Comprehensive Gynecology Chaptercauses of Infertility

CAUSES OF INFERTILITY
Ovulatory disorders   27 %
male factors                     25 %
tubal disorders               22 %
endometriosis                  5%
other                                    4 %
unexplained factors     17 % DIAGNOSTIC EVALUATION
For those with regular menses, a serum progesterone level should bemeasured in the midluteal phase
* an indirect evidence of ovulation and normal luteal function

Women with oligomenorrhea or amenorrhea who wish to conceive should be treated with agents that induce ovulation regardless of whether they have occasional ovulatory cycles

progesterone measurement -not necessary in pts w/ oligo or amenorrhea
SEMEN ANALYSIS                             
VOLUME                                           1.5-5ml
pH                                                         >7.2
VISCOSITY                                          <3 (scale 0-4)
SPERM CONCENTRATION      >20 million ml
TOTAL SPERM NUMBER         >40 million ejaculate
PERCENT MOTILITY                  >50 %
FORWARD PROGRESSION     >2 (scale0-4)
NORMAL MORPHOLOGY      >50 % normal,>30 % normal
>14 % normal
ROUND CELLS                              < 5millions ml
SPERM AGGLUTINATION        <(scale 0-3)

EVALUATION AND LAB TESTS
healthy, asymptomatic woman
* CBC, blood type,RH, rubella status, pap smear

infectious diseases screening during pap smear

Cystic fibrosis screening in all women

Screening for  Syphilis, hepa ,etc for all who will have IVF or artificial insemination
For  >35 years old, serum FSH and estradiol on Day 2 and 3
FSH > 15 mU/ml are abnormal, decreased ovarian reserve

--values over 20mU/ml are bad prognosis

E2 levels  >70pg/ml - suggest decreased prognosis regarding ovarian reserve

TSH and PRL measurement=usually normal, not cost effective
If there is abnormality in documentation of ovulation and semen analysis, treat the abnormality first prior to proceeding to costly and invasive procedures

HSG - done at  follicular phase of nxt cycle if there is no abnormality in prior tests
MANAGEMENT OF CAUSES OF INFERTILITY
ANOVULATION
Clomiphene citrate
aromatase inhibitors
Metformin
Thiadolazimediones
Gonadotropin
GnRH 
ovarian  elctrocautery should be reserved for those with difficulties with gonadotropin stimulation

Management of Male Cause of infertility
IUI on the day of or day 1 before ovulation, utilize urinary ELISA kits to determine optimal date

ICSI-ART of choice for all causes of male infertility and those with unknown cause of infertility  in whom IVF did not produce fertilization

UTERINE CAUSES OF INFERTILITY
INTRAUTERINE ADHESIONS- hysteroscopic lysis

LEIOMYOMA- myomectomy if it can interfere with sperm transport

TUBERCULOSIS- if Hysterosalpingogram reveals pelvic TB(calcified lymph nodes or granulomas,pipe stem configuration of the tube ,multiple strictures, irregular contour of the ampulla and deformity of endometrium in a patient w/o previous curettage), do endometrial biopsy and culture
if it is present in oviduct, not the uterus,it can still be pregnant
consider those w/ pelvic TB as sterile
TUBAL CAUSES OF INFERTILITY
DISTAL OBSTRUCTION IS MORE COMMON THAN PROXIMAL OBSTRUCTION

FOR LARGE HYDROSALPINGES,AND EXTENSIVE TUBAL DISEASE -DO  in vitro fertilization 
EXCISE Hydosalpinx before IVF  if it is large and visible in ULTRASOUND  

DISTAL TUBAL DISEASE
extent determined by HSG and laparoscopy
Laparoscopy-determines size pof hydrosalpinx, amt of muscularis and thickness of the wall of the oviduct

Hysterosalphingogram (HSG)- determines :
partial or complete obstruction
size of distal sacculations
appearance of mucosal folds and rugal pattern of endosalpinx
If there were fixed adhesions,absent rugal folds and a thick,fixed tubal wall-don't do distal reconstructive surgery

FIMBRIOPLASTY-relatively normal fimbriae,partial occlusion by adhesions or fimbrial bridges

salpingolysis-adhesiolysis of the peritubal adhesion with normal distal ostium

laparoscopic salpingostomy-procedure of choice vs. laparotomy  because of less morbidity, length of hospital stay and cost

microsurgery increases chance of ectopic pregnancy

PROXIMAL TUBE BLOCKADECauses: residual damage after infection or endometriosis

SUSPECT IF during HSG, no dye reaches the oviduct
Confirm w/ laparoscopy under GA
also it allows examination of the distal portion of the oviductIf pregnancy does not w/in 6 to 12 months after tubal reconstruction , do another HSG

PROXIMAL TUBE BLOCKADE
MICROSURGICAL TUBOCORNUAL REANASTOMOSIS

Diseased portion of the  oviduct is excised  and the patent distal oviduct is reanastomosed to the patent interstitial segment

in most centers, Outpatient selective salpingography with tubal cannulation is done now.
probes, cannulas or balloons are placed under fluoroscopic or hysteroscopic guidance
the initial treatment of choice
if tubal obstrucion persist- do IVF_ET( in vitro fertilization w/ embryo transfer)

If pregnancy does not w/in 6 to 12 months after tubal reconstruction , do another HSG
MILD ENDOMETRIOSIS
If no other cause of infertility is present on laparoscopy, do Controlled Ovarian Hyperstimulation and Intrauterine insemination(IUI) 
MODERATE ENDOMETRIOSIS
endometriomas >1 cm in diameter and if adhesions can't be lysed at the time of laparoscopy, medical therapy will not cause regression to improve fertilityu rates and SURGERY shld be done

otherwise, medical therapy can be done

the use of danazol, GnRH agonist , progestin or OCp has not increased fertility rates compared to observation alone
SEVERE ENDOMETRIOSIS
IN the absence of pain, if laparoscopy can't treat adequately, IVF shld be done instead of laparotomy

20 % pregnancy rates after IVF

UNEXPLAINED INFERTILITY
COH  w/ Human Menopausal Gonadotrophin or clomiphene

preovulatory IUI

pregnancy rates will become 20 %