National Clinical Training Center for Family Planning – NCTCFP



Official VCB TranscriptTitle: Basic Infertility Services in Family Planning SettingsSpeaker: Jordan Vaughan, MSN, WHNP-BCDuration: 00:37:59NCTCFP (00:00):Welcome to this Virtual Coffee Break sponsored by the National Clinical Training Center for Family Planning. The National Clinical Training Center for Family Planning is one of the training centers funded through the Office of Population Affairs to provide training to enhance the knowledge of family planning staff. In this presentation entitled Basic Infertility Services in Family Planning Settings, Jordan Vaughan, MSN, will define infertility, discuss common causes and outline the services that can be performed in Title X settings to help patients achieve healthy pregnancies.NCTCFP (00:34):Before we begin, we'll go over disclosures. Successful completion. This webinar offers 0.5 contact hours for nurses. To receive contact hours, participants must complete the course with a satisfactory grade of 80% or higher on the quiz and complete the Evaluation and Request for Credit Form. CNE and CME certificates as well as certificates of attendance will be emailed within three to four weeks.NCTCFP (01:02):Commercial support or sponsorship. There's no commercial support for this training. Non-endorsement of products. The University of Missouri-Kansas City School of Nursing, the Office of Population Affairs and the American Nurses Credentialing Center's Commission on Accreditation do not approve or endorse any commercial products associated with this activity.NCTCFP (01:24):Conflict of interest. In accordance with continuing education guidelines, the speakers and planning committee members have disclosed commercial interests/financial relationships with companies whose products or services may be discussed during this program. Our speaker Jordan Vaughan, WHNP-BC receives an honorarium nurse educator speaker for EMD Serono. The planning committee, Katherine Atcheson, Angela Bolen, and Sharon Colbert have nothing to disclose. Jacki Witt serves on the advisory panel for Afaxys, which has been resolved. Kristin Metcalf-Wilson serves on the Afaxys Pharmaceuticals advisory board as well, which has also been resolved.NCTCFP (02:03):Acknowledgement of funding. This presentation was supported by grant number 5 FPTPA006029-02-00 from the US Department of Health and Human Services or HHS, Office of the Assistant Secretary of Health or OASH, Office of Population Affairs or OPA. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS, OASH or OPA.NCTCFP (02:33):Accreditation Statement. Continuing nursing education. The University of Missouri-Kansas City School of Nursing and Health Studies is accredited as a provider of continuing nursing professional development by the American Nurses Credentialing Center's Commission on Accreditation. This program offers up to 0.5 contact hours for nurses.NCTCFP (02:53):Our speaker today is Jordan Vaughan, MSN, WHNP-BC. Jordan Vaughan is a native of Nashville and is board certified as a Women's Health Nurse Practitioner. She graduated from the University of Texas at Austin in 2005, and then earned her MSN at Vanderbilt University. Jordan has over nine years experience working in outpatient infertility care for women, in addition to providing care for other gynecological health issues throughout the lifespan. She's been a guest instructor at Vanderbilt University's Nursing Program and is currently an Adjunct Instructor at Tennessee Tech University. Welcome, Jordan.Jordan Vaughan (03:28):Thank you all for having me. It's such an honor to be talking to you all today. At the end of today's lecture, my hope is that we will be able to define infertility and list its common causes, review pertinent medical history questions, discuss physical exam techniques, noting abnormalities, review semen analysis parameters, identify methods to maximize fertility and discuss the effects of lifestyle factors on fertility and when a referral will be warranted.Jordan Vaughan (03:53):So I understand that we may not all have all of the resources in the world. And so, what I really hope that you gained from this presentation is getting some pearls in order to help maximize your patient's chances of conception, as well as knowing when to refer them on for care. So the US Office of Population Affairs really addresses several family planning services and those include contraceptive services, pregnancy testing, and counseling, helping clients achieve pregnancy, basic infertility services, preconception health services, and of course screening for sexually transmitted infection.Jordan Vaughan (04:28):Quality family planning services addressed from the US Office of Population Affairs covers several entities. You've got your contraceptive services, pregnancy testing and counseling, helping clients achieve pregnancy, your basic infertility services, and then preconception health services, including sexually transmitted infection services.Jordan Vaughan (04:47):And so, really the idea is we have a lot of patients that for a lot of time in their life were trying to avoid pregnancy or prevent pregnancy. So what are we trying to do for those patients that really want to achieve pregnancy?Jordan