00:01
So for today, we're going
to talk about infertility.
00:05
Now, infertility is defined
differently depending on one's age.
00:10
If someone is under the age of 35,
the definition of infertility
is an inability to conceive
after 12 months of
unprotected intercourse.
00:20
If you're over the age of 35,
however, the time changes.
00:24
It's an inability to conceive
after only six months
of unprotected intercourse.
00:30
Now, the reason for that difference
is pretty simple.
00:32
If you're over the age of 35,
your chances of not
being able to conceive
are going to go up.
00:37
So we don't want to wait
that extra six months
before we intervene.
00:41
Now, there's also a thing called
primary infertility.
00:45
Primary infertility
refers to an inability
or difficulty in conceiving
when someone's
never been pregnant before.
00:53
Secondary infertility,
on the other hand,
happens when someone was previously
able to achieve a pregnancy,
and now they're having
challenges and difficulty.
01:03
Fecundity, really just refers
to an ability to achieve
a live birth at all.
01:08
So those are our definitions.
01:10
Make sure you have them
in your head.
01:12
First, we're going to talk about
female factor infertility.
01:16
I make one small side note here
that when we discuss female factor
and male factor infertility,
we're talking about
sex assigned at birth.
01:26
When you take someone's history,
a female client who comes in
for an assessment for infertility,
there are several areas you want
to make sure that you assess.
01:34
First of all, knowing what their
medical and surgical history
may have been.
01:38
So do they have diabetes
or chronic hypertension?
Or have they had surgery?
Some sort of operation?
Not necessarily on their
reproductive system, but anywhere
because that can have
ramifications for fertility.
01:51
We also want to talk about
their sexual history.
01:53
Are they engaged in intercourse?
I know that seems sort of illogical
that someone would expect
to be pregnant,
if they're not having intercourse.
02:01
But we do have to have
that conversation.
02:03
How often and with whom?
We also want to know a bit
about their GYN history,
or gynecologic history.
02:09
Had they had a
series of infections?
Or have they been
treated for abnormalities
of the cervix or the uterus?
That's really important when
we're talking about infertility.
02:19
Also their OB history.
Have they been pregnant before?
Have they had a series of losses?
That's really
important for assessing,
why someone may or may not be
having trouble getting pregnant
at this point.
02:31
And finally, what's been their
history with infertility in general?
So is this something they've
been working on for a month,
two months, six months, two years,
eight years? All of that matters.
02:43
Now, we also want to think
about the environment,
where do they live, work, and play?
So sometimes at work, we're exposed
to certain environmental toxins
that may impact fertility.
02:53
And sometimes,
what we do in our off time
can expose us to the same
chemicals and toxins.
02:59
So make sure that you assess
the environment.
03:03
We also want to think about
other habits
someone may have in
terms of substance use.
03:07
So there's been a lot
of changes in laws about,
what's acceptable and what's not?
But we have to know that
recreational drug use
can definitely impact our
ability to produce sperm
or to achieve fertility.
03:20
We also want to think about weight.
03:22
So being overweight or underweight
can absolutely affect
especially for the female
their ability to ovulate.
03:29
So we need to talk about that.
03:31
And then we need to do
a physical assessment.
03:34
So our next few slides,
we're going to visit
what's included
in that physical assessment?
Let's talk about the assessment
for female factor infertility
We'll always begin
with a pelvic exam.
03:47
This allows us to palpate the uterus
and note any structural anomalies.
03:52
We will also need to evaluate
the hormones.
03:55
So I don't just mean
estrogen and progesterone.
03:58
We also need to check
FSH and LH, and maybe a thyroid
because any abnormality
here can affect ovulation,
which affects fertility.
04:08
We may also need to do
a post coital test.
04:11
Now this test is a
little more complicated.
04:13
It involves being exposed to sperm,
and then testing
the vaginal environment afterwards.
04:19
We're looking to see if
the sperm are still alive
after they're exposed
to cervical mucus.
04:24
We may also do an ultrasound
to give us a better idea
of the shape of the uterus.
04:29
There's some things we're not going
to be able to feel on a pelvic exam.
04:33
We may also do a
hysterosalpingogram
and for this we'll do an ultrasound
and actually shoot fluid
through the fallopian tubes
to see if they're actually open.
04:43
So in order for the sperm and egg
to get together,
the highway has to be clear.
04:49
A hysteroscopy may be performed
in order to really see
what's going on
in the inside of the uterus.
04:55
So we can see the endometrium.
04:57
There may be polyps or other tumors
that would affect implantation.
05:01
And finally, a laparoscopy
will allow providers
to actually see what's going
on in the abdominal cavity.
05:08
So we can see again, if there are
tumors or other structural blockages
that can impact fertility.
