Female infertility - 1
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Transcript of Female infertility - 1
Female infertility(part-1)Female infertility(part-1)
Dr. JASMINA BEGUMDr. JASMINA BEGUMASSOCIATE PROF. (O &G)ASSOCIATE PROF. (O &G)
Learning objectivesLearning objectives
• know definitions of primary and secondary infertility
• understand the causes of infertility• know the initial investigations of the
infertile couple• Test for ovulation• Test for tubal patency• Investigation role of laparoscopy and
hysteroscopy
DefinitionDefinition
• Infertility is the inability to achieve a
pregnancy after 12 months of unprotected regular intercourse
Primary infertilityPrimary infertility
• Primary infertility is the term used to describe a couple that has never been able to conceive a pregnancy, after at least 1 year of unprotected intercourse
Secondary infertilitySecondary infertility
• Secondary infertility describes couples who have previously been pregnant at least once, but have not been able to achieve another pregnancy
causescauses
• Female factor 30%• Male factor 30%• Combined factor 30% • No cause 10%
• Female partner alone should not be
blamed
Female genital tractFemale genital tract
Female InfertilityFemale Infertility
1
23
4
6
5
General factorsGeneral factors
Diabetes mellitusThyroid disordersAdrenal disease Significant liver, kidney disease Psychological factors
Hypothalamic-pituitary factorsHypothalamic-pituitary factors
Kallman syndromeHypothalamic dysfunctionHyperprolactinomaHypopituitarisum
First visitFirst visit• Have both come to all visits
• Get a complete history
• Sexual history
• Educate/ Counselling
Visit 1: Female HistoryVisit 1: Female History
• Prior infertility; evaluation, treatments
• Hx of PID; postpartum/ post TB infection
• Pelvic pain, dysmenorrhea;
endometriosis
• Medical: diabetes, thyroid; pelvic surgery
• Medications, alcohol, street drugs
Contd….
Visit 1: Female HistoryVisit 1: Female History
• Cigarette smoking
• Galactorrhea
• Menstrual patterns
• Cycle length range (best 25-35 days
apart)
• Moliminal symptoms (if present,
ovulating)
Visit 1: Female ExaminationVisit 1: Female Examination
• Weight, BMI, waist circumference (PCOS)
• Skin: axial hirsuitism, acne, male-pattern
balding (PCOS)
• Breasts: galactorrhea ( prolactin)▲
• Cervix: mucus, friability (infection)
• Uterine corpus
• Size, shape (fibroids, uterine anomalies)
• Corpus tenderness (PID)
• Fixed retroflexion (EM)
• Adnexa: tenderness (PID, EM), mass
• Time intercourse just before ovulation
• Use menstrual calendar to predict
ovulation
• Shortest cycle length minus 14 days
• Ovulation prediction kit to confirm
ovulation
Visit 1: CounselingVisit 1: Counseling
Coital frequency and TechniqueCoital frequency and Technique
• Every other day intercourse starting 4-5
days before expected ovulation
• Lay supine with knees up x 20 minutes
after intercourse
• No sperm-toxic lubricants
Visit 1: CounselingVisit 1: Counseling
• Stop smoking (both partners)
• If BMI > 30, recommend/assist with weight
loss
• Preconceptional care
Folic acid 400 mcg PO per day
Rubella serology; immunize if seronegative
Contd…..