Vaughan (04:59):So, let's review the definition of infertility. For under the age of 35, it is one full year of unprotected intercourse. And then over the age of 35, it's the inability to conceive after six months of unprotected intercourse. Half of couples starting infertility services will become pregnant within the following year. And the time is sped up for women over the age of 35, because of advanced maternal age. And there's a steep decline in fertility that begins in our early 30s and becomes more pronounced in our mid to late 30s. And other considerations would include history of severe endometriosis, a male factor fertility or ovulation factors.Jordan Vaughan (05:38):So, let's look at a little bit of the typical conception timetable. I think this slide is really important to review because it gives us some perspective here. So on any given month in maximum chance of fertility, your chances of pregnancy are about 25%. And I think that gives a realistic expectation for clients and couples seeking pregnancy. After about three months, the typical timetable goes up to 57%. You have 72% at six months, and then within a year, about 85% of your patients are going to achieve pregnancy.Jordan Vaughan (06:10):Women reach peak fertility between 20 and 24 years old. And I think that's a big surprise to clients. And it's important to remember that we have a fixed number of oocytes or eggs within our ovaries. At birth, women will have between 6 and 7 million eggs, which will then decrease to about 500,000 at puberty. So, the most we're ever going to have in our entire lifetime is about 20 weeks gestation or before we're even born. By age 30, fertility starts to decline and you get a more rapid decline about age 35. And the reason for that is, if you think back to the menstrual cycle, you have one, maybe two follicles that you ovulate every month, but in the running, you have about 1,000 eggs that are running for that one coveted spot.Jordan Vaughan (06:56):And so, through the process of atresia, after ovulation, those eggs go away, never to be used ever again. And as we get older, that process becomes faster and faster. And we are more likely to have ovulatory eggs or function that have chromosomal abnormalities.Jordan Vaughan (07:15):I really like it this graphic because it gives us perspective of an inverse relationship between the percent of maximum fertility and the percent of miscarriage. And so, you see this decline in fertility as women get older and an increased risk of miscarriage. Age affects both men and women, but men don't seem to see the effect until about age 50 or so.Jordan Vaughan (07:36):This graph looks at some of the common causes of infertility and it's broken up by couples and women. If you look at the right to the pie chart of the women itself, you've got a pretty even breakdown here of ovulatory dysfunction, tubal and pelvic pathology. And then you have about 20% that either is unexplained, or you have these unusual problems.Jordan Vaughan (07:57):When you look at couples, you're looking at about half that are related to male factor. If you factor in some of the unusual problems and unexplained. And then it's just broken down by ovulatory dysfunction and tubal pathology. And so it's important to remember that your male factor or your male partner is about 50% of this challenge. So, you don't want to ignore them in the workup.Jordan Vaughan (08:20):Let's review some of the common causes of female infertility. Number one, ovulatory factors. So you have anovulation and reasons for anovulation could include polycystic ovarian syndrome, hyperprolactinemia, hypothalamic amenorrhea. They might have a luteal phase insufficiency, and that's a little controversial, but that's where it's important to get a really good menstrual history from your patients. Are they having any bleeding in-between periods? Are they spotting right before their period? And so, that's going to guide really where you think your diagnosis might fall.Jordan Vaughan (08:52):Do they have poor ovarian reserve? Are they advanced reproductive age? And then, really how do we know whether or not she's actually ovulating? It's really important to get a good menstrual history. You may consider doing a serum progesterone level around cycle day 21 for patients that have somewhat regular cycles or about seven days before they start their period. Or have they used an LH kit or an ovulation predictor kit at home. So these are some common things to think about with ovulatory factors.Jordan Vaughan (09:22):Here are some common causes for tubal infertility. So do they have tubal occlusion? Do they have a history of pelvic inflammatory disease, a sexually transmitted infection or previous ectopic? Just a point to note that the number one reason that people have tubal occlusion or tubal blockage is from the presence of either an existing or previous infection with sexually transmitted infection. Do they have Adhesions? Have they had multiple surgeries within the pelvis? Do they have a uterine abnormality, for example, do they have a bicornuate uterus? Is there a septum within the uterus?Jordan Vaughan (09:57):And then are they at risk for endometriosis? Or do they have that history? Endometriosis is, it