Published on March 4, 2014
MANAGEMENT OF THE INFERTILE COUPLE IN A PRIMARY CARE SETTING PART ONE MILIE NWOYE MD SHAPE ARMY MEDICAL CLINIC FEBRUARY 20TH 2014
OUTLINE • GENERAL GYNECOLOGY • Gynecologic cancer screening • Pre-conception counselling • Tests for ovarian reserve • THE INFERTILE COUPLE • Definition • Evaluating the infertile couple • Managing the infertile couple (PART 1)
CERVICAL CANCER SCREENING • Screening starts at age 21 regardless of sex initiation • Ages 21-29: Pap test only every 3 years • Ages 30-65: Pap test every 3 years OR Pap and high risk HPV testing every 5 years • Women without a cervix: No Pap test required except less than 20 year history of high grade abnormality OR history of DES in-utero exposure
Population Recommended Screening Method Women younger than 21 years No screening Women aged 21–29 years Cytology alone every 3 years Women aged 30–65 years Human papillomavirus and cytology co-testing (preferred) every 5 years Comment Screening by HPV testing alone is not recommended Cytology alone (acceptable) every 3 years Women older than 65 years No screening is necessary after adequate negative prior screening results Women with a history of CIN 2, CIN 3 or adenocarcinoma in situ should continue routine age-based screening for at least 20 years Women who underwent total hysterectomy No screening is necessary Applies to women without a cervix and without a history of CIN 2, CIN 3, adenocarcinoma in situ, or cancer in the past 20 years Practice bulletin, ACOG, November 2012
BREAST CANCER SCREENING • Mammography has a false negative rate of 20%* • Age <40: Self breast awareness • Age >40: Self breast awareness, annual clinical breast exam and mammogram (except women with first degree relatives with premenopausal breast cancer OR women with BRCA mutation) ACOG guidelines *National Cancer Institute
Mammography American College of Obstetricians and Gynecologists Age 40 years and older annually Clinical Breast Examination Age 20-39 years every 1-3 years Breast SelfExamination Instruction Consider for highrisk patients Breast SelfAwareness Recommended Age 40 years and older annually Practice Bulletin, ACOG, August 2011
ENDOMETRIAL CANCER SCREENING • Most common gynecologic cancer Risk Factor Relative Risk • No screening tool. Longterm high dose HRT 10-20 • Red flags: postmenopausal bleeding Tamoxifen 3-7 • Diagnosis: PCOS or estrogen producing tumor >5 • Endometrial biopsy or D&C Obesity 2-5 • Transvaginal ultrasound Nulliparity 3 ACOG practice bulletin, August 2005
OVARIAN CANCER SCREENING • Lifetime risk of 1/70 • No evidence that screening leads to earlier detection or improved survival • Diagnostic tests: CA 125 and transvaginal ultrasound ACOG, July 2007
PRE-CONCEPTION SCREENING • Folic acid 0.4mg (or 4mg with a history of open neural tube defects) • Risk factor-based genetic screening/ counselling • Optimize medical conditions (HTN, DM) • Domestic violence screening • Avoid alcohol, tobacco, radiation, and illegal drugs • Weight reduction • Vaccinations (Rubella, influenza) ACOG Committee opinion, 9/2005
TESTING FOR OVARIAN RESERVE • ASRM, 2005 Speroff, 2005
THE INFERTILE COUPLE DEFINITION For women ≤ 35: No conception after 1 year of unprotected intercourse For women >35: No conception after 6 months of unprotected intercourse Only 43% seek medical care Age (years) Infertility rates (%) 15-24 4 25-34 13 35-44 30 Age and infertility. Science 1986;233:1389-94
CAUSES OF INFERTILITY- COUPLES 5% 10% 35% 15% Tubal and pelvic pathlogy Male factor Ovulatory dysfunction Unexplained Unusual problems 35% Speroff, 2005
CAUSES OF FEMALE INFERTILITY 10% 10% 40% Ovulatory dysfunction Tubal and pelvic disease Unexplained Unusual problems 40% Speroff, 2005
STANDARD FERTILITY WORK-UP • Assessment of male factor infertility: semen analysis • Assessment of ovulation: history, BBT, day 21 progesterone • Assessment of uterus/endometrium and ovaries: transvaginal ultrasound • Assessment of tubal patency: hysterosalpingogram or laparoscopy • Assessment of endometriosis: laparoscopy ASRM Fact sheet 2005
INFERTILITY MANAGEMENT • Timed intercourse • Ovulation induction • Intrauterine insemination (+/- ovulation induction) • In-vitro fertilization (IVF) • Intracytoplasmic sperm injection (ICSI)
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