From: Subject: Best Dx/Best Rx: Infertility Date: Wed, 3 Jun 2009 21:54:22 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_028B_01C9E495.DAB53AE0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_028B_01C9E495.DAB53AE0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx1607.htm Best Dx/Best Rx: Infertility



Infertility =

Alan H. DeCherney, M.D.
University of = California, Los=20 Angeles, UCLA School of Medicine

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key Clinical=20 Features

  • Inability to conceive after 1 or more years of = regular=20 coital activity without contraception=20
  • Affects nearly 10% of all couples in the = United=20 States=20
    • Male infertility in ~ 35%=20
    • Female pelvic factors in ~ 35%
    • Abnormal cervical mucus in 5% to 10%
    • Ovulatory dysfunction in 15%=20
    • Unexplained infertility in 15% to 20% =
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Differential = Diagnosis

Male = Infertility=20
  • Idiopathic oligospermia=20
  • Advanced age=20
  • Testicular injury=20
    • Trauma=20
    • Infection=20
    • Surgery=20
    • Radiation=20
    • Chemotherapy
  • Penile and testicular anomalies=20
    • Hypospadia=20
    • Cryptorchidism=20
    • Varicocele
    Female Infertility=20
    • Advanced age=20
    • Tubal and pelvic factors=20
      • Sexually transmitted disease=20
      • Pelvic inflammatory disease=20
      • Appendicitis with rupture=20
      • Pelvic tuberculosis=20
      • Adnexal surgery=20
      • Endometriosis=20
      • Ectopic pregnancy=20
      • Submucous myomas
    • Cervical factors=20
      • Abnormal cervical mucus
    • Ovulatory factors=20
        Oligo-ovulation
    • Anovulation=20
      • Hypothyroidism=20
      • Pituitary adenoma=20
      • Polycystic ovary syndrome=20
      • Cushing syndrome=20
      • Androgen tumor=20
      • Congenital adrenal hyperplasia (late = onset)=20
      • Anorexia=20
      • Stress=20
      • Exercise=20
      • Ovarian failure=20
      • Resistant ovary syndrome =
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      Best=20 Tests

      Male = Infertility=20
      • Semen analysis=20
      • Sperm penetration assay=20
      • Immunobead-binding assay=20
      • Urology evaluation if semen analysis is = persistently=20 abnormal
      Female = Infertility=20
      • Uterine, tubal, or pelvic abnormality=20
        • Hysterosalpingography (HSG)=20
        • Laparoscopy with chromotubation=20
          • Indicated for patients with abnormal = HSG=20
      • Cervical factors=20
        • Postcoital cervical mucus examination =
      • Ovulatory factors=20
        • Basal body temperature chart=20
        • Serum progesterone=20
          • Measurement on day 21 of menstrual cycle =
          • Provides indirect assessment of ovulatory=20 status
        • Endometrial biopsy=20
          • Can be performed on cycle days 23 to = 26=20
          • Assesses ovulatory status, luteal phase=20 adequacy
      • Anovulation=20
        • Serum prolactin=20
        • Thyroid-stimulating hormone (TSH)=20
            Evaluate if prolactin elevated, with or = without=20 galactorrhea
        • Follicle-stimulating hormone (FSH), = luteinizing=20 hormone (LH), estradiol
          • Evaluate if patient is found to be = hypoestrogenic on=20 initial exam=20
          • Identifies hypogonadotropic hypogonadism, = ovarian=20 failure=20
          • Gonadotropin-releasing hormone stimulation = test=20
            • Determine whether hypogonadotropic = hypogonadism is=20 reversible
          • Serum dehydroepiandrosterone sulfate = (DHEAS), total=20 testosterone, 17-hydroxyprogesterone, 8 A.M. free urine = cortisol=20
            • Hyperandrogenism, virilization on = physical=20 exam=20
              • Polycystic ovary syndrome=20
              • Ovarian and adrenal neoplasms=20
              • Congenital adrenal hyperplasia=20
              • Cushing syndrome =
          • CT/MRI of head=20
            • Indicated if prolactin elevated and TSH=20 normal
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      Best=20 Therapy

      • Tubal surgery=20
        • Selective tubal cannulation: proximal tubal=20 occlusion=20
        • Corrective tubal surgery: distal tubal=20 occlusion
      • Intrauterine insemination (IUI)=20
        • Cervical factor infertility =
      • Ovulation induction with clomiphene citrate or = gonadotropins=20
        • Anovulation not corrected by treatment = specific to=20 cause=20
        • Unexplained infertility; combined with = IUI=20
      • Progesterone supplementation after = ovulation=20
        • Luteal-phase defect
      • In vitro fertilization=20
        • Male infertility=20
        • Tubal occlusion (proximal, distal, or = combined)=20
        • Ovarian failure=20
        • Resistant ovary syndrome=20
        • Unexplained infertility not responsive to = ovulation=20 induction for 6 mo =B1 IUI

       

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        Best References

        ACOG Practice Bulletin: Obstet Gynecol 99:347, = 2002 [PMID=20 11814521]

        Colao A, et al: Ann Med 30:452, 1998 [PMID=20 9814831]

        Guzick DS, et al: Fertil Steril 70:207, 1998 = [PMID=20 9696208]

        Keck C, et al: Int J Androl 20(suppl 3):55, 1997 = [PMID=20 9466187]

        Kousta E, et al: Hum Reprod Update 3:359, 1997 = [PMID=20 9459281]

        October=20 2006

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