causes this chronic inflammation within the pelvis. And those little endometrial deposits can become problematic on the ovary and on the bowel. And it just causes this inflammation within the pelvis and can certainly impact their chances of pregnancy. And that's one that I think people don't fully consider. And so, really, again, getting a great menstrual history for your patients is really, really important.Jordan Vaughan (10:27):And then do we have cervical factors? There were, in previous evaluations you would consider doing antisperm antibodies or do they have a hostile cervical mucus environment? And those really aren't recommended for practice anymore, but are they able to notice their cervical mucus around the time of ovulation? is also helpful.Jordan Vaughan (10:47):Here are some common causes of male factor infertility, and they're really broken up into two categories. You have obstructive azoospermia and nonobstructive azoospermia. Obstructive could be from genetic conditions. So, for example, if the patient has cystic fibrosis, they may have congenital bilateral absence of the vast deferens. So they're producing sperm. It's just not able to come out in the ejaculate. Obviously, if they've had a vasectomy.Jordan Vaughan (11:10):The more challenging piece comes in with the nonobstructive azoospermia with regard to evaluation. So this chronic overheating of the testicles, maybe they have a varicocele or a dilation within the testicular vein. Have they been exposed to toxins in their work environment? Are they on certain medications? And hypogonadism, just like women can experience that as well, so can men. And so these are the main issues with regard to male factor infertility.Jordan Vaughan (11:38):So what should be done at the first visit for these patients. You really want to gain as much knowledge and do as much counseling as you can on their first visit. However, these patients are pretty compliant. And so you're probably going to see them wanting to come back and visit you and have these discussions. But it's to assess the expectations of infertility treatment, particularly in family planning settings.Jordan Vaughan (11:58):So, you're not going to be able to necessarily do all of the ovulation induction. They may have to consider paying for some of these lab tests and imaging studies out of pocket. And so, having an understanding of whether or not that's important enough to them to consider doing, or if it's even a possibility, is important to know on the front-end, so that you can manage those expectations for the patient.Jordan Vaughan (12:22):You want to gain a complete medical history and sexual health assessment for both partners. Ideally, you would do a physical exam for your female patient. You do not have to for the male patient, the guidelines really say that if you're able to get a semen analysis for the male partner, you do not have to do a physical exam for them.Jordan Vaughan (12:39):And you want to discuss the treatment plan, whether that be ways to maximize their own infertility or their fertility at home, or if there are some medications or supplements that you may be able to address with them.Jordan Vaughan (12:49):So, over the next few slides, you're going to see a lot of information when it comes to their medical history. And I'm not going to read everything off the slide, but it's important to get as much information as you possibly can.Jordan Vaughan (12:59):So, the big pieces from their medical history, have they had any previous surgeries within the pelvis itself or any hospitalizations? Any history of thyroid disorders, are they up to date on their cervical cancer screenings? Have they had to have any intervention done within the cervix? So cone biopsies or LEEPs. What medications are they on? Any family history of reproductive failure or developmental delay or genetic conditions that you may need to offer resources for screening?Jordan Vaughan (13:26):And then what they do for a living, if they do work, and their exposure to tobacco, alcohol or other drug use. Because that certainly can impact the chance of pregnancy as well as carrying a healthy pregnancy.Jordan Vaughan (13:37):Again, their reproductive history is really important. This is where I spend the majority of my time talking to patients. Do you want to have an understanding of the gravity, parity and pregnancy outcomes and complications. Things that they may not think is really significant, you might. And so, really gaining information on their previous pregnancies or how long they've been attempting pregnancy is really important.Jordan Vaughan (14:00):The age at which they started having periods, what are their cycles like and their characteristics. This is really the nuts and bolts of what you're trying to establish with their reproductive history. And you can gain a lot of information by a really good menstrual diary. Obviously, if patients are not having periods efficiently every month, or maybe it's every few months, you can gain a lot of information on how you can tailor this discussion for the patients.Jordan Vaughan (14:24):So, you want to know how long the interval is between bleeds, how many days they bleed for, do they have dyspareunia? Do they have dysmenorrhea? Do they