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Male and FemaleMale and Female
InfertilityInfertility
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GoalsGoals
Enhance comfort level with workupEnhance comfort level with workup
Basic Management StrategiesBasic Management Strategies
TRICARETRICARECoverageCoveragehttp://www.rotundaivf.com/http://www.rotundaivf.com/
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DefinitionDefinition
12 months of unprotected intercourse12 months of unprotected intercourse
Earlier for certain historical factorsEarlier for certain historical factors
Older than 35Older than 35
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Infertility EtiologyInfertility Etiology
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Female FactorsFemale Factors
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Male FactorsMale Factors
General CausesGeneral Causes
Unknown: 40Unknown: 40--50%50%
11 HypogonadismHypogonadism: 30: 30--
40%40%
Altered SpermAltered SpermTransport: 10Transport: 10--20%20%
22 HypogonadismHypogonadism: 1: 1--2%2%
MedsMeds
11 or2or2
HypogonadismHypogonadism
Common medicationsCommon medications
KetoconazoleKetoconazole
CimetidineCimetidine SpironolactoneSpironolactone
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The ScenarioThe Scenario
Tech: Husband and wife cant getTech: Husband and wife cant get
pregnant.pregnant.
You: OB rotation was last infertility workupYou: OB rotation was last infertility workup
What now?What now?
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WorkupWorkup
History is KEYHistory is KEY
Focused Physical ExamFocused Physical Exam
Labs and Specialized TestsLabs and Specialized Tests
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Workup: HistoryWorkup: History
Coital PracticesCoital Practices
Gestational HistoryGestational History
PMHx/PSHxPMHx/PSHx
MedsMeds
Menstrual HistoryMenstrual History
SubstancesSubstances
Recent High FeverRecent High Fever
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Workup: Physical ExamWorkup: Physical Exam
MaleMale
InfectionInfection
HerniaHernia Vas deferensVas deferens
Androgen deficiencyAndrogen deficiency
Testicular massTesticular mass
VaricoceleVaricocele
FemaleFemale
Breast FormationBreast Formation
GalactorrheaGalactorrhea
GenitaliaGenitalia
HyperandrogenismHyperandrogenism??
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WHO Seminal FluidWHO Seminal Fluid
Analysis (1999)Analysis (1999) Volume: >2mlVolume: >2ml
Sperm concentration: >20 million/mlSperm concentration: >20 million/ml
Total Sperm Number: >40 million/ejaculateTotal Sperm Number: >40 million/ejaculate Sperm Motility:Sperm Motility:
>50% motile and/or>50% motile and/or
>25% progressively motile>25% progressively motile Sperm Morphology: >14% normal formsSperm Morphology: >14% normal forms
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Workup: Special TestsWorkup: Special Tests
FemaleFemale
TransvaginalTransvaginal
UltrasonographyUltrasonography
(TVUS)(TVUS)
HysterosalpingographyHysterosalpingography
(HSG)(HSG)
HysteroscopyHysteroscopy
LaparoscopyLaparoscopy
MaleMale
ScrotalScrotal
UltrasonographyUltrasonography
TransrectalTransrectal
UltrasonographyUltrasonography(TRUS)(TRUS)
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Our Couple: Exam,Our Couple: Exam,
Labs &T
estsLabs &T
ests Normal male examNormal male exam
Normal initial labsNormal initial labs
Oligospermia on 2 separate semenOligospermia on 2 separate semen
analysesanalyses
TRUS and postejaculatoryUA normalTRUS and postejaculatoryUA normal
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Management: GeneralManagement: General
ConceptsConcepts 41 different methods41 different methods
Fertile window intercourseFertile window intercourse
EE--type vaginal dischargetype vaginal discharge
Avoid lubricants and douchesAvoid lubricants and douches
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Management: FemaleManagement: Female
Treat underlying causeTreat underlying cause
HyperprolactinemiaHyperprolactinemia
PCOSPCOS
GonadotropinGonadotropin therapytherapy
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Management: FemaleManagement: Female
OvulatoryOvulatory dysfunction (Unknown etiology)dysfunction (Unknown etiology)
ClomipheneClomiphene 50mg PO daily x 5 days50mg PO daily x 5 days
Start on days 3Start on days 3--55 Can increase to 100mg daily next cycleCan increase to 100mg daily next cycle
ResultsResults
80% will ovulate80% will ovulate
HyperstimulationHyperstimulation and Twinningand Twinning
HigherHigher--order multiples rareorder multiples rare
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Management: FemaleManagement: Female
Clomiphene Failure?Clomiphene Failure?
IVFIVF
Injectable ovulationInjectable ovulation--inducing agentsinducing agents
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Management: FemaleManagement: Female
Tubal/Pelvic/Uterine IssuesTubal/Pelvic/Uterine Issues
Reparative Surgery (low success)Reparative Surgery (low success)
IVFIVF
EndometriosisEndometriosis
Laparoscopic ablationLaparoscopic ablation
LaparotomyLaparotomy
Ovulation induction +/Ovulation induction +/-- IUI and IVFIUI and IVF
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Management: MaleManagement: Male
HyperprolactinemiaHyperprolactinemia
Surgical repairSurgical repair
Fertility SpecialistFertility Specialist
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Stress and InfertilityStress and Infertility
69% Women and 21% Men have69% Women and 21% Men have
preexisting conditionpreexisting condition
Greater risk for psychological stressGreater risk for psychological stress
No significant difference inNo significant difference inpsychopathologypsychopathology
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Stress and InfertilityStress and Infertility
Men have increased stress over time,Men have increased stress over time,
same as womensame as women
Watch for normal grief vs. psychopathologyWatch for normal grief vs. psychopathology
Same rates of depression as other chronicSame rates of depression as other chronicdiseasedisease
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Stress and InfertilityStress and Infertility
BottomBottom lineline: Not a means to improve: Not a means to improve
pregnancy rates.pregnancy rates.
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Management: Our CoupleManagement: Our Couple
Male:Male: ImipramineImipramine Mar 08Mar 08
Pregnant inPregnant inhttp://www.rotundaivf.com/http://www.rotundaivf.com/
June 2008!June 2008!
Separated from USAF in July2008Separated from USAF in July2008
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Questions?Questions?