Infertility

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    Infertility

    • Fertility drops >32yo
    • Defined as inability to conceive after 1yr, but realistically
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    • History
      • Previous surgery
      • Past PID
      • Past surgeries (
      • Thyroid (Thyroid binding globulin goes up, demand goes up)
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    Approach

    Female Partner
    1. Egg quality problem / Age / FSH
      • Age (decr at 35y and significantly after 40)
      • Check FSH at day 3: Normal is <10 mIU/L
      • Antral follicle counts (day 3-6)
      • Clomifene challenge test (100mg day 3-7 and check FSH on day 10)
        • Clomifene increases FSH by >50%
    2. Ovulation Defect
      • Menstrual Hx (cycle length etc... 24-35d normal)
      • Sx of ovulation: breast tenderness, moodiness, bloating
      • Basal Body Temperature
      • Serum Progesterone (to monitor ovulation induction)
      • Urine LH kits
      • PCOS: 2000-2500mg metformin, stop at 12 weeks because women with PCOS have high risk of first trimester loss
    3. Anatomical Problem
      • Do Hysterosalpingogram (HSG): tubal patency, contour of uterus, and 
      • sonohysterogram (SHG) U/S + saline
      • Hysteroscopy
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    Male Partner
    1. Semen Analysis
    2. Hx or Surgery etc...
    3. Erectile Dysfunction
    4. Other: diabetes, HTN, medications (CCB, AntiCh, antideperssants)
    Intercourse Timing
    1. 2-3x/week
    2. Need to have sex mid-cycle
    3. Avoid lubricants, spermicides (egg white, canola oil ok
    Treatment:
    1. Counselling
    2. Meds (clomiphene citrate vs gonadotropins), thyroid
    3. Intrauterine insemination
    4. IVF, IVF with intracytoplasmic sperm injection (ICSI), oocyte donation, sperm donation, embryo donation, gestational surrogate

    PCOS

    • Anovulation (irregular menses), testosterone signs (hair growth, acne, andogeneic alopecia), cystes in ovaries
    • PCOS causes abnormal GnRH secretion is changed leading to increase in LH, and low FSH.  LH causes theca cells to secrete androgens
     
     
     
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