have dysgeusia? So, all of those things will add to the consult and being able to determine really where we think the root cause is.Jordan Vaughan (14:42):Another really important thing to consider is their history of pelvic inflammatory disease and their exposure to STDs. Because again, you've got to think, "Okay, are they at risk for tubal factor infertility based on that?" Have they had any previous workup done before? I find that that can be frustrating when you get into this consult with patients and then all of a sudden they're like, "Oh yeah, I actually went to a fertility center two years ago and they ran all these tests or what have you." And you're like, "Oh, I should have led with that question." And so, making sure that you get a full understanding of how much this has been worked up for them is important too.Jordan Vaughan (15:16):More on the female examination. You want to document height, weight and Body Mass Index. Menstrual irregularities are associated with BMIs of less than 19 and above 35. And I know you certainly see, in practice, patients that fall outside that window. And so having that educational component of ovulation insufficiency or irregular menstrual cycles can be associated with an elevated BMI or an underweight patient as well is really important for that patient education. You want to know thyroid enlargement, you would do a clinical breast exam, and you're looking for signs of androgen excess as well with your [inaudible 00:15:53].Jordan Vaughan (15:54):For the pelvic exam, you want to note pelvic and abdominal tenderness. Maybe they have an enlarged uterus, or you suspect a fibroid. Vaginal or cervical abnormalities, including secretion or discharge. And at this point, you may consider STI screening based on the history. So these are really some pearls when you're doing the pelvic exam to really know. Particularly, masses within the cul-de-sac for tenderness, you would be suspicious of endometriosis at that point.Jordan Vaughan (16:18):Providers should discuss the client's reproductive life plan with the male couples or male partner as well. And ideally, they'd be present for one of these visits, that doesn't happen all of the time, but it's helpful to get that perspective from the male partner as well. So, coital frequency and timing. Have they ever fathered pregnancies before? What is their sexual history with regard to sexually transmitted infections? Because, again, the male reproductive organs can also be damaged by previous infection. And so it's important to make sure that you have an understanding of their exposure to chlamydia and gonorrhea as well. And have they had any past surgeries? Have they had an inguinal hernia repair? Have they had a varicocele repair, for example? Those are two big components when you think about structural abnormalities for male infertility.Jordan Vaughan (17:06):Just some brief history for the male partner, you want to consider other health conditions, including hypertension, diabetes, hyperlipidemia. And those are because some of the medications that patients are on can affect sperm production. So, for example, calcium channel blockers can inhibit sperm capacitation, and you may need to change them over to something else or consult another provider or managing provider. Are they taking testosterone or have they been exposed to anabolic steroids? So, if they're taking testosterone, it basically tells their body that they don't need to make it. And so you're going to see a huge decrease in sperm production because the brain basically doesn't have that communication with the testes. And so they're not going to produce the sperm.Jordan Vaughan (17:45):Medications and allergies, and then how much alcohol, tobacco or illicit drug use are they having? Because that will impact the volume of sperm, the motility of the sperm and whether or not that sperm is morphologically normal.Jordan Vaughan (17:57):So, really the nuts and bolts. What are we looking at here? These are three components when you're thinking about patients trying to get pregnant. Number one, is the patient ovulating? Number two, does she have tubal patency or a nice environment within the uterus that would promote implantation? And number three, does he have a reasonable sperm count? Ultimately, at the end of the day, those are the three pieces of the puzzle that we're trying to explain.Jordan Vaughan (18:21):So, this is some routine testing for infertility evaluation, and I understand within the confines of your practice, you may not be able to do all of these. And that's okay. But having the conversation with patients of, "Here are the options, here's how much these things may cost. Are you in a position that you want to explore these things or not?" So testing for ovarian reserve, basal FSH and estradiol levels are done on cycle day three. For many of your patients, that's going to be challenging to be able to pinpoint a cycle day three, which is where anti-Mullerian hormone comes in or AMH. That's really a better indicator of ovarian reserve. And we'll cover that in the next couple of slides.Jordan Vaughan (18:58):That test, if a patient were to pay out of pocket for it, is about $100 and then consider a transvaginal ultrasound for antral