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Infertility

Neda Frayha, MD and Lauren Roth, MD
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Infertility affects 1 in 8 couples in the U.S., and patients often present first to their primary care providers. In this segment, reproductive endocrinologist and fertility specialist Dr. Lauren Roth takes us through the workup and treatment algorithm of patients with infertility, including treatment risks and success rates.

Pearls:

  • Infertility is usually ⅓ male factors (sperm, sexual dysfunction), ⅓ female factors (eggs, anatomy, ovarian reserves) and ⅓ mixed.

  • Anti-mullerian hormone is a great way to assess ovarian reserve and can be drawn at any point in the ovulatory cycle.

  • Treatment includes IVF, intrauterine insemination (IUI) and ovulatory stimulants like clomiphene or letrozole. IVF has success rates of up to 70-80%, while IUI is successful 10% of the time.

 

  • Infertility definition:

    • If female age <35, one year of unprotected sex without getting pregnant.

    • If female age >35, 6 months of unprotected sex without getting pregnant.

    • If female age >40, 3 months of unprotected sex without getting pregnant.

  • Major causes:

    • ⅓ female factor

      • Egg

        • Irregular or absent ovulation

      • Anatomy (uterus, fallopian tube)

        • Fibroid

        • Fallopian tube scarring or pelvic adhesive disease

        • Endometriosis

      • Ovarian reserve

        • Less reserve with age

        • Smoking, chemotherapy and Fragile X carriers have reduced reserve

        • Less quality eggs with age

          • At 35, ½ eggs are normal

          • At 40, ⅔ are abnormal

          • Early 40’s, 90% are abnormal

    • ⅓ male factor

      • Sperm (count, motility)

      • Sexual dysfunction

    • ⅓ combined

    • 10% unexplained

  • Work-up:

    • Male partner:

      • Semen analysis

    • Female partner:

      • TSH

      • Anti-mullerian hormone (ovarian reserve = higher the more eggs you have), can be drawn at any time

      • Pelvic ultrasound to evaluate for fibroids

      • Hysterosalpingogram (HSG) after the period but before ovulation

  • Treatment:

    • In-vitro fertilization (IVF) - cycle takes 4-6 weeks and may result in more than one viable embryo

      • Process:

        • 1. Medications stimulate the ovaries

        • 2. Eggs are retrieved surgically

        • 3. Sperm from semen sample are used to fertilize the eggs in a lab

        • 4. Embryo is transferred via a catheter through the cervix into the uterus

      • Risks: Multiples

      • Rate of success depends on age:

        • Age < 35, chance of live birth from one transfer is 50-60%. Excess eggs can be frozen, increasing the chance of live birth to 70-80%.

        • Age > 35, depends on egg number

    • Clomiphene: anti-estrogen that leads to increased ovulation

      • Common side effects include hot flashes and mood swings

    • Letrozole: aromatase inhibitor (inhibits conversion of testosterone to estrogen) so the pituitary sees less estrogen → more FSH and LH → more ovulation

      • Common side effects include fatigue and headache

    • Intrauterine insemination (IUI): sperm is concentrated and placed through the cervix into the uterus at ovulation

      • Usually used in combination with ovulation stimulant like clomiphene or letrozole

      • Pregnancy chance is 10% per cycle

        • There are no good predictors for success

  • Treatment risks:

    • Multiples - with medication about 10% will lead to multiple gestation pregnancies

    • Ovarian hyperstimulation syndrome: ovaries get large, leak fluid into the abdomen leading to other complications like renal compromise and blood clots

      • People at risk are young, thin and with high eggs numbers or have had it before

      • Treated with IV hydration, pain control and sometimes paracentesis as well as anticoagulation

    • Embryo loss during IVF. Common to start with 20 and end with 3 or 4.

  • Costs: varies greatly by state and insurance coverage

    • IUI ranges $1500-$2500 per cycle

    • IVF ranges $12000 or more per cycle

  • References:

    • Boltz MW, Sanders JN, Simonsen SE, et al. Fertility treatment, use of in vitro fertilization, and time to live birth based on initial provider type. J Am Board Fam Med 2017;30(2):230-8.

    • Boulet SL, Mehta A, Kissin DM, Warner L, Kawwass JF, Jamieson DJ. Trends in use of and reproductive outcomes associated with intracytoplasmic sperm injection. JAMA 2015;313(3):255–263. doi:10.1001/jama.2014.17985

    • Gurunath S, Pandian Z, Anderson RA, Bhattacharya S. Defining infertility—a systematic review of prevalence studies. Human Reproduction Update 2011;17(5):575-588. https://doi.org/10.1093/humupd/dm

    • Kamel RM. Management of the infertile couple: an evidence-based protocol. Reproductive Biology and Endocrinology 2010;8(21):1-7. https://rbej.biomedcentral.com/articles/10.1186/1477-7827-8-21

    • Luke B. Pregnancy and birth outcomes in couples with infertility with and without assisted reproductive technology: with an emphasis on US population-based studies. American Journal of Obstetrics and Gynecology 2017;217(3):270-281.

    • Rossi BV, Abusief M, Missmer SA. Modifiable risk factors and infertility: what are the connections? American Journal of Lifestyle Medicine 2014;10(4):220-31.

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Retrieve Those Filters Full episode audio for MD edition 170:36 min - 80 MB - M4APrimary Care RAP September 2018 Written Summary-V2 590 KB - PDF

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