Infertility Lecture Final
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INFERTILITY
Emad Darwish MDProfessor of Obstetrics &
GynecologyAlexandria Faculty of Medicine
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Role of male partner in conception:•Spermatogenesis: production of a
sufficient amount of normal motile sperm capable of fertilizing the ovum.
•Production of normal seminal fluid for sperm transportation and nutrition.
•Deposition of semen in the vagina near the cervix:▫Patent duct system (epididymis , vas
deferens & ejaculatory ducts)▫Prober coitus.▫Prober ejaculation.
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• Role of female partner in conception:• Ovarian factor:
▫Normal ovulation & functioning corpus luteum.• Tubal factor:
▫Oocyte pick up & transportation.▫Sperm transportation.▫Site for fertilization and zygote transportation to
the uterine cavity.• Uterine factor:
▫Normal cavity & endometrium for implantation & fetal growth.
• Cervical factor:▫Patent cervix & adequate cervical mucus.
• Vaginal factor:▫proper coitus, semen deposition & transportation.
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Conception:
Regular unprotected coitus (without contraception) results in pregnancy in:
•25 % within one month.•60 % within 6 months.•80 % within one year.•90 % within 18 months.
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Fecundability:• It is the ability to have pregnancy within a single menstrual
cycle (20-25 %).
Fecundity:• It is the ability to have live birth baby within a single
menstrual cycle. Infertility:• Failure of conception after one year of regular unprotected
coitus. N.B.: Some define infertile after 18 months of regular
unprotected coitus, (as 90 % of women get pregnant within this period).
Sterility:• Complete inability to achieve conception.
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Physiological infertility:•Before menarche.•After menopause. •Fertility is reduced during lactation.
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Types of infertility:Primary infertility: • No history of previous pregnancy.
Secondary infertility: • History of previous pregnancy regardless of the mode
of termination. Relative infertility:• History of conception with inability to achieve a live
birth baby. N.B.: Unexplained infertility: is failure to achieve
pregnancy without any obvious cause (fertility workup is usually normal).
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Etiology of infertility:
Male factor 30%
Female factor 40%
Combined factors
10-20 %
Unexplained 10-20%Infertility
Male factor Female factor Combined factors Unexplained
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Male factor of infertilityEtiology of male infertility:1- Defective spermatogenesis:It includes: • Azoospermia: no spermatozoa in the semen.• Aspermia: complete absence of semen.• Hypospermia: decreased semen volume (<2 ml
on at least two semen analyses).• Oligospermia: decreased sperm number (< 15
million/ml). • Asthenospermia: decreased sperm motility.• Teratospermia: increased abnormal sperm
morphology.
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Causes of defective spermatogenesis: a) Primary testicular disorder: (Due to testicular defect with
intact hypothalamic - pituitary axis). • Chromosomal disorders: Klinefelter syndrome (XXY).• Undescended testicles.• Infection: Orchitis (after mumps infection in adult life).• Testicular atrophy: after accidental ligation of the testicular
artery during operation.• Chemicals & drugs (cemetidine- spironolactone - heavy metals –
insecticides – beta blockers-ethanol- nitrofurane –excessive smoking & narcotics).
• Immunological disorders: antisperm-antibodies may develop after orchitis or testicular trauma suppression of spermatogenesis.
• Malnutrition.• Chronic illness (malignancy- tuberculosis & renal failure).• Aging is associated with reduced spermatogenesis.• Idiopathic.• Irradiation.
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2- Defective seminal plasma:• Chronic infection of accessory reproductive glands (prostatitis or
seminal vesiculitis) Pyospermia or leucocytospermia (Excessive pus in semen) hostile to sperm impaired sperm function & motility.
3- Duct obstruction:• Bilateral obstruction of the epididymis, vas deferens or
ejaculatory ducts (may be congenital, inflammatory or accidentally ligated) obstructive azoospermia.
4- Coital defects:• ↓ Frequency: due to stress, travel or marital problems).• Impotence: psychologic or organic (due to diabetic neuropathy,
secondary to drugs as β-blockers or cimetidine).5- Defective ejaculation:• Premature ejaculation or hypospadias sperm deposition extra
vaginal.• Retrograde ejaculation: (due to prostatectomy, diabetic
neuropathy or drugs)
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Evaluation of the male factor of infertility:
A. History:- Age & occupation: exposure to heat, chemicals or irradiation.- Habit: smoking, alcohol or drugs.- Pubertal development & undescended testis.- Orchitis or genital infection.- Genital tract surgeries.- Detailed coital history (potency, frequency). B. Physical examination:- General examination:- Nutritional status (over & under weight)- Systemic disorders (thyroid enlargement)- Secondary sex characters, hair distribution & gynecomastia.- Local examination:- Penile: anomalies as hypospadias - Testes: number, size, consistency & varicocele.- Rectal examination: to detect prostatic enlargement.