follicle count. So looking at the really early on follicles within their ovaries. They may have already had this for a diagnosis of polycystic ovarian syndrome, but it gives you an understanding of are there any abnormalities within the ovaries that you can see on ultrasound?Jordan Vaughan (19:19):The testing to look at the uterine cavity and the fallopian tubes consists of an HSG or a hysterosalpingogram, a sonohystogram, where water is actually put into the uterus, or certainly a laparoscopy, if you're concerned about endometriosis, which is certainly not first-line treatment. But an HSG, if a patient's willing to pay out of pocket for, it will cost you about $250. And that's the best test we have to evaluate tubal patency, particularly with exposure to sexually transmitted infections or previous ectopic pregnancies. And then a covered service for male factor testing is a semen analysis. And so, that is really the only way to assess male factor fertility other than an exam.Jordan Vaughan (20:01):Anti-Mullerian hormone, I'd like to talk about just for a minute, because I do think it is the best, according to the literature, the best way to evaluate ovarian reserve within the blood certainly. I mean, evaluating ovarian reserve is a complicated process and there is not one diagnostic test, but this is a pretty good one. And again, if your patients are wanting to pay out of pocket for this, I think it's about $100.Jordan Vaughan (20:22):So anti-Mullerian hormone is secreted by the granulosa cells and it's involved in the recruitment process of the primordial follicle pool. And the benefit of this test is that it has a low intracycle and intrapersonal variability. So what does that mean? It means that you can draw it really at any time during the menstrual cycle and from month to month, that ought to be consistent from patient within that patient, which is very different than follicle-stimulating hormone, which was the gold standard several decades ago for ovarian reserve.Jordan Vaughan (20:49):I really like this graph because it gives you a visual with regard to AMH and where it is best produced or highest produced in the initial recruitment and where FSH kicks in. And so, just for your reference, you can see that AMH starts to be expressed in this primordial follicle pool all the way over to the left of the diagram. And then as the follicles get bigger and bigger, you're going to see the highest expression in the antral follicles. But these follicles are really only about two to seven millimeters. So they're even smaller than what you're seeing on ultrasound. Where it's highest expressed, AMH, is before FSH even kicks in.Jordan Vaughan (21:26):So, what I want you to gather from this particular slide is that AMH is an earlier indicator of ovarian reserve. Whereas the follicle-stimulating hormone produced by your brain, that tells your brain how hard it is to work to make a follicle every month is a much better earlier indicator than FSH, because by the time the FSH becomes abnormal, it may be too late for this patient to really seek some intervention. So maybe a little bit more than you need to know, but I think it's really interesting and gives you some concept of what this test looks like.Jordan Vaughan (21:57):So, as family planning providers, you may not be able to do all of these labs, but these are important to consider. And so I've just given you some reference ranges here and particular labs that I draw in my practice and things that you can consider when you're looking at a healthy pregnancy, as well as methods to evaluate irregular menstrual cycles. So, things like your TSH, your prolactin, vitamin D, those kinds of things.Jordan Vaughan (22:19):The World Health Organization changed its reference ranges for semen analysis back in 2010. And what I want you to gain from this slide, there are a couple of parameters that are important. Men regenerate sperm about every 72 days, and it is a really inefficient process. And so if you think about the volume of sperm within the semen, most of the sperm is going to be abnormal, and that's a very typical thing.Jordan Vaughan (22:43):And so, the benefit for men is that they regenerate sperm all the time, again, about every 72 days. And so if they're having poor lifestyle choices, maybe they're drinking quite a bit of alcohol, which we'll cover in a little bit, or they're smoking. If they discontinue and then repeat a semen analysis in three to six months, you can see a significant change most likely within those parameters.Jordan Vaughan (23:05):So the things I want you to take away from this slide, progressive motility, you're looking at about 32% of the sample to be moving and moving in the right direction. So, that means moving in a linear fashion. They're not spinning on themselves. They're not just sitting there wiggling around and then they're certainly not dead. But it's a small percentage of the sample that you're really looking to be moving. Normal forms, again, because it's such an inefficient process, you're only looking for about 4% of the sample to be considered normal. And what that means is it's got one head, one mid piece, one tail, it looks to be morphologically normal.Jordan Vaughan (23:40):And so, again, just to remember