Preconception Counseling & Infertility

Preconception Counseling:

- One half of your plate should be fruits and vegetables. The other half should be grains and protein foods. Protein foods include meat, fish, beans and peas, nuts and seeds, and eggs. You also should have a small amount of dairy foods, such as milk, cheese, or yogurt, at each meal. Try to make at least one half of the grains you eat whole grains, such as brown rice, whole-wheat bread, and whole-wheat pasta. Eat more low-fat foods, such as low-fat or nonfat milk and dairy products. Eat fewer foods that are high in sugar and fat.

- Try to do 150 minutes of moderate physical activity each week (a little more than 20 minutes a day) or 75 minutes of vigorous intensity activity a week (about 10 minutes a day). Most people who have lost weight and kept it off get 60–90 minutes of moderate physical activity on most days of the week. You do not have to do this amount all at once. For instance, you can do 20–30 minutes of exercise three times a day.

- If you are unable to lose weight through diet and exercise, and your BMI is higher than 30 (or higher than 27 and you have health problems caused by your weight), your health care provider may recommend medication to help with weight loss. If your BMI is higher than 40 or between 35 and 39 and you have major health problems caused by your weight, bariatric (“weight loss”) surgery may be an option. If you are considering bariatric surgery or if you have already had it done, you should delay getting pregnant for 12–24 months after surgery, when weight loss is the most rapid.

- Take prenatal vitamins with 400mcg of Folic acid and with iron supplementation.

- Quit alcohol, smoking and drug use.

- Control medical problems such as diabetes, hypertension, depression and seizure disorders.

- Ensure vaccines are up-to-date.

- Family history/genetic counseling.

(AP056, Good Health Before Pregnancy)

FAQ136:

Detailed medical history and a physical exam. During the medical history, you will be asked questions about your menstrual period, abnormal vaginal bleeding or discharge, pelvic pain, and disorders that can affect reproduction, such as thyroid disease. If you have a male partner, both of you will be asked about the following health issues:

• • Medications (both prescription and over-the-counter) and herbal remedies

  • Illnesses, including sexually transmitted diseases, and past surgery

  • Birth defects in your family

  • Past pregnancies and their outcomes

  • Use of tobacco, alcohol, and illegal drugs

  • Occupation

You and your partner also will be asked questions about your sexual history:

• • Methods of birth control

  • How long you have been trying to become pregnant

  • How often you have sex and whether or not you have difficulties

  • If you use lubricants during sex

  • Prior sexual relationships

Optimizing Natural Fertility ASRM Committee Opinion: http://www.fertstert.org/article/S0015-0282(16)62849-2/pdf

Initial Infertility Workup:

Indications:

- No pregnancy after 1 year of having regular sexual intercourse without the use of birth control.

-Older than 35 years and have not become pregnant after 6 months of having regular sexual intercourse without the use of birth control.

- Irregular menstrual cycle.

- Patient or partner has a known fertility problem.

*Three major potential etiologic factors are assessed to uncover the causes of infertility: 1) male factor dysfunction, 2) ovulation dysfunction, and 3) female anatomic abnormalities (non-patent tubes).

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- History and Physical

- Semen analysis

- Documentation of normal ovulation (regular menses approx. q4weeks usually indicates normal ovulation)

- mid-luteal phase progesterone (collected 7 days before expected menses, or on day 21 of a normal 28 day cycle). Normal: progesterone level >3 ng/mL.

- If the mid-luteal progesterone conc. is <3 ng/mL, the patient is evaluated for causes of anovulation: minimal work-up includes serum prolactin, thyroid-stimulating hormone (TSH), FSH, and assessment for polycystic ovary syndrome (PCOS).

- OTC ovulation kits (Detects LH surge via urine dipstick. Typically start checking cycle day 11, and keep checking until "positive").

- Hysterosalpingogram or laparoscopic chromotubation

- Laboratory tests include tracking basal body temperature, a urine test, a progesterone test, thyroid function tests, prolactin level test, and tests of ovarian reserve. Imaging tests and procedures include an ultrasound exam, hysterosalpingography, sonohysterography, hysteroscopy, and laparoscopy.

