This is intended for primary care physicians. It is a 2 part presentation that begins with gynecologic cancer screening and ends with the evaluation and management of the infertile couple
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Management of the Infertile Couple in a Primary Care Setting. Part I
1. MANAGEMENT OF THE
INFERTILE COUPLE IN A
PRIMARY CARE SETTING
PART ONE
MILIE NWOYE MD
SHAPE ARMY MEDICAL CLINIC
FEBRUARY 20TH 2014
2. 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)
3. 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
4. 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
5. 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
6. 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
7. 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
8. 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
9. 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
11. 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
12. CAUSES OF INFERTILITY- COUPLES
5%
10%
35%
15%
Tubal and pelvic pathlogy
Male factor
Ovulatory dysfunction
Unexplained
Unusual problems
35%
Speroff, 2005
13. CAUSES OF FEMALE INFERTILITY
10%
10%
40%
Ovulatory dysfunction
Tubal and pelvic disease
Unexplained
Unusual problems
40%
Speroff, 2005
14. 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