Compre - Infertility

• Infertility


  Reduced capacity to conceive compared with the mean capacity of the general population
• Infertility


  • Considered a disease
  • Affects approximately 7% of all U.S. couples of reproductive age-more than 7 million women in the United States
• Systematic evaluation of infertility

  1. Rapid evaluation of factors involved

  2. Evaluation of markers of ovarian reserve (antral follicle count, antimüllerian hormone)

  3. Helps frame discussion with couples on treatment
• Prognosis for fertility after tubal reconstruction

  • Depends on amount of damage to tube and location of obstruction
  • Mild proximal tube abnormalities may be treated with selective catheterization/cannulation under fluoroscopy
  • Large hydrosalpinges (distal disease) best treated by salpingectomy and in vitro fertilization (IVF)
• Treatment for unexplained infertility

  1. Use of controlled ovarian stimulation (COS) and intrauterine insemination (IUI) with clomiphene/IUI or gonadotropins/IUI

  2. Yields monthly fecundity rates of approximately 8% to 10%

  3. At least doubles the baseline rate

  4. Should be the initial treatment for unexplained infertility

  5. Use of gonadotropins does not offer major advantage over clomiphene and carries more risks in terms of hyperstimulation and multiple pregnancies
• Treatment progression for unexplained infertility

  1. After 3-6 cycles of COS/IUI, IVF should be offered as next step

  2. IVF should be primary therapy in women around age 40
• Fecundability


  Monthly ability to get pregnant
• In a group of normally fertile couples, the monthly fecundability is approximately 20% (0.02)
• Fecundability can be as high as 25% for the first 3 months of trying to conceive, but then decreases after that for the following months going forward
• Definition of infertility


  Inability of a couple to conceive after 1 year of trying
• In women older than 35 years, the timeline for infertility investigation should be after 6 months of trying
• Early investigation is also warranted if: oligomenorrhea or amenorrhea; known tubal obstruction, uterine disease, or severe endometriosis; or known male factor infertility
• The World Health Organization (WHO) has defined infertility as a disease and a significant cause of disability
• Approximately 6% to 7% of all reproductive-age women (15 to 44 years) in the United States are considered to be infertile
• The number of women in this age group who have ever used infertility services has been estimated to be 12% or 7.3 million women in the United States
• The percentage of infertile couples increases with increasing age of the female partner
• Infertility rates by female partner age

  • 1 in 7 couples if wife is 30-34
  • 1 in 5 couples if she is 35-40
  • 1 in 4 couples if she is 40-44
• Compared to women aged 20-24, fertility is reduced by 6% in the next 5 years, by 14% between ages 30-34, by 31% between ages 35-39, and to a much greater extent after age 40
• The most common diagnostic category among women undergoing IVF in the US is diminished ovarian reserve: 17% of cycles
• Causes of infertility


  • Ovulatory disorders (27%)
  • Male factor (25%)
  • Tubal disorders (22%)
  • Endometriosis (5%)
  • Other (4%)
  • Unexplained (17%)
• With current techniques, it is not possible to diagnose the cause of infertility in up to 20% of couples, who are considered to have unexplained infertility
• After a rigorous investigation, other reports have suggested the figure for unexplained infertility to be as low as 10%
• Most couples with unexplained infertility are subfertile rather than infertile, and some are able to conceive without treatment, although it may take several years
• The cumulative live conception rate among 873 infertile couples in several Canadian centers was 38.2% at 3 years and 45% after 7 years without treatment
• Among the total group with unexplained infertility who received no treatment, one-third had a live birth during the first 3 years of observation without treatment
• Diagnostic evaluation of infertility

  1. Thorough and completed rapidly

  2. Couple informed about normal human fecundity and how probabilities decrease with age and duration of infertility

  3. Various tests and therapies explained

  4. Cause cannot be determined in large group of couples
• For many couples, reduced fecundability can be suggested to be age related
• Optimal timing of intercourse for conception

  1. Intercourse on the day before ovulation

  2. If husband has normal sperm, daily intercourse for 3 consecutive days at midcycle

  3. When ovulation precisely determined, intercourse for 2 consecutive days around LH surge
• Pregnancy rate is approximately 30% if intercourse occurs on the day of ovulation, as well as 1 and 2 days before ovulation
• Pregnancy rate is approximately 10% if intercourse occurs 3, 4, or 5 days before ovulation
• No pregnancies occur when intercourse takes place 6 days or more before ovulation
• Luteinizing hormone (LH) measurement


  • Best way to determine optimal time for intercourse or insemination
  • Peak LH occurs 1 day before ovulation
  • Ovulation most commonly occurs on the day after detection of LH in a random urine specimen
• Basal body temperature (BBT) charts are not as precise for determining ovulation, with ovulation occurring over a span of several days of the thermogenic shift
• In some cases, women produce less than adequate amounts of vaginal lubricant
• LH peak


  Occurs 24-36 hours after the LH surge is detected in the first morning urine specimen
• LH kits


  • Several types are available
  • Women who find it difficult to determine a hormone change using one type can try another system or kit
  • Kits may vary in sensitivity and can give false positive tests due to conditions like PCOS
• Basal body temperature (BBT) charts


  Not as precise for determining ovulation, which occurs over a span of several days
• Fertility apps and bracelet

  Provide information on a 5-day fertile window
• Vaginal lubricants and chemicals

  May interfere with sperm transport
• Midcycle impotence


  Due to the pressure of performing intercourse on demand