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C. Investigations of the male factor of infertility:
i. Semen analysis:Done by direct visualization under
microscope or by computer (CASA: computer assisted semen analysis).
Semen is obtained after 2-5 days of abstinence period by masturbation or coitus interruptus into a clean container.
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Volume Normal: 2-6 ml
> 6 ml may be due to chronic prostatitis or seminal vesiculitis.
<2 ml may be due to obstruction or retrograde ejaculation (hypospermia)
Sperm count: > 20 million/ml (new WHO strict criteria: < 15 million/ml)
Reaction (pH): 7.2-8 (alkaline)
Liquefaction: Completed within 30 minutes.
Motility: > 50 % motile
morphology: > 30 % is considered normal according to the WHO criteria.
Agglutination: not exceed 10 %.
Cellular elements:
< 5 x106/ml rounded cells of which < 1x106/ml are WBCs.
Semen Analysis
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. Testicular biopsy:•To differentiate between obstructive &
non-obstructive azoospermia. •Should be done where facilities for sperm
freezing is available.
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Treatment of male infertility:
A. Non-specific measures:- Correction of unfavorable conditions
(stress, excessive smoking, alcohol …).- Weight reduction.- Preserve testicular low temperature by
avoiding tight clothes, cold showers.- Treatment of systemic & endocrinal
disorders as hypothyroidism & diabetes.- Vitamins & minerals supplements.
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B. Medical treatment: Hormonal therapy:• Estrogen like compounds: clomiphene citrate & tamoxifen
have been used in treatment of oligospermia.• Gonadotropins:
▫ FSH & hCG may be used in treatment of hypogonadotrophic hypogonadism
• Androgens:▫ Testosterone or synthetic androgen may be used in cases
of oligospermia & asthenospermia.• Bromocriptine: In case of hyperprolactinemia.
• Antibiotics: In cases of chronic infection of prostate & seminal vesicles.
• Steroid therapy: In cases of immunological infertility associated with the presence of antisperm antibodies.
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C. Treatment of erectile & ejaculatory disorders:
- Psychotherapy & Sildenafil (Viagra).- α adrenergic agonists: in retrograde
ejaculation to increase the tone of urethral sphincter.
- ART: as IUI. D. Surgical treatment:- Varicocelectomy.- Short-circuit operations: in cases of
obstructive azoospermia.
All these modalities are less important after ART
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E. Assisted reproductive techniques (ART) :
1- Artificial insemination (intrauterine insemination IUI):
• in cases of poor semen quality (oligospermia, asthenospermia, teratospermia & leucocytospermia) or in cases of erectile or ejaculatory disorders.
• Technique: Prepared semen is injected into the uterine cavity at the time of ovulation (determined by transvaginal US). Controlled ovarian stimulation may be done to improve pregnancy rate.
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IUI
ICSI
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2- In-vitro fertilization - embryo transfer (IVF-ET) & Intracytoplasmic sperm injection (ICSI):
•Done in cases of severe oligospermia (sperm count < 10 million /ml) or azoospermia.
N.B.: IMSI: using a high power magnification to select morphologically normal sperms for ICSI
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Other methods of assisted reproductive techniques (rarely done):
a) Gamete intrafallopian transfer (GIFT):•The ovum & the sperm are placed into a
patent fallopian tube via laparoscopy.b) Zygote intrafallopian transfer (ZIFT):•A zygote is placed into a patent fallopian
tube via laparoscope.c) Subzonal insemination (SUZI):•A small hole is made in the zona pellucida
by micromanipulation (zonal drilling) then a sperm is introduced in the perivitelline space under the zona.
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Ovarian factor of infertility
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Incidence: 30-40 % of female infertility.Causes:•Ovulatory failure (i.e. anovulation).•Luteal phase defect (LPD).
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• A. Ovulatory failure (anovulation):• Causes:• i. Hypothalamic disorders:• By altered GnRH or dopamine release (prolactin
inhibiting factor).• Stress, psychological & environmental upsets
desire or fear of pregnancy.• Body weight changes: obesity or underweight
“anorexia nervosa”• Drugs:
▫Hormonal contraceptives (post pill amenorrhea).▫Antidepressants & Phenothiazine derivatives.
