The approach in this section is to take the most common causes of infertility as outlined in the first two sections of this chapter and discuss medical management options.
1. Endometriosis: Endometriosis lesions have estrogen, androgen, and progesterone receptors. The concentration of these receptors is lower than that of eutopic endometrium. However, estradiol is the critical hormone regulating growth and development of endometriosis. Androgens and progestins produce atrophy in endometriosis lesions.
(1) Derivative of 17-ethinyltestosterone.
(2) Produces a high-androgen, low-estrogen environment.
(3) Should no longer be used as first-line treatment for endometriosis, ji
(4) Dose greater than 100 mg/day leads to pain relief in most patients.
(5) Doses of 100 to 800 mg/day are most effective for treatment purposes.
b. GnRH analogs
(1) The mechanism of action is effectively to shut down GnRH stimulation of FSH and LH, leading to a hypoestrogenic state.
(2) The first 8 to 10 days after administration, the effects are stimulatory until downregulation occurs. Therefore, Depo-Lupron should be administered 8 to 10 days before expected menses (day 20) and then every 28 days after this for 6 months.
(3) Most patients can be started on 3.75 mg of Depo-Lupron. Two weeks after the second shot, a serum estradiol level should be checked to make sure the patient is suppressed (E2 < 20 pg/mL). If the level is greater than 20 pg/mL, the next injection should be 7.5 mg.
(4) Most patients require 6 months of therapy.
(1) These agents produce a hypoestrogenic state by suppressing FSH and LH.
(2) Good choices are Provera (10 to 30 mg day) and Depo-Provera 150 mg every 3 months.
d. Oral contraceptives
(1) There is a dual mechanism of action (i.e., suppression of LH and FSH as well as decidualization of the endometrium).
(2) The most effective regime is a continuous regimen, but cyclic administration can also provide relief.
(3) This is not a “treatment” for endometriosis; it is suppressive therapy.
(4) Lo-Ovral is a good choice for this therapy. Cervical factor.
a. The medical treatment of choice for cervical factor infertility is intrauterine insemination.
b. The oral administration of estrogen does not improve cervical mucus or enhance pregnancy rates and should not be done.
(1) Indications for medical therapy of myomas
(c) Preoperative therapy: to improve hemoglobin and decrease the risk of blood transfusion
(2) GnRH agonists
(a) They are the only real medical therapy.
(b) They must suppress estradiol levels to less than 45 pg/mL.
(c) Optimal therapeutic benefit comes after 3 months of therapy (Depo-Lupron, 3.75 mg, every 28 days).
(d) Myomas will undergo rapid regrowth upon cessation of therapy.
(1) Adenomyosis is a condition in which endometriosis is found within the myometrium.
(2) It is characterized by chronic pelvic pain.
(3) It is found in approximately one of every six patients at the time of hysterectomy (most are multiparous).
(4) Its effect on fertility is unknown.
(5) Medical therapy is the same as that for pelvic endometriosis. Male factor.
a. Disorders of ovulation (usually require ovulation induction) (1) Clomid.
(a) Clomid works by blocking estrogen receptor binding or replenishment at hypothalamic or pituitary level, thus blocking estrogen feedback, leading to increased serum gonadotropins.
(b) It is administered orally day 3 to day 7 or day 5 to day 9.
(c) Dosage can be increased if ovulation does not occur. Recommended doses are 50 to 150 mg.
(d) Human chorionic gonadotropin (HCG) (Profasi) can be added to increase ovulation rates. Administer IM 5000 or 10,000 IU when follicles are greater than 20 mm.
(a) These are injectable gonadotropins consisting of 75 IU of FSH and 75 IU of LH or HCG.
(b) They act by directly stimulating the ovaries to produce follicles. Ovulation is accomplished by using HCG (Profasi).
(c) Monitoring is by serum estradiol and LH. There should be a serum E2 level of approximately 250 pg/mL for each follicle.
(d) Patients are also monitored by ultrasound.
(e) Each follicle should be 18 to 20 mm at the time of ovulation.
(3) Metrodin: partially purified FSH. It is the drug of choice in the treatment of patients with PCO.
(4) GnRH pump (Factrel or Lutrepulse).
(a) It is administered via an automatic portable infusion pump with a pulsatile mechanism.
(b) It is a good choice for hypothalamic amenorrhea, b. Lymphoproliferative disease (LPD)
(1) The correction of a LPD is usually directed at enhancing the follicular phase, thus leading to an improved luteal phase with Clomid or Pergonal/Humegon.
(2) Progesterone supplementation can benefit those patients with a LPD who produce inadequate amounts of progesterone.
6. Pelvic adhesions: The treatment of pelvic adhesions is surgical.
7. Ovarian failure: The current therapy for infertility associated with ovarian failure is egg donation.
8. Unexplained infertility.
a. Unexplained infertility is a diagnosis of exclusion.
b. Therapy is usually ovulation induction with intrauterine insemination or an assisted reproductive procedure.