Infertility
multifactorial with mied etiologies
infertility- black and white definition
failure of a couple to conceive after 12 months of regular intercourse without use of contraception in women less than 35yo OR failure to conceive after 6 months of regular intercourse in women 35 years or older
fecundability
the probability of achieving pregnancy in one menstrual cycle; it is a more accurate descriptor because it recognizes varying degrees of infertility
etiology of infertility diff in each sex?
believed to be roughly equally divided between male and female causes- approx 1/3 of affected couples experience a combined problem
fecundability teaches that:
- the possibility of infertility may be suspected after only 6 mos of unprotected intercourse without conception
- decreases over time and with increasing age of the female partner
decrease in fecundability with aging likely d/t
decline in both the quantity and quality of the ooctyes
Absolutes: infertility occurs when there is a:
- azoospermia (no sperm cells in ejaculate)
- longstanding amenorrhea
- bilateral tubal obstruction
Not so absolutes: infertility occurs when
- reduced # of sperm compare to absolute absence (from testicular atrophy, could be the consequence of taking testosterone)
- oligomenorrhea with some ovulatory cycles
- partial tubale obstruction
- intermittent ovulation
biggest caveat aside from absolute when’s
an abnormal test result cannot be said to be the cause of infertility in all couple
when to start evaluating who
- initiate evaluation after 12 mos of unprotected frequent intercourse in women under 35 w/o risk factors
- initiate eval after 6 mos for women 35- 40
- initiate eval upon presentation despite less than 6 mos for women 40+ years, women with oligomenorrhea/ amenorrhea, women w/ h/o chemo, raditation, or advanced endometriosis, women w/ known or suspected uterine/ tubal dx, and women whose male partner has a h/o groin or testicular surgery, adult mumps, impotence or other sexual dysfunction, chemo/ radiation or h/o subfertility wi/ another partner
initial diagnostic eval should include:
complete h&p and PE, eval of both partners performed concurrently, same approach used in both primary and secondary infertility
primary infertility
when a woman has never had a successful birth of a child- potentially more ominous dx than secondary
secondary infertility
difficulty conceiving after any prior conception with a successful birth
infertility eval- what history to ask about (male)
duration of infertility, fertility in other relationships, medical and surgical hx, including testicular surgery and h/o mumps or adult chicken pox, meds, h/o chemo/ radiation, smoke cigs or weed, ETOH use, environmental/ occupational exposures, sexual dysfunction or impotence, frequency of sex, use of lubricants, previous infertility testing/ therapies, and family hx of birth defects, mental retardation or reproductive failure
infertility eval- what history to ask about (female)
duration, # and outcome of any prior pregnancies (including ectopic and miscarraiges) with the same or diff partner, any and all gyn hx, menstual hx, changes in hair growth/ body weight/ breast discharge, other medical and surgical hx, meds, h/o chemo/ radiation, smoke cigs or weed, ETOH use, environmental/ occupational exposures, exercise/ dietary hx, frequency of sex and use of lub, previous infertility testing/ therapies, family hx of birth defects, mental retardation or reproductive failure, and any pelvic/ abdominal pain or sx of thyroid dx
when do women have the highest chance of getting pregnant?
1- 2 days before ovulation or on the day of ovulation**
to get pregnant what has to happen
woman must have sex with a man around the time she ovulates (releases egg from the ovary), then the man’s sperm must swim up the vagina, into the uterus and up the fallopian tubes (they connect the ovaries to the uterus). when the sperm reaches the egg, at least one sperm must eat through the outer casing of the egg and make it inside AKA fertilize this is fertilization. then the egg must secure itself to the wall of the uterus which is called implantation
factors affecting fertility (age & weight)
maternal age (biological age more important than chronological age) generally women's fertility begins to decline at 34- risks after: gestational DM, preg- insuced HTN, premature labor, stillbirth and placenta problems body weight- extremes are associated with altered ovarian function
consider ovarian function
- ovulatory dysfunction in 15% of infertile couples and 40% of infertile women
- ovulatory dysfunction can result in mentrual disturbances (oligo/amenorrhea, dysfunctional uterine bleeding) or more subtle disturbances (polumenorrhea, short luteal phase)
- important to discover underlying cause (hyperandrogenism, pituitary tumor, eating disorders, extreme weight loss or exercise, hyperprolactinemia, obesity)
consider normal semen analysis parameters
- volume > 1.5 mL
- pH 7.2- 7.8
- count: 15 million per mL or greater
motility: 32% or greater - forward progression: greater than 2 (on a scale of 0 to 4, 0 being no movement, 4 being excellent)
- morphology: 30% or greater have normal oval heads, midpiece and tail
abnormal semen analysis requires
the test to be repeated in 4- 6 weeks; if time is not critical 3 mos should be allowed to complete a sperm cycle
if semen parameters are normal
no further male evaluation is necessary unless infertility persists
factors affecting infertility (smoking)
- shown to be reproductive toxin in men and women
- reduces fertility in women, increases rate of spontaneous abortion, and increases incidence of abruptio placentae, placenta previa, bleeding during pregnancy, and premature rupture of placental membranes
- women who smoke generally go through earlier menopause by 1- 5 years
- tobacco decreases sperm motility and density
factors affecting infertility (alcohol)
- ETOH- known human teratogen, embryotoxic
- any degree of etoh intake can decrease chances of conception
- shown to reduce ability to conceive in dose- dependent fashion
- 2+ drinks per day associated with spontaneous abortion