• Change medications to safer FDA
pregnancy
category
»Antihypertensives
»Anti-epileptic drugs
• Blood glucose control in diabetics
Visit 1: Counseling
Investigations of female Investigations of female
• General Hb, urine RE, Blood group,sugar VDRL, HIV, Hbsag, Mx, Urea, creatinine
• Semen analysis (report must before further work up is taken)
• Tests for ovulation• Tubal patency• FSH, LH, Thyroid function, prolactin• Screen for gonorrhea, chlamydia (if indicated)• Microscopy of cervical mucus
• Diagnostic pelvic ultrasound
• >10 to 12 follicles per ovary (PCOS)
• Persistent hemorrhagic cysts with low-level echoes (endometriosis)
• Anatomical conditions: fibroids, polyps, and
• Müllerian anomalies (uterine septum)
• Decreased ovarian volume and reduced antral follicle count associated with reduced fertility
• Serial TV ultrasound used to document ovulation
Visit 1: Pelvic UltrasoundVisit 1: Pelvic Ultrasound
Ultrasound scan showing follicleUltrasound scan showing follicle
Infertility workup calenderIdentificationof factor
Methods employed Day of cycle Observation
Ovulation
•BB T
•Endometrial biopsy
•Cervical mucusNatureThreadabilityFern pattern
•Serum progesterone
•Serum LH• Urinary LH
•Serial transvaginalsonography•Laparoscopy
Throughout cycle
D 21–23
D 12–14 and D 21–23
D 8 and D 21
Midcycle daily (D 12–14)
D 12–14
Secretory phase
Biphasic pattern
Secretory endometrium
Clear, watery Thick, viscid
D-8 < 1 ng/ml D-21 > 6ng/ml
Ovulation: About 10–12 hours afterLH surge
DominantFollicle 20 mmRecent corpus luteum
Identificationof factor
Methods employed
Day of cycle
Observation
Tubal factor
HSG
Laparoscopy and dye test
Sonohysterosalpingography
ProliferativePhase D6-D10
ProliferativePhase D6-D10
Proliferative phase
Spillage of dye into the peritonealCavity
Peritubal pathology• Pelvic pathology (Endometriosis)• Ovulation• Tubal patency by dye spillage fromboth the tubes
Better than HSG for detection of intrauterinepathology
Identificationof factor
Methods employed
Day of cycle
Observation
Cervical •Postcoital test (PCT)
• Sperm cervical mucuscontact test (SCMCT
Around ovulation(D 12–14)
(D 12–14)
Presence of progressive motile sperm(10 per high power field)
Sperm antibodies
Role of LaparoscopyRole of Laparoscopy
• Controversial as to whether to include it in
the basic evaluation or not
• Studies indicate that it may demonstrate
previously undetected stage I or II
endometriosis, periovarian or peritubal
adhesions.
Contd…..
Role of LaparoscopyRole of Laparoscopy
• This may alter treatment plans such as
surgery for endometriosis or directly IVF
for peritubal adhesion
• Can be avoided in women with a normal
HSG in patients who may need IVF
Laproscopy findings Laproscopy findings
• Uterus ---- fibroids uterine anamoly
• Tubes --- patency hydrosalpinx • Ovaries --- PCOS
chocolate cyst • POD --- endometriosis adhesions
Hysteroscopy findingsHysteroscopy findings
• Cervical canal --- polyps
• Uterine cavity --- adhesions
polyps
fibroids
uterine anamoly
• Endometrium --- proliferative/hyperplastic
• Tubal ostium --- visualised or not
Fertility Treatment: GoalsFertility Treatment: Goals
• To ensure patient safety
• To help a couple experience a healthy
pregnancy and birth or an alternative
way to build a family
• To use as little of a couple’s resources
as necessary.
Fertility Treatment: OptionsFertility Treatment: Options
• Correct ovulatory dysfunction
• Correct tubal or uterine abnormalities
• Overcome subfertile sperm parameters
• ART
Management of infertility in women >30 years Management of infertility in women >30 years
For couples who do not desire
medical intervention
• Ovarian stimulation with IUI
• Ovarian stimulation with IVF (own eggs)
• Ovarian stimulation with IVF (donor eggs)
• Surrogacy
• Adoption
Conservative Active
SummerySummery
Tests of ovulationTests of ovulation
• LH kit• Progesterone assay• Basal body temperature• Cervical mucus
•Spinnbarkit•fernning
• Vaginal epithelium cytology• Endometrial biopsy• TVS follicular monitoring
Tests of tubal patencyTests of tubal patency
• Hysterosalpingography (HSG)• Diagnostic laparoscopy• Sonosalpingography• Air insufflation• Falloposcopy
Expected Short answerExpected Short answer
• Define primary infertility and list any five female factors responsible for it?
• List the tests for ovulation ?.• List any two indications and any three
contraindications of hysterosalphingography?
• List the who criteria for semen analysis?
Thank youThank you