• Hypothalamic syndromes: as Kallmann’s, Fröhlich, Chiari-Frommel, Laurence-Moon-Biedl syndromes, all are associated with hypothalamic dysfunction ovarian dysfunction & anovulation.
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• ii. Pituitary disorders:• Prolactinoma (micro or macroadenoma):
hyperprolactinemia ovariandysfunction & anovulation.
• Sheehan's syndrome & panhypopituitarism.• iii. Other endocrinal disorders: may be associated with
ovarian dysfunction & anovulation such as:• Thyroid dysfunction: hypothyroidism or hyperthyroidism.• Adrenal dysfunction: Cushing's syndrome & adrenogenital
syndrome.• Uncontrolled DM.• iv. Ovarian dysfunction:• Ovarian dysgenesis.• Ovarian resistant syndrome.• Premature ovarian failure. • Polycystic ovarian syndrome.• iv. Chronic debilitating diseases.
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• B. Luteal phase defect:• In which the luteal phase may be: • Too short (< 8 days ) or • Inadequate progesterone release by corpus
luteum.• Both cause lead to implantation failure of
fertilized ovum or early pregnancy loss.
• N.B.: Luteinized unruptured follicle (LUF) syndrome: Characterized by normal biological & biochemical manifestations of ovulation with no release of ovum. LUF syndrome is usually due to inadequate folliculogenesis.
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Evaluation of the ovarian factor:
History:• Menstrual history (as regular cycle exclude ovulatory
cause).• History of post partum hemorrhage (Sheehan’s syndrome).• History of psychological, stress & weight changes (weight
loss or obesity).• History of chronic & endocrine dysfunction.• History of drug or hormonal contraceptive intake.
Physical examination:▫ General examination: for secondary sex characters
(exclude Turner's stigma, hirsutism & galactorrhea) & thyroid enlargement.
▫ Local examination: To exclude abnormal development of the genital system, adnexal cysts or tumors.
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•Diagnosis of ovulation:▫Symptoms suggestive of ovulation :
Regular menstruation. Mid-cyclic pain (Mittle Schmerz), mid-cyclic
spotting & mid-cyclic excessive mucoid vaginal discharge.
Basal body temperature chart: as Progesterone is a thermogenic hormone causes ↑ body temperature by 0.3 - 0.5 ° C.
•Temperature is recorded daily in the early morning & blotted on chart, Biphasic curve of basal body temperature is characteristic of ovulation.
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Hormonal assay:▫Serum progesterone: measured in mid-luteal phase
(usually day 21 of 28 days cycle). The most important.Serum progesterone 10 ng/ml or more indicates
ovulation.▫LH: Detection of LH.▫Urinary pregnanediol (metabolite of
progesterone excreted in urine after ovulation.Premenstrual endometrial biopsy: • Progesterone secreted by the corpus luteum secretory
endometrium. • So endometrial biopsy taken 2 days before the expected
menstruation (in case of regular cycles) or on the first day of menstruation (in case of irregular cycles) shows secretory endometrium in cases of ovulatory cycles.
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Vaginal cytology:E2 secreted by the growing follicles
changes in the exfoliated vaginal cells cells are separate, large, polyhedral with eosinophilic cytoplasm and pyknotic nuclei & have no folded edges.
Vaginal smear is clean (i.e. no leucocytes are present).
Progesterone moderate sized oval cells with basophilic cytoplasm and vesicular nuclei & folded edges. The cells tend to aggregate in clumps.
Vaginal smear is dirty (i.e. contains leucocytes).
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Cervical mucus changes:•The pre-ovulatory cervical mucus
(estrogenic) is:▫Clear, acellular, copious & less viscous ▫Can be stretched between two points into
threads (positive Spinnbarkeit test) ▫Shows arborization or palm-leaf appearance
on drying (positive Ferning test).•The post-ovulatory cervical mucus
(Progesterone) is ▫Cellular, Scanty & viscid▫Negative both Spinnbarkeit & Ferning tests.
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•Ultrasound monitoring :▫Transvaginal ultrasound
is used to monitor follicular growth until the dominant follicle reaches 18-25 mm in diameter (mature follicle).
▫Ovulation is characterized by a sudden reduction in the size of the follicle ± appearance of fluid in Douglas Pouch.
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•Laparoscopy & transvaginal endoscopy (fertiloscope):▫The hole for release of mature follicle
(stigma of ovulation) can be seen by laparoscopy.
▫Corpus luteum (yellow) can be seen by laparoscopy or fertiloscope in ovulatory cycles.
