Infertility: Inability to achieve pregnancy after 12 months of unprotected and frequent intercourse. Primary Infertility vs.

. Secondary Infertility Subfertility vs. Sterility Fecundity: is the probability of achieving a live birth in 1 menstrual cycle. Fecundability is expressed as the likelihood of conception per month of exposure.

Abnormal spermatogenesis Endocrine disorders Hypothalamic dysfunction (Kallmann's Chromosomal abnormalities syndrome) Mumps orchitis Pituitary failure (tumor, radiation, Cryptorchidism surgery) Chemical or radiation exposure Hyperprolactinemia (drug, tumor) Abnormal motility Exogenous androgens Absent cilia (Kartagener's Thyroid disorders syndrome) Adrenal hyperplasia Varicocele Anatomic disorders Congenital absence of vas deferens Antibody formation Obstruction of vas deferens Sexual dysfunction Congenital abnormalities of Retrograde ejaculation ejaculatory system

Impotence Decreased libido

Central defects Chronic hyperandrogenemic anovulation Hyperprolactinemia (drug, tumor, empty selia) Hypothalamic insufficiency Pituitary insufficiency (trauma, tumor, congenital)

Peripheral defects Gonadal dysgenesis Premature ovarian failure Ovarian tumor Ovarian resistance Metabolic disease Thyroid disease Liver disease Renal disease Obesity Androgen excess, adrenal or neoplastic

Pelvic Factor Infection Appendicitis Pelvic inflammatory disease Uterine adhesions (Asherman's syndrome) Endometriosis Structural abnormalities Diethylstilbestrol (DES) exposure Failure of normal fusion of the reproductive tract Myoma

Cervical Factor Congenital DES exposure Mllerian duct abnormality Acquired Surgical treatment Infection

Congenital abnormalities Undescended testes Prior paternity Frequency of intercourse Exposure to toxins Previous surgery Previous infections (mumps), treatment Drugs and medications General health (diet, exercise, review of systems) Decreased frequency of shaving Excessive heat exposure (spermicidal)

Size of testicles Testicular descent Varicocele Outflow abnormalities (hypospadias,etc)

In utero diethylstilbestrol (DES) exposure History of pubertal development Present menstrual cycle characteristics (length, duration, molimina) Contraceptive history Prior pregnancies, outcomes Previous surgeries, especially pelvic Prior infection History of abnormal Papanicolau (Pap) smear, treatment Drugs and medications General health (diet, weight stability, exercise patterns, review of systems)

Pelvic masses Uterosacral nodularity Abdominopelvic tenderness Uterine enlargement Thyroid exam Uterine mobility Cervical abnormalities

Sperm count/motility
> 20 million sperm/ml Check motility and morphology x >50% motile x >30% structurally normal

If low check LH and androgen levels Testicular biopsy

Sperm Count

For ovulation
Basal body temperature Ovulation kit (LH surge) Other hormone tests (steroids)

Post ovulatory block

Laparoscopy-fiber optic look Hysterosalpingogram-dye Post-coital /cervical mucous and sperm Sperm antibodies Endometrial biopsy

Sperm good for 2-3 days, egg for 2

Can find adhesions, structural abnormality, etc

Hysterosalpingogram

Blocked tubes

Hypogonadotrophism
hMG GnRH CC, hCG results poor

Varicocoele
Ligation? (no definitive data yet)

Retrograde ejaculation
Ephedrine, imipramine AIH with recovered sperm

Drug treatment for ovulation block Intrauterine insemination Tubal surgery

IVF-in vitro fert and embryo transfer GIFT-gamete intrafallopian tube transfer ZIFT-zygote intrafallopian tube transfer Intracytoplasmic sperm injection

Basic Steps in IVF Ovary stimulation Egg retrieval Sperm retrieval-wash sperm Fertilization Embryo transfer Progesterone

Drugs used for ovary stimulation

Clomiphene (clomid)-anti-estrogen hMG (pergonal)-menopausal gonadotropin (FSH and LH) FSH-(metrodin) GnRH GnRH agonists (lupron)-FSH/LH first promoted, then inhibited hCG-acts like LH In a single cycle, could take clomid, pergonal, hCG shot, then progesterone

IVF Success Rates Stage Women Cycle initiation Ovulation Oocyte retrieval Fertilization Embryo Transfer Pregnancy Birth Number of 100 95 90 85 70 24 18

GIFT

If fertilization needs help-transfer zygote ZIFT

ICSI