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APGO educational topic number 48
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infertility infertility affects 15% of
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reproductive age couples in the United
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States there are medical psychosocial
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financial and ethical considerations
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that are all issues pertaining to the
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discussion of infertility this video
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will discuss infertility from the
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standpoint of a heterosexual couple and
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it is important to recognize that
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fertility treatments offer the
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opportunity for Parenthood too many
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non-heterosexual individuals and couples
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the objectives of this video are to
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define infertility and list the causes
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of male and female infertility describe
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the evaluation and initial management of
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an infertile couple describe the
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psychosocial issues associated with
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infertility describe management options
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for infertility describe ethical issues
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confronted by patients with infertility
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and lastly describe the impact of
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genetic screening and testing on
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infertility associated treatments let’s
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start with some basic definitions
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infertility is defined as the failure of
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a couple to conceive after 12 months of
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frequent unprotected intercourse for con
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nobility is the probability of achieving
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a pregnancy in one menstrual cycle it is
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estimated to be 20 to 25 percent in
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healthy young couples after 12 months of
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unprotected intercourse eighty-five
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percent of couples will achieve
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pregnancy what are the possible causes
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of infertility let’s start with the
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basics there needs to be production of a
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good lewisite and production of a good
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sperm the oocyte and sperm need to meet
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to generate an embryo and this embryo
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needs to make it to the uterine cavity
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and successfully implant into the
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endometrium what are the potential
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causes that negatively affect this
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process male factors account for 20%
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female factors account for 65% and there
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are unexplained or other conditions in
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15% let’s start with male factors the
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male needs to produce a good sperm thus
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the evaluation of male infertility
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involves a semen analysis it is obtained
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by masturbation after two to three days
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of abstinence a semen analysis evaluates
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the volume sperm concentration motility
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rapid progression motility and normal
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morphology if the results are abnormal
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then the semen analysis should be
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repeated and a
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assistant Li abnormal the malefactor
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should be evaluated by urologist or
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reproductive endocrinologist who
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specializes in male infertility let’s
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now move to female factors first there
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needs to be production of a good Oh a
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site a good history can often help you
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determine if a woman is ovulating each
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month a history of regular predictable
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menses suggests of the Tori cycles
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remember that after ovulation there is
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an increase in progesterone and this can
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cause symptoms such as abdominal
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bloating weight gain and breast
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tenderness in the luteal phase of the
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cycle in addition the progesterone
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causes a slight increase in body
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temperature so women can monitor their
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ovulation by checking their daily
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temperature which is known as basal body
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temperature charting alternatively women
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can purchase ovulation predictor kits
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which assess ovulation based on the
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increased LH production which can be
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detected in urine
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these ovulation predictor kits can be
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quite expensive however in order to
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achieve pregnancy a woman has to ovulate
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and she has to ovulate a quality OA site
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common causes of ovulatory dysfunction
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and reproductive age women include
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polycystic ovarian syndrome or PCOS
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thyroid disorders and hyperprolactinemia
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a woman’s age also has a significant
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impact on ovulation and OSI quality as a
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woman ages
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unfortunately sodor sites remember that
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a female has at 20 weeks in utero about
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6 to 7 million oay sites and she is born
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with about 1 million u.s. i’ts she has
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about 400,000 at the time of puberty and
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there is a more rapid depletion starting
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at around age 38 thus there is a marked
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reduction of fecund ability in a woman’s
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late 30s let’s now talk about what
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happens after ovulation here’s the ovary
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and the OA site which gets picked up by
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the fallopian tube and fertilization
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occurs in the ampulla a portion of the
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fallopian tube the embryo will then
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enter the endometrial cavity
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approximately 5 days after fertilization
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this process can be impaired if there is
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damage to the fallopian tube by prior
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pelvic inflammatory disease or abdominal
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or pelvic surgeries a history or cell
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pentagram evaluates the fallopian tube
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patency for this procedure contrast
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is injected into the uterine cavity note
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the dark contrast filling the
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triangular-shaped uterine cavity if the
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fallopian tubes are paitent then the dye
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will travel through both of the tubes