that it's a really inefficient process. So, these are the parameters you're looking at. And if you're working with a really good lab, they will also give you a sheet of paper that explains these particular guides, and it can help guide the conversation with the patient. So, management of these results, if they're normal, you can consider proceeding with evaluation, or if they have oligospermia or significant decreases in either of these parameters, it may consider a conversation for referral. And that may not be possible for all of your patients. I certainly understand that. But having the realistic expectations discussion with patients I think is really, really important.Jordan Vaughan (24:18):So, what would be the next step here? Let's say your patient has documented ovulation and a normal semen analysis. So these are some pearls that you can give them. You want to encourage them to have intercourse every other day around mid-cycle. You may refer for an HSG to consider tubal patency, again, and that's where the conversation comes in of this test is about $250. This is what we're looking for. And is this something that you want to pursue or are you not in a place to do so.Jordan Vaughan (24:44):You could consider also referring for pelvic ultrasound of the uterus and the ovaries and the approximate cost for that is about $200. And then also to refer to a specialist for further evaluation and ovulation induction. It's certainly within the scope of your practice to be able to prescribe these medications. However, in the confines of your setting and in your clinic, that may not be possible. And that's okay. But there are resources available for patients if they're in a position to do so.Jordan Vaughan (25:10):So, what are some suggestions for patients that have amenorrhea or oligomenorrhea. The number one thing you're going to want to counsel for patients, particularly when they have a BMI greater than 35, is unfortunately diet and weight loss. And that is really, really difficult for patients. I'm not going to sit here and pretend that that's an easy discussion to have. I think everybody's looking for a magic fix and when patients want to have a baby, they want to have a baby yesterday. And so, you're hitting them at their vulnerable place of their inability to have a child. And maybe the fact that they're a little bit overweight or maybe a lot overweight. And so having this conversation of, "I will help guide you with this weight loss and these diet modifications. We will work on a plan together. But this is going to be the best and the most appropriate step moving forward to get you to your overall goal."Jordan Vaughan (25:58):Women that are already taking Metformin might see some benefits. The days of putting everybody that has polycystic ovarian syndrome on Metformin are gone. So if they have other comorbidities, maybe they have some glucose intolerance or they're insulin resistant, or they're being managed by another provider for those conditions, Metformin may be a reasonable option, but it is not first-line for ovulation induction. And you have to be careful with giving patients Metformin because of the side effects. Many of them are not able to tolerate it. But if they're already taking Metformin and they have some other comorbidities, they certainly might see some benefits.Jordan Vaughan (26:33):Cessation of continuous OCPs. So, in the literature, there's not a whole lot of evidence that does support this. However, anecdotally, if you have patients that have been on combined contraceptives for a long time and you take them off. Sometimes their ovaries get a little excited and they're more likely to ovulate within the first three months. And so, for patients that are having dysfunctional bleeding or have a really thickened endometrial lining that you've noted on ultrasound or something like that, that would benefit from a few months of combined contraceptive anyway, it might help them.Jordan Vaughan (27:08):And then, of course, you have ovulation induction with clomiphene citrate or with Letrozole, and that can be done at another provider's office or reproductive endocrinology.Jordan Vaughan (27:17):So, if a client's situation does not meet one of the standard definitions of infertility, then he or she may be counseled about how to maximize fertility. This is where I spend the majority of time with patients that are not able to take ovulation induction medication for whatever reason. The lack of knowledge about the optimal timing of intercourse for conception can lead to infertility. And so, this is an important graph for us all to understand. So sperm can survive in the female genital tract for up to about five days. Whereas the egg is really only good for a few hours or close to 24 if it's not fertilized.Jordan Vaughan (27:51):And so, because of this discrepancy in the lifespan between the sperm and the egg, the most effective time to have intercourse when you're trying to conceive is before ovulation. And I think, for a lot of patients, that's surprising to them. So, couples having intercourse on the day of ovulation may not conceive because they've passed that window. And so, we refer to this as this six-day fertile window that you want to have intercourse about