to specimen collection
– Analysis should be performed as soon as possible
after the liquefaction of semen
(Semen Analysis)
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Volume: >2.0ml
Concentration: >20 million/ml
Total Cells: >40 million
Motility: ~50%
Normal Forms: >14%
White & red blood cell counts
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
If abnormally high, antibiotics may be recommended
• Semen Viscosity
• Coagulated sperm should liquefy within an hour
• Sperm Agglutination
• Sperm that "clump together” - indicates autoimmune
response or presence of infection
Infertility Workup
• CBC, UA, cervical cytology (PAP)
• If over 35 years old, serum FSH, estradiol on
day 2, 3, or 4 of cycle
– If FSH >24 mlU/ml, ova unable to be artificially
fertilized
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CA-125 serum levels
Serum prolactin
Pelvic ultrasound
Thyroid panel - esp if cycles irregular
Antibodies to Chlamydia
– High correlation between Ab titer and tubal
adhesions/ obstruction
Infertility other possible factors
• Women may have an occult (asymptomatic)
infection of upper genital tract
• Women may produce antibodies to sperm
that may immobilize them or cause them to
agglutinate
– These antibodies have been found in both fertile
and infertile women
– Not a established cause of infertility
Infertility Workup
Hysterosalpingogram if tubal adhesions/
blockage suspected
• Performed during the week following menses
• Involves a steady beam of X-rays to visualize
uterus and Fallopian tubes while a contrast
media is applied through cervical os
Diagnostic laparoscopy if suspect endometriosis
• Usually performed after several rounds of
ovarian hyperstimulation and intrauterine
insemination
Infertility Prognosis
• Better in cases due to:
– Anovulation
– Uterine adhesions
• Lower in cases due to:
– Sperm abnormalities
– Tubal disease
Infertility Management
• Annovulation
– Agents to induce ovulation
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Clomiphene citrate/ Clomid (synthetic estrogen), hMG,
FSH, GnRH
Bromocriptine if due to hyperprolactinemia
Corticosteroids if due to excess adrenal androgens
• Intrauterine adhesions
– Hysteroscopic lysis
– Good prognosis if no other contributing factors
Infertility Mgmt
• Leiomyoma
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May physically distort the endocervix and interfere with
normal sperm transport or if submucous could interfere
with implantation
Myomectomy justified in cases where they are of
moderate size and position and no other factor that
contributes to infertility
• Infection causing cervicitis
– High levels of WBC kill off sperm as they enter os
– Cervical mucus may be to acidic for sperm
– Appropriate antibiotic or antimicrobial agent
Infertility Mgmt
• Tubal problems
– Scarring from PID is leading cause of female
infertility
– Scarring may also be from prior surgery (e.g.
ectopic pregnancy) or congenital tube defects
• Management of tubal problems:
– Selective salpingography and tubal cannulation
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Done in cases of proximal tubal obstruction
Purpose is to “open” tubes– achieve tubal patency
– Surgical tubal reconstruction
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Prognosis depends on amount of damage to tubes
If damage extensive, greater chances of conceiving with
IVF than with tubal reconstructive surgery
Infertility Mgmt
• Endometriosis: up to 40% of infertile women
have endometriosis
– Blood from endometrial tissue irritates tubes,
producing scarring, adhesions, or cysts
– May cause hypertrophy of uterine lining, interfering
with implantation
• Mild cases: 65% of women can conceive
without treatment (if no other contrib factor)
• Moderate to severe cases: only 0-25% can
conceive
Infertility Mgmt
• Endometriosis
– Surgical treatment in absence of tubal adhesions
or endometrioma (mild endometriosis) does not
result in improved fertility rates
– Medical treatment of mild endometriosis has not
been shown to improve fertility rates (vs. no
treatment)
– Surgical treatment of moderate (over 1cm size
endometrioma) endometriosis slightly improves
fertility rates
– Surgical treatment of severe endometriosis
improves fertility rates
Infertility Mgmt
• Unexplained infertility
– Controlled ovarian hyperstimulation (usu.
via Clomid)
– Intrauterine insemination (IUI)
– Initial treatment consists of 4-6 cycles
– Pregnancy rates with this method decrease
dramatically after age 40
IVF
• In Vitro Fertilization
– Ovarian hyperstimulation to harvest as many ova
as possible
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Success rate proportional to number of implanted
embryos
– Ova are retrieved via follicle aspiration
– Oocytes cultured and incubated in a rigidly
controlled, sterile environment
– A few hours post retrieval, sperm separated from
semen are added to culture medium
IVF continued
– 18 hours later oocytes are observed to determine if
fertilization has occurred
– Those that have been fertilized are cultured for 4896 hours
– Embryos are placed via catheter through cervical
canal
– Rate of pregnancy following IVF is directly related
to number of implanted embryos
– After six failed cycles of IVF, chances of pregnancy
very low
Infertility
• Unexplained infertility
• May be due to environmental pollutants or
exposure to other toxic chemicals
– Heavy metal burden (lead, mercury, cadmium, etc.)
– Chelation therapy
– The couple must REFRAIN from actively trying to
conceive during ANY form of chelation / cleanse
• Endocrine disruptors:
– exogenous estrogens, pesticides, chemical solvents
• Electromagnetic radiation
Infertility
Other Helpful Modalities
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Energy work
Counseling
Spinal manipulations
Mayan uterine/abdominal massage
…