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this HSG demonstrates normal fallopian
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tubes for the dye travels all the way
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through both of them uterine anomalies
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are surprisingly uncommon causes of
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infertility if there is a history such
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as abnormal bleeding pregnancy loss
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preterm delivery or previous uterine
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surgery then assessment of the uterus is
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important let’s now talk about
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management options we have to go back to
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our basic causes of infertility male
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factors female factors and unexplained
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or other conditions in order to
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optimally try to achieve pregnancy we
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need to think about how best to correct
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any or all of these factors ovarian
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stimulation these agents will stimulate
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and effectively improve ovulation
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clomiphene citrate is a selective
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estrogen receptor modulators
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which competes for estrogen receptors at
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the level of the hypothalamus and
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pituitary this leads to increase granada
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trope and release from the pituitary
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which stimulates increased follicular
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development from the ovaries there is an
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approximate 10% risk of multiple
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gestation with clomiphene citrate
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similarly controlled ovarian
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hyperstimulation with purified human
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gonadotropin stimulates the ovary to
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increase follicular development there is
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a 25% incidence of multiple gestation
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with purified gonadotropins with
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intrauterine insemination ejaculated
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semen is washed to remove prostaglandins
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bacteria and proteins and suspended in a
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small amount of medium a catheter is
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advanced through the cervix into the
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uterine cavity let’s now move to
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assisted reproductive technologies in
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the United States in vitro fertilization
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or IVF accounts for 99% of all AR T
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procedures the IVF process involves
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ovarian stimulation to produce multiple
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follicles then there will be retrieval
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of the oocytes from the ovaries lewisite
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fertilization and embryo incubation will
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occur in the laboratory and then there
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will be transfer of embryo or embryos
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into the woman’s uterus through the
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cervix there is an approximate 30
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percent risk of multiple gestation with
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IVF and this will of course depend on
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the number of embryos that are implanted
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into the uterus the indications for IVF
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include blocked or absent fallopian
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tubes a history
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of tubal sterilization severe pelvic
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adhesions severe endometriosis pour-over
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and response to stimulation severe male
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factor infertility and failed treatment
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with less aggressive therapies the
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success rates for IVF will depend on the
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etiology of the infertility
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pre-implantation genetic diagnosis is
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the genetic profiling of embryos prior
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to implantation for example if a patient
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knows that she or her partner is a
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carrier for a disease such as cystic
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fibrosis or ty Sachs disease and the
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embryo can be tested for this prior to
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implantation there are risks to the
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embryo during the biopsy procedure which
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points to the ethical questions of fetal
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selection what if a patient desires to
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have pre-implantation genetic diagnosis
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performed because they do not want a
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certain gender child the discussion of
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infertility and assisted reproductive
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technologies should also include the
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discussion of ethical issues that are
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confronted both by patients and
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providers with infertility therapy
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should insurance companies be required
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to pay for IVF should there be an age
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limit for which IVF should not be
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offered there is always the question and
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costs of higher order multiple births
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what about egg banking young women can
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be recruited to donate eggs and through
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this process some argue that women are
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not counseled adequately about the risks
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of ovarian hyperstimulation syndrome and
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can and should a physician legally and
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ethically decline ovulation induction
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for patients with diminished ovarian
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reserve when chances of successful
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pregnancy or futile these questions are
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complex and many factors including
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social class gender race healthcare
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utilization and access need to be
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considered in weighing these complicated
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decisions let’s conclude by discussing
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psychosocial stress associated with
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infertility the amount of social support
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that a patient receives can have
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significant effects on stress levels
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compared to white and Asian women black
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women were less likely to report
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encouragement for treatment from their
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partners and family members it is
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important to recognize that the
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psychological stress exists and to
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determine the patient’s support network
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and help our patients find resources to
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help them through this process this
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concludes the aapko video on infertility
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we have described evaluation at initial
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management of an infertile couple and
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described the ethical and psychosocial
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issues associated with this common
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condition