every other day within this window that you think you may be ovulating.Jordan Vaughan (28:21):This graph looks at day relative to ovulation and chances of pregnancy. And you can see their peak chance of pregnancy occurs about two days prior to ovulation for both age groups. So how do we monitor ovulation for patients? What are some tools that we can give them to do at home? And some of these are pretty inexpensive. So for example, evaluating the cervical mucus is completely free for them to do. And for some patients, this is enough in order to be able to track their cycles. So, due to the rising estrogen, cervical mucus is going to increase about five to six days prior to ovulation. And it's going to peak around two to three days of ovulation.Jordan Vaughan (28:57):And you want to see this clear, slippery, stretchy, egg white looking discharge and mucus. And so how do you do that? You collect it from the vaginal opening with your fingers by wiping them front to back. And you're going to record that on your fertility calendar by making note of the color, the consistency and the feel. And ovulation usually occurs within one to two days when the mucus is clearest, slippery and most stretchy. And that could also be the peak day itself. So this is a guide for patients to note their own cervical mucus and give them a little bit of control with this process as well.Jordan Vaughan (29:38):You can also use a menstrual calendar. The first day of your fertility window is determined by subtracting about 18 days from the length of your shortest cycle. So, for patients that have irregular cycles, this is going to be challenging. I'm just going to plant that seed. But if you have more regular cycles, this is not a bad way to monitor ovulation. And so let's say your shortest menstrual cycle was 26 days. You're going to subtract 18 from 26, which is going to give you the number eight, which means that the first day of your fertility window starts on the eighth day of your cycle.Jordan Vaughan (30:13):The last day of the fertility window is determined by subtracting about 11 from the length of your longest cycle. And so let's say your longest cycle is 32 days, 11 from 32, you're going to get 21. And so that's the span of your reproductive or your fertile window. And that's going to vary from cycle to cycle and it's going to vary from person to person, and this can become challenging for patients. But you also may be able to keep track of it with cycle beads and just really documenting.Jordan Vaughan (30:41):So it's a good way to retrospectively look at when ovulation would occur or when you need to have intercourse. But for some patients, like I said, with irregular cycles, it's going to be a little bit challenging.Jordan Vaughan (30:53):Basal body temperature method can help identify changes in temperature that occur ovulation and it's going to remain elevated until your next period. So you have to use a very specific thermometer for this. So it has to be a basal body temperature thermometer. You can't just use a regular one. So what you would do is you take your temperature orally each morning before you get out of bed and you use this basal thermometer and it recognizes very small changes within the temperature.Jordan Vaughan (31:17):So your body is going to rise between 0.4 and 1 degree when you ovulate. And you're going to record your temperature every morning on your chart. So when you see that rise, as indicated within this graph, you can see the time of ovulation. And so it's going to fall right before ovulation. And then it goes up as progesterone is then produced by the cells within the ovary, or in the corpus luteum I should say. Again, it's a nice way to retrospectively look at when you're ovulating. It's not as great of a predictor, because once you look for that dip, you've already passed the two days prior to ovulation. But it can give you an understanding of when you need to have intercourse based on previous months on registering.Jordan Vaughan (31:59):Then, you have patients that use ovulation predictor kits, or LH kit. And these are nice to use at home. They can get pretty expensive depending on the brand, but what's great about these tests is that patients have control over when you do it. I think the best time to do this is somewhere in the mid afternoon or late morning. So, around lunchtime-ish. Because most patients are going to surge in the morning and it only lasts for a few hours and you're going to miss it if you're not careful.Jordan Vaughan (32:28):And so, it's a urine test. And the rise in serum LH begins about 36 hours. So, in the blood. And then it's going to spill over into the urine about 12 hours later. So you're looking at about a 24-hour window of a positive surge as related to ovulation. And so if you get a positive surge on one of these tests, you would have intercourse that day, the following day and the next day in order to cover your fertile window, because you know you're going to ovulate about 24 hours after that.Jordan Vaughan (33:01):The challenge with this is that for patients that don't ovulate efficiently or have polycystic ovarian syndrome, for example, they may always get a positive because their LH is endogenously higher than maybe the general