Fertility Facts

Definition:unprotected sex for one year, not pregnant

Frequency: 1 out of 6 couples in the US

Responsibility: 35% female infertility 35% male 20% both 10% unknown

Maternal Age USA20-24 4.1% 30-34 9.4%25-29 5.5% 35-39 19.7%

85% treated successfully Increase 1970-now-Why?

What can cause infertility?Unexplained-18%

Female Male

• Ovulation disorders• Tube/uterus blockage• Cervix• Endometriosis• Other

• Sperm count and defects

• Erectile or ejaculation deficiency

Intrinsic vs. Extrinsic, Environmental

More detail on female infertility• Ovulatory failure-polycystic ovarian syndrome (high

androgen/estrogenlevels), resistant ovarian syndrome, gonadal dysgenesis

• Impaired gamete/zygote transport-pelvic inflammatory disease, endometriosis

• Implantation defects-progesterone low

• Spontaneous abortion-chromosome abnormality

More detail on male infertility

• Cryptorchidism-Why?

• Chromosome disorders-gonadal dysgenesis

• Obstructions

• Gonadotropin deficiency

Result in:Low sperm count, sperm of poor quality

Female Infertility Tests

• For ovulation• Basal body temperature• Ovulation kit (LH surge)• Other hormone tests (steroids)

• Post ovulatory block•Laparoscopy-fiber optic look•Hysterosalpingogram-dye•Post-coital /cervical mucous and sperm•Sperm antibodies•Endometrial biopsy

Sperm good for 2-3 days, egg for 2

Can find adhesions, structural abnormality, etc

Hysterosalpingogram

Blocked tubes

Male Infertility Tests

• Sperm count/motility– > 20 million sperm/ml– Check motility and morphology

• >50% motile

• >30% structurally normal

• If low check LH and androgen levels•Testicular biopsy

Sperm Count

Older, low tech treatments

• Drug treatment for ovulation block• Intrauterine insemination• Tubal surgery

High tech Assisted Reproduction Technologies• IVF-in vitro fert and embryo transfer•GIFT-gamete intrafallopian tube transfer•ZIFT-zygote intrafallopian tube transfer•Intracytoplasmic sperm injection

frozen eggs/ ovary transplant; cloned human embryo

First test-tubebaby

Assisted Reproductive Technology

• Estimate 1/100 births now

• Around 40,000/year

• Costs between $7,000 to 15,000 per attempt

IVF

In Vitro Fertilization and Embryo Transfer

Basic Steps in IVF

•Ovary stimulation•Egg retrieval •Sperm retrieval-wash sperm•Fertilization•Embryo transfer•Progesterone

Drugs used for ovary stimulation

•Clomiphene (clomid)-anti-estrogen•hMG (pergonal)-menopausal gonadotropin (FSH and LH)•FSH-(metrodin)•GnRH•GnRH agonists (lupron)-FSH/LH first promoted, then inhibited•hCG-acts like LH

Start with more than 1 egg

In a single cycle, could take clomid, pergonal, hCG shot, then progesterone

Why transfer more than one embryo?

• Increase the pregnancy rate

• Leads to increased risk of multiple pregnancies

• In future- Test embryos before transfer

sHLA-G measure of embryo health

Egg retrieval, vaginal, with ultrasound

Gametes mixed for GIFT

Modifications if tube not blocked

GIFT

If fertilization needs help-transfer zygoteZIFT

Intracytoplasmic sperm injection

ICSI

Additional twists

• Surrogacy– Gestational– Egg donor plus gestational– Egg donor plus sperm donor plus gestational

• Frozen embryos• Egg donors• Frozen eggs• Cloning

From CDC

IVF Success Rates

Stage Number of WomenCycle initiation 100Ovulation 95Oocyte retrieval 90Fertilization 85Embryo Transfer 70Pregnancy 24Birth 18

From The Baby Business by Debora Spar

Risks of ART?

• To woman– Overstimulation of ovary syndrome– Multiple pregnancies– Risk of ovarian cancer (clomid, pergonal)

• To baby– ICSI associated with problems (XYY)

Discussion questions-what treatment(s) would you select given the following:

• Male with low sperm count

• 30 year-old female not ovulating

• 40 year-old female not ovulating

• Undiagnosed infertility