Infertility

Inability to conceive after 1 yr unprotected intercourse 6 months if the women is older than 35, Inability to carry a pregnancy to live birth, Involuntary ability to conceive when desired

Couples that have never conceived a child

Couples that have conceived before but are unable to conceive again

1/8 of couple have trouble getting pregnant or maintaining a pregnancy, 20% of infertile couples have no identified problems and yet still are not able to conceive (even with infertility treatments), A normal fertile couple in their mid 20s that is having regular intercouse with no contraception has a 1 in 5-6 chance of conceiving each month, 1/3 of infertility is a female factor, 1/3 is a male factor, 1/3 is both or unknown

Delayed childbearing is increasing the incidence of infertility, New infertility methods are offering more options to infertile couples. Some couples that prev. would not have sought out care are doing so since there are more options available, Women without a male partner may seek out infertility services to conceive

Intracytoplasmic sperm injection

Preimplantation genetic diagnosis

Ave. # of sperm/ ejaculations is 400 million Normal conception requires approx. 20 million/ml with normal motility per ml, Sperm count and infertility severity:, Mild: 15-20 million/ml, or 35-50% motility, Moderate: 5-10 million/ml, or 20-35% motility, Severe: <5million/ml or <20% motility

The far left is what sperm should look like all the others are abnormal shapes that impact motility

Abnormal hormone levels, Illness, mumps, cirrhosis, renal failure, Infections of the genital tract, Anatomic abnormalities, varicocele, Exposure to toxins, lead, pesticides, chemicals, Chemotherapy, radiation for CA, Ecessive ETOH use, marijuana, cocaince, Elev. scrtoal temp, febrile illness, saunas, hot tubs, Autoimmune response by the male upon himself or by the women

15% of men have, Think varicose vein in the testes, Most do not impair testicular functions, 40% of men with infertility problems have varicoceles, Impaired sperm production via elevated testicular temperature, 40-70% with varicocele repair have improved semen quality

Reduces the man’s ability to deposit sperm in the woman’s upper vagina, Caused by:, CNS dysfunctions; drugs, psychiatric disturbance, or chronic illness, Surgery to thee spinal cord, Peripheral vascular disease; diabetes, Anithypertensive drugs

Preevent deposit of sperm at the base of the cervix, Problems:, Retrograde ejaculation: backward release of semen into the bladder, Hpospadias, urethral opening on underside, Excessive ETOH intake or illicit drug use

Hypospadias urethral opening on underside of penis, Epispadias urethral opening on upper side of penis

Seminal fluid nourishes, protects, and carries sperm into the vagina, Normally semen coagulates immediately after ejaculation but liquefies within 30 min facilitating forward movement of sperm., Infertility: semen remains thick and raps the sperm.

Semen analysis (Usually the 1st and easiest test performed) -Structure -Volume -Motility, Endocrine tests -Testosterone levels, Ultrasound genitalia, Testicular biopsy

Women receive entire lifetime supply of ova (eggs) prior to birth, After birth - gradual process of decreasing numbers -Birth 700 million eggs -300,000 at puberty -Few thousand in late 30s, Vulnerable to cumulative toxic effects -Chemo, abused drugs, excessive ETOH, cigarette smoking

A balance between: 1. Hpothalamus 2. Pituitary 3. Ovaries, Hypothalamus -Secretes gonadotropin-releasing hormone (GnRH), GnRH -Stimulates the pituitary, Pituitary releases -Folical-stimulating hormone (FSH) and luteinizing hormone (LH), Hypothalamus > GnRH > Pituitary > FSH & LH

FSH: -*stimulates maturation of several follicles* in the ovary -as follicles mature, the ovary secretes *ESTROGEN to THICKEN THE ENDOMETRIUM*, LH - 24-36 hrs prior to ovulation LH increases -*Stimulates final maturation and release of ovum*, Corupus Luteum: -The collapsed follicale from which the ovum was released -Produces *progesterone and estrogen* which further prepares the endometrium for implantation

Ok thanks!

Secretes GnRH which stimulates the pituitary gland

Release FSH and LH FSH: stimulates ovary which causes maturation of follicles LH: Stimulates ovary and final maturation and release of the ovum

As follicle matures estrogen is released (which thickens the endometrium)

The collapsed follicle from which the ovum was released which produces Progesterone & estrogen (prepares endometrium for implantation)

Ovulation disorders (oligoovulation {low}, anovulation {no}), Abnormal levels of: GnRH, FSH, LH, estrogen, and progesterone, Majority of women who fail to ovulate have pituitary gland which is functional & plenty of eggs, Common finding is lack of FSH to keep follicles developing to maturity, TX: common starting drug is Clomig (clomiphen citrate) -Classified as an anti-estrogen — blocks the effects of estrogen -Pituitary perceives only low levels of estrogen and secretes more FSH & LH which induce ovulation

Reproductive tract infections, chlamydia, GC = tubal obstruction, Endometrious = tubal obstruction, Scaring from PID, surgery, peritonitis = tubal obstruction, Ovarian cysts = tubal obstruction, Congenital anomalies = tubal obstruction, At least one tube is required for natural conception, Parital fallopian tube obstruction may result in ectopic pregnancy