population. And so, these can be really frustrating for patients that have polycystic ovarian syndrome.Jordan Vaughan (33:22):So what are some major takeaways with coital practices? Ideally, you would have intercourse about every other day mid cycle, and you want to begin four to five days prior to expected ovulation. And so, I say, for a week, before you think you're going to ovulate, do you have intercourse every other day. And that's more than going to cover your fertile window. Coital position does not matter. I get that question a lot. And you want to be very careful with vaginal lubricants.Jordan Vaughan (33:48):Lifestyle factors really can impact whether or not patients are able to achieve pregnancy. So the big ones here, weight and fertility, again, you're looking for a BMI between 19 and 35. It can be really challenging for patients to lose some of that weight if their BMIs are higher than that. But you're going to see more ovulatory dysfunction when you fall outside those parameters.Jordan Vaughan (34:09):Personal habits. Smoking. Smoking accelerates menopause by one to four years, and it certainly can increase the chances of miscarriage. So, that's a big one. Exercise, you want to make sure that the hypothalamus is not significantly impacted by the amount of exercise that you're doing. It's certainly important to be active and not sedentary. But you don't want to be challenging that function. Caffeine and alcohol. So high levels of caffeine greater than five cups of coffee is associated with decreased fertility and then certainly alcohol as well. The problem is nobody knows how much is too much, but we feel as though more than two to three drinks in one sitting can cause some ovulatory dysfunction. Whether or not that's hugely impactful for the fertility patient, we don't know. But again, we are trying to maximize their chances of fertility. So, I either encourage patients not to be drinking at all or consume less than five drinks a week.Jordan Vaughan (35:04):And then diet and supplementation. So healthy diet with fruits, vegetables, monounsaturated fats, and limiting your red meats and avoiding trans fat. These are the lifestyle factors that I was reviewing. This is a nice slide. A lot of these references are older, and I understand that, but these are some hallmark studies when it looks at smoking, alcohol, caffeine and illicit drug use. So I like this slide because it puts everything in a nice, concise format.Jordan Vaughan (35:30):These are some tips for patients maybe that aren't necessarily trying to get pregnant in the immediate future, but ways that you can help them with their future fertility. So, you want to prevent tubal factor infertility. And we do that by chlamydia screening annually. You look at targeted chlamydia and gonorrhea screening, if they have risky behaviors. You want to prevent pelvic inflammatory disease by using a barrier contraceptive.Jordan Vaughan (35:55):Prevention of ovulatory factor infertility. So having patients complete childbearing by mid to late 30s is helpful. I know it's not always possible that way, but our chances of pregnancy just go up if we are able to have pregnancies earlier on in our reproductive years. And then prevention of male infertility, you want to prevent epididymitis, again, by using a barrier contraceptive. And I'm just encouraging healthy behaviors.Jordan Vaughan (36:23):So, in summary, the definition of infertility, again, the inability to conceive after six to 12 months. It's important to remember that time to conceive increases with age and efforts should be made to complete childbearing by mid to late 30s. We need to have a discussion on the client's reproductive life plan, detailed medical history, sexual health history, physical exam. A semen analysis should be considered.Jordan Vaughan (36:44):You may want to consider referral testing with an HSG, and AMH for ovarian reserve. If they have the money that they're able to do that. And they really want that testing.Jordan Vaughan (36:54):And for those that don't meet the definition of infertility, we should be counseling them on how to maximize their own chances of pregnancy. And so, reviewing when the fertile window occurs, how to have intercourse within that timeframe, how to monitor ovulation, these lifestyle modifications to improve ovulatory dysfunction. And the use of tobacco, alcohol consumption and illicit drugs. And vaginal lubricants should be discouraged.Jordan Vaughan (37:18):These are some further resources for you all to have access to within your clinical setting. And they offer a lot of guidance for you to consider when you're having these challenging conversations with patients. My hope is that you've been able to gain some clinical pearls that you can take back in your practice as we try to navigate this road for our patient population. Thank you so much for joining me.NCTCFP (37:39):Thank you so much for joining us for this Virtual Coffee Break. For more content and continuing education opportunities, please visit us at . Follow us on Twitter @NCTCFP, or search for our podcast, The Family Planning Files. We hope that you'll join us for our next Virtual Coffee Break. ................
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