Male and Female
Infertility
Capt. Christopher W. Bunt, MD
Ehrling Bergquist Family Medicine Residency
Offutt AFB, NE
Goals

Enhance comfort level with workup

Basic Management Strategies

TRICARE Coverage
Demographics

80-168 million people worldwide

2.1 million couples in the US

9.3 million US women
Definition

12 months of unprotected intercourse

Earlier for certain historical factors

Older than 35
Infertility Etiology
Female Factors
Male Factors
General Causes
Meds

Unknown: 40-50%

1° or 2°
Hypogonadism

1° Hypogonadism: 3040%

Common medications


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Altered Sperm
Transport: 10-20%
2° Hypogonadism: 1-2%


Ketoconazole
Cimetidine
Spironolactone
The Scenario

Tech: “Husband and wife can’t get
pregnant.”

You: OB rotation was last infertility workup

What now?
A. Refer
 B. Google
 C. Use online EBM resources

Online EBM Resources

www.aafp.org/afp
American Family Physician
 March 2007: Jose-Miller, Boyden and Frey.


www.infopoems.com
Cochrane
 Systematic reviews
 Original research

Workup

History is KEY

Focused Physical Exam

Labs and Specialized Tests
Workup: History

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Coital Practices
Gestational History
PMHx/PSHx
Meds
Menstrual History
Substances
Recent High Fever
Our Couple: History
Female

G1 P0010

No hx of STIs


Male

No previous partner
pregnancies

Gonorrhea hx

No meds

Occasional EtOH
Normal menses
Unprotected sex for
15 months
Workup: Physical Exam
Female

Breast Formation
Male

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Galactorrhea

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Genitalia


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Hyperandrogenism?
Infection
Hernia
Vas deferens
Androgen deficiency
Testicular mass
Varicocele
Workup: Labs
Female

Ovulation problems
Male
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Ovulatory Dysfunction

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Ovarian Reserve


CBC
FSH, Testosterone
GC/Chlam, UA
Renal and Liver
Function
Semen analysis
Postejaculatory
urinalysis
WHO Seminal Fluid
Analysis (1999)



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Volume: >2ml
Sperm concentration: >20 million/ml
Total Sperm Number: >40 million/ejaculate
Sperm Motility:
>50% motile and/or
 >25% progressively motile


Sperm Morphology: >14% normal forms
Workup: Special Tests
Female

Transvaginal
Ultrasonography
(TVUS)

Hysterosalpingography
(HSG)

Hysteroscopy

Laparoscopy
Male

Scrotal
Ultrasonography

Transrectal
Ultrasonography
(TRUS)
Our Couple: Exam,
Labs & Tests

Normal male exam

Normal initial labs

Oligospermia on 2 separate semen
analyses

TRUS and postejaculatory UA normal
Management: General
Concepts

41 different methods

“Fertile window” intercourse

“E-type” vaginal discharge

Avoid lubricants and douches
Management: Female

Treat underlying cause

Hyperprolactinemia

PCOS

Gonadotropin therapy
Management: Female

Ovulatory dysfunction (Unknown etiology)
Clomiphene 50mg PO daily x 5 days
 Start on days 3-5
 Can increase to 100mg daily next cycle
 Results

80% will ovulate
 Hyperstimulation and Twinning
 Higher-order multiples rare

Management: Female

Clomiphene Failure?

IVF
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Injectable ovulation-inducing agents
Management: Female

Tubal/Pelvic/Uterine Issues
Reparative Surgery (low success)
 IVF

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Endometriosis
Laparoscopic ablation
 Laparotomy
 Ovulation induction +/- IUI and IVF

Management: Male

Hyperprolactinemia

Surgical repair

Fertility Specialist
Stress and Infertility

69% Women and 21% Men have
preexisting condition

Greater risk for psychological stress

No significant difference in
psychopathology
Stress and Infertility

Men have increased stress over time,
same as women

Watch for normal grief vs. psychopathology

Same rates of depression as other chronic
disease
Stress and Infertility

Bottom line: Not a means to improve
pregnancy rates.

Websites and Organizations:
American Society for Reproductive Medicine
www.asrm.org
 American Fertility Association www.theafa.org
 RESOLVE: The National Infertility Association
www.resolve.org

Management: Our Couple

Male: Imipramine Mar 08

Pregnant in June 2008!

Separated from USAF in July 2008
TRICARE Coverage

Will cover diagnostic tests, workup and
treatment of physical conditions

Will cover some fertility drug prescriptions


May require pre-authorization
Will cover any pregnancy issues once
pregnant
TRICARE Coverage
Exceptions
Artificial methods of reproduction:
Artificial insemination
 IVF
 Gamete intrafallopian transfer (GIFT)
 ICSI
 Reversal of prior surgical sterilization

Military Infertility Specialists
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All 3 Services have treatment centers

Many can be accessed through
Permissive TAD/TDYs or Leave
(Command-dependent)

Some are restricted to locally assigned
members only
USA Options

Walter Reed (DC)

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Tripler (HI)

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IVF, IUI (Intra Uterine Insemination)
Womack (NC)

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IVF, ICSI (Intracytoplasmic Sperm Injection),
Assisted Hatching (AH)
IVF, ICSI, IUI, AH, Frozen Embryo Transfer
(FET)
Madigan (WA)

IVF, ICSI, AH, FET
USN Options
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San Diego

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IVF, IUI, AH, ICSI
Portsmouth

IUI only
USAF Options
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Wilford Hall (TX)
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IVF, ICSI, AH
Wright-Patterson (OH)
Locally stationed military only
 IUI only


Keesler (MS)
IUI only
 Hope to start IVF program soon

Review

Comfort level

Demographics

Workup and Management

TRICARE options
Questions?