Cervical or endometrial abnormalities -Malformation, previous surgery, scarring, Endometriosis, Age - Age 30 has 20% chance of getting pregnant each month age 40 has 5%, Lifestyle factors -Stress, smoking, ETOH, certain drugs -Obesity, anorexia, Anatomic abnormalities

Unicornuate- uterus having a single horn and only 1 fallopian tube, Single uterus with a midline septum, Bicornuate- uterus have two horns with and indentation at the top, Double uterus with one vagina, Double uterus and vagina

Just look at the picture

Ovaries are enlarged with multiple small cysts, Mestrual irregularities, TX Clomid, May have amenorrhea, irregular periods, or heavy bleeding, Impaired fertility R/T lack of regular ovulation, Higher risk for miscarriage, cause is unknown, Hair and Skin problems (acne) -excessive testosterone production, Greater risk for developing DM, Obesity, Heart disease

MOST COMMON CAUSE: abnormalities in the fetal chromosomes - SAB 1st trimester - chromosomal analysis frequently order on fetuses delivered 2nd or 3rd trimester, Abnormalities of the cervix or uterus:, -Stenosis/ congenital malformations of cervix or uterus, -DES (Diethylstilbestrol)- exposure often causes uterine malformations or incompetent cervix, vaginal carcinoma (a medication given in 1940s-60s to prevent SAB), -Damage from surgery or trauma from previous birth, -Incompetent cervis: painless, premature dilation = cerclage to keep closed, -Uterine myomas (benign tumors of uterine muscle) and adhesions alter perfusion to the developing fetus or cause preterm labor

Basal body temperature (BBT), -Identifies probable time of ovulation, -Failure rate as a contraceptive 25%, -Contraception: avoid intercourse from the onset of menstrual period through the 2nd day of elevated temperature

Is the lowest or resting temp of the body (first thing in the morning), 1st half of menstrual cycle BBT is lower than in the 2nd half, BBT drops just slightly before ovulation!, BBT remains high if conception occurs and falls 2-4 days b4 menstruation, Special BBT thermometer, rage is smaller (96-100) each degree is divided into 10ths, Temp rise is very slight about 0.4 to 0.8 F

Illness, Restless or inadequate sleep, Waking later than usual, Traveling across time zones, Electric blanket, Heated water bed, Activity before taking temp, ETOH intake evening before

Still 14 days from 1st day of last menstrual period LMP

Cervical mucus changes just prior to ovulation, Spinnbarkheit: how much the mucus can be stretched between fingers or slid/cover slip, Just before and after ovulations mucus is scan, thick, sticky, and opaque, stretches <6cm, Prior and for 2-3 days fire ovulation, mucus in thin, slippery, and clear, like egg white, stretches 6+cm, Influencing factors: antihistamines, vaginal infection, contraceptive foams, sexual arousal, semen, Clomid

Bromocriptine (Parlodel) -Corrects excess prolactin scretion by the anterior pituitary - Increases ovulation & stimulates progesterone secretion by the corpus leteum, Clomiphene citrate (Clomid) -Causes ovulation, increases GnRH secretion from the hypothalamus, thus increasing FSH & LH, Slidenafil (Viagra), Cialis -Increases blood flow to the penis, improving erectility

Chorionic gonadotropin (hCG, personal) -Stimulates ovulation in the female or sperm formation in the male, stimulates production of progesterone by corpus luteum, Leuprolide (Lupron) -Reduces endometriosis, Nafarelin (Synarel) -Reduces endometriosis

Best results achieved when insemination is coupled with ovulation stimulating drugs, Procedure:, - Druge TX to encourage ovulation/ follicle growth, Hormone levels are closely monitored, Ultrasound to evaluate follicles (goal is 2-3), Semen sample is obtained and washed -Semen usually obtained from male partner but may artificial insemination by donor (AID), Semen is inserted through the cervis and placed in the uterus

Bypasses blocked or absent fallopian tubes, Ova is removed by laparoscope or ultrasound guided transvaginal retrieval, Sperm from partner/ donor is mixed with ova, Approx 2 days later, 2-5 embryos are returned to the uterus, Give progesterone to promote implantation, Excess embryos may be frozen, Issues of concern: success rate, multiple conceptions, may require selective reduction

Just look at the picture

Requires 1 functioning fallopian tube, Retrieve multiple ova similar to IVF, Obtain sperm, Ova are drawn into a catheter along with prepared sperm, Inserted into fallopian tube through a laparoscope, in which fertilization may occur, Give woman progesterone

Involves the deliberate use of oocytes (eggs) provided by a donor for in vitro fertilization, Donors may be either unknow or known, Usually young women who are paid to donate, Recipients -Women with diminished ovarian reserve -AMA -Used to avoid transmitting a genetic illness, Ethical issues

Involves the deliberate use of sperm provided by a donor for conception, Donors may be either unknow or known, Usually young men who are paid for donation, Recipients -Men with inadequate or abnormal sperm -Used to avoid transmitting a genetic illness -No male partner, lesbian, single female parent, Ethical issues