(FAQ136)

Of couples having regular, unprotected intercourse, 50-60% will conceive in 3 months, 70% will conceive in 6 months, 85% will conceive in 1 year and 90% will conceive in 2 years.

Irregular menses and ovulation induction:

- Start provera (10mg tab daily for 10 days) on day 16 of your cycle. This should induce a bleed within the 7 days of stopping Provera.

- Take OTC urine LH test to check for ovulation (follow package instructions, some brands have you start testing different days based on your cycle length).

- Or order a serum progesterone level for a day between 18 and 24 (Vandermark does day 21) of the cycle, or 7 days before next expected menses.

- Normal is 6 and 25 ng/mL...If less than 2-3ng/mL, then consider repeat in 2-3 days.

- On Day 35 take a pregnancy test. If negative, then restart 10 days of Provera.

- Start Clomid on day 3 (50mg for 5 days).

- If no ovulation at 50mg for 3 cycles, then increase to 100mg for 5 days for the next 3 cycles.

- For PCOS: Femara 2.5 to 7.5 mg daily on days 3 to 7. Up to 5 treatment cycles with the dose increased in subsequent cycles for nonresponse or poor ovulatory response as determined by progesterone levels; max dose 7.5 mg daily.

*"Twin and triplet gestations occur in approx 7 to 9 and 0.3%, respectively, of clomid-induced pregnancies. The incidence of miscarriage and birth defects appears to be similar to that in spontaneous pregnancies, and the rate of ectopic pregnancy is probably not increased. The risk of ovarian hyperstimulation syndrome (OHSS) is less than 1%." (UpToDate)

REI rotation with Dodds and Young:

Before pregnancy - Get TSH to less than 2.5 and Hgb A1c to less than 6.0.

Femara is first line for anovulatory patients. It also has less side effects than Clomid, so should be used in patients who do not tolerate clomid (due to mood swings, hot flashes, etc...)

- Femara is "not as strong of a drug" so they start at 5mg/day. It also has lower chance of multiples.

- For oligomenorrhea or amenorrhea, you can do a TVUS to make sure there are no large cyst/follicles or thickened endometrium (if thickened endometrium, then do Provera first - Dodds does 10mg for 7 days), do a pregnancy test, then just start Femara without cycling with Provera. 12 days after the first day of Femara, check a midcycle TVUS to check for growing follicles.

- They often check a mid-cycle TVUS after using Femara or Clomid to measure follicles. If follicles are >15mm, or preferably 20mm, then consider Ovidrel injection (250mcg once, recombinant hCG/Luteinizing hormone analogue produced by recombinant DNA techniques; stimulates late follicular maturation and initiates rupture of the ovarian follicle once follicular development has occurred). *Hold ovidrel if 3 or more follicles (>15mm) are present.

- Time intercourse approx. 36 hours after ovidrel, which causes ovulation in 24-36 hrs.

For patients attempting pregnancy:

- Women: Prenatal vitamin, plus Vit D supplement (for total of 2000 IU daily), omega-3

- Men: Fertilaid For Men (order online), omega-3

- Men and women - exercise regularly, but not strenuous exercise.

- Men and women - stop smoking (3 months before benefit is seen)

- Men and women - Diet high in lean meat, fresh fruits and vegetables, low carb (especially PCOS pt)...even for couples of healthy weight.

- Men and women - limit alcohol 2 drinks per day and 5 total per week

http://www.fertilitycentermi.com/wp-content/uploads/2014/07/PRECONCEPTION.pdf

**Initial workup for infertility of unknown origin**

- Estradiol and FSH (cycle day 2-3) - esp. if >35yrs old (Dr. Shavell will order AMH first, then reflex estradiol/FSH if AMH abnormal)

- HSG (cycle day 5-10)

- TVUS with antral follicle count (cycle day 2-3) - esp. if >35yrs old

- Midcycle TVUS to access ovarian follicle maturation (if patient has completed urine ovulation kits, time US based on ovulation).

- Semen analysis

- TSH, CBC, type and screen, antibody screen, TSH, varicella and rubella.