Transcript The Challenge of the Miracle of Life

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
 US ~ 15% couples
Incidence has remained stable over last
three decades


Primary Infertility ??
Secondary Infertility ??
Average Conception Rates
% of Couples
Length of time
20%
Conceive within
1 month
60%
Conceive within
6 months
75%
Conceive within
9 months
80%
Conceive within
12 months
90%
Conceive within
18 months
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%
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

Aging and female infertility
Age
20-25
Pregnancy
(1yr)
90
Miscarriage
Rate
9.7%
26-30
85
10%
31-35
75
11.5%
36-40
65
21.4%
>40
50
42.2%
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
So what’s so hard??
Parts is Parts
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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)
Male Factor Evaluation
Physical exam
Environmental/occupational exposures
 Semen analysis


> 20 million
Motility > 50%
Volume > 2mL
Morphology > 30% normal

Endocrine evaluation if warranted
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
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
Evidence of Ovulation
Basal body temperature
Serum progesterone (mid-luteal Day19-22)

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12 - 15 ng/mL considered evidence of ovulation

Ovulation predictor kits (LH surge)
 Ultrasound
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!

Female Factor Infertility - Uterine &
Tubal Factors
Fibroids
 Intrauterine adhesions (Asherman’s)
 Congenital malformations
 Tubal occlusion (PID most common)
 Endometrial abnormalities

Tubal Adhesions
Mullerian Anomalies
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)

Hysterosalpingogram
Radiopaque dye through the cervix
under x-ray watching dye fill uterus and
spill from tubes into peritoneal cavity

Ultrasonography
Non-invasive
3D contours of uterus and endometrium
as well as ovaries
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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.

Female Factor Infertility - Cervical
Factors
Structural abnormalities
Abnormal mucous production
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Evaluation should include post-coital test
Treatment includes intrauterine
insemination
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%)
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
Smoking and Male Fertility

Impaired sperm concentration, motility
& morphology
 Decreased libido
 Combined with caffeine consumption
increases number of non-viable sperm
Assisted Reproduction
IVF (in vitro fertilization)
GIFT (gamate intra-fallopian transfer)
ZIFT (zygote intra-fallopian transfer)
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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)

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