05:15
Now, looking at an entire graphic
of all the causes of infertility,
there are a couple of things
we want to take note of.
05:22
First is the most common cause.
05:24
And you can see here that 25%
of female factor infertility
is caused by ovulatory disorders.
05:31
So in this particular situation,
someone is not ovulating regularly
or maybe at all,
and that's why they're unable
to conceive.
05:39
The second most common reason
is endometriosis.
05:42
So if you'll remember, endometriosis
is caused by retrograde bleeding,
which means that
instead of the menses
coming out through the cervix,
it's going out through the tubes.
05:51
So it gets mixed in
with the peritoneum,
and so you'll have scar tissue that
actually will grab on to the tubes
and pull it in
lots of different directions.
06:01
So it makes it very difficult
for there to be fertilization.
06:05
And then there's 10%,
that's completely unexplained.
06:08
So for some clients,
they will never know the reason
for their infertility.
06:13
Let's talk about the
hormonal and ovulatory factors
in a bit more detail.
06:18
So developmental anomalies
can absolutely affect fertility
for the female client.
06:24
So thinking about an
abnormally formed ovary,
or maybe the oocytes or the eggs
that are formed inside the ovary
are impaired in some way,
and this may happen long before
pregnancy is desired.
06:36
The female client
can also experience what we call
anovulatory cycles.
06:40
As the name suggests,
ovulation does not occur.
06:44
There may be issues
with the pituitary
or the hypothalamus
that can affect ovulation.
06:50
There can be a situation
where a client is experiencing
congenital adrenal hyperplasia.
06:55
And this is an abnormality
in terms of the adrenal glands.
06:59
And this can definitely
impact fertility.
07:02
Premature ovarian failure can
also lead to anovulatory cycles.
07:07
Polycystic ovarian syndrome
can lead again to
anovulatory cycles.
07:13
Increased prolactin
can actually suppress GnRH,
gonadotropin releasing hormone,
which as we know begins the
whole menstrual cycle at all.
07:24
So if any of these factors are off,
we will not have ovulation,
and without ovulation,
fertility is impossible.
07:33
Now, let's look at some
of the structural issues
that the female might experience
that could impact fertility.
07:40
Any type of infectious process
in the lining of the endometrium
can make implantation
difficult or impossible.
07:48
Tumors inside the uterus
or in the fallopian tubes,
again can affect the passage
of the sperm and the egg.
07:55
So if they're not
able to get together,
we can't have fertilization.
07:59
Adhesions inside the endometrium
can make it very difficult
for implantation to occur.
08:05
But it can also be a barrier
for sperm to get out to the egg
in the first place.
08:11
Again, endometriosis.
08:13
So think about what this causes that
scar tissue is like sticky fingers,
and if it causes the tubes
to be torturous,
then it will be very difficult
for the egg
even if it's fertilized to make
its way back to the endometrium.
08:27
And finally, inflammation.
08:29
So infection does not
always cause inflammation.
08:33
When we think about
the uterine walls,
if they're endometrial
or myometrial tumors
that can also affect implantation.
08:42
When we think about
the uterine walls,
if they're endometrial
or myometrial tumors
that can affect implantation.
08:50
And again,
not making pregnancy impossible,
but being able to sustain a
pregnancy very, very difficult.
08:57
There may also be
developmental anomalies.
09:00
So you can see in this graphic,
we have what looks like a septation
in the middle of the uterus.
09:05
So that actually almost
two uteri here, in this picture.
09:08
So this can affect spatial issues,
this can affect implantation.
09:13
Either way,
this makes fertility very difficult.
09:17
And finally,
Asherman syndrome.
09:19
So, Asherman syndrome
results after a procedure,
such as a dilation and curettage
where the lining of
the uterus is scraped,
and scar tissue is left behind.
09:29
If there scar tissue
in the endometrial lining,
then it's impossible
for implantation to occur.
09:36
If that scarring is low enough,
it can actually cover the cervix,
and in that case,
menstrual blood flow
will be impeded.
09:46
Not just the endometrial lining
is important to consider
when we talk about
factors in the uterus.
09:51
We also have
to think about the cervix
and the mucus that's
produced by the cervix.
09:56
If it's thick, dry or sticky,
then that will be impede
sperm transport.
10:02
So the sperm can't even make it
through the cervix
to get to the egg.
10:06
Also, if the environment
is particularly acidic,
that may be inhospitable to sperm.
10:12
We also have to think about
inflammatory cells.
10:15
Again, creating a situation
that's not a warm and fuzzy
for the sperm to get through.
10:20
And finally, there can actually
be antisperm antibodies.
10:24
So that goes in step further.
10:26
And they actually attack the sperm
when they come.
10:29
This is why the post coital test
might be particularly helpful.