•N.B.: laparoscopy is not a routine for diagnosis of ovulation, but diagnosis of ovulation is done during laparoscopy for investigation or management of a case of infertility.
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Fertiloscope
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IV. Diagnosis of luteal phase defect:By:•Serial serum progesterone assessment.•Endometrial biopsy: Endometrium is out
of phase (i.e. the histological dating is behind the cycle dating by more than 2 days).
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The most important :1- Mid luteal serum progesterone
2- U/S follicular scanning3- BBT chart
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Treatment of defective ovarian factor:
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A. Treatment of ovulation failure (anovulation):
I. Medical induction of ovulation:a) Estrogen-like compounds: - Act on the hypothalamic-pituitary axis.- Compete with E2 for the estrogen
receptors escape of the hypothalamus & anterior pituitary gland from the estrogen negative feed-back mechanism GnRH pituitary FSH & LH ovarian stimulation & ovulation.
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Clomiphene citrate:•It is non-steroidal drug, has both
estrogenic & antiestrogenic effects. Tamoxifen:Side effects of estrogen-like compounds: •Ovarian hyperstimulation.•↑ rate of multiple pregnancy.•Hot flushes & visual disturbances.
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b) Gonadotropin therapy (FSH): Preparations of FSH:
Human menopausal gonadotropin hMG. Purified FSH. Recombinant FSH (manufactured by genetic
engineering).• Administered (IM injections) is done by different
induction protocols according to the condition & follicular response monitored by the TV ultrasound.
• When the stimulated follicles reach 18 mm bt TVUS hCG (5000 IU) is given to trigger ovulation.
• Careful monitoring during gonadotropin therapy is important to ensure successful outcome & avoid ovarian hyperstimulation syndrome (OHSS) by:▫Serial serum E2.▫TV Ultrasound monitoring of follicles size & number.
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Side effects & complications:•Ovarian hyperstimulation•Characterized by: •Abdominal distension.•Nausea.•Vomiting. •Diarrhea.•Ovarian enlargement.•In severe cases: ascites, pleural effusion,
hypovolemia & thromboembolic disorders due to hemoconcentration.
•Multiple pregnancies.
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GnRH therapy: Agonist and Antagonist• Is indicated in hypothalamic dysfunction (Given in
pulses of 10-20 µg at 90 minutes intervals (IM or subcutaneously) by a pump).
• But used mainly to down regulate the pituitary prior to ovulation induction with HMGto ensure maturation of all follicles at the same time and to prevent premature LH surge.
• Or: given to suppress ovulation in cases of endometriosis as a treatment.
Dopamine agonist therapy:• Bromocriptine (2.5-5 mg/day) or Lisuride (0.2-0.4
mg/day) in cases of hyperprolactinemia.
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II. Surgical induction of ovulation:Laparoscopic wedge resection: obsolete operation done in cases of PCOs, but
seriously affects ovarian reserve.Laparoscopic ovarian drilling: (by electrocautery) in cases of polycystic
ovarian disease (its use should be limited to PCO resistant cases to medical Rx).
Other surgical procedures:•Surgical excision of prolactinoma in case of
hyperprolactinemia.•Surgical excision of adrenal tumors.
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Ovarian Drilling
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B. Treatment of luteal phase defect:- Induction of ovulation followed by
progesterone (IM, oral or vaginal) given during the luteal phase.
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Vaginal factor of infertilityThe vagina may be unable to receive the
semen or its secretion or discharge is hostile to the sperm.
Etiology of defective vaginal factor:•Congenital vaginal anomalies:
▫Vaginal aplasia, atresia or hypoplasia▫Vaginal septum: transverse or longitudinal
•Acquired vaginal stenosis: post operative or post infection
•Vaginismus: aparuria or failure of intercourse
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•Evaluation of the vaginal factor:
•History & vaginal examination: to know the cause.
•Treatment:•Surgical correction of vaginal congenital anomalies, surgical excision of vaginal tumors.
•Psychotherapy for cases of vaginismus.
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Cervical factor of infertilityFunctions of Cervical mucus:• Sperm capacitation: by providing energy supply
during transport through the cervical canal.• Ferning: cervical mucus at time of ovulation is
arranged in lanes to facilitate ascent of sperm, while in the luteal phase it forms a network with narrow meshes impenetrable to sperm.
• Neutralizes vaginal acidity.• Acts as a reservoir for continuous supply of
sperm to the fertilization site in the fallopian tubes.
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Etiology of cervical infertility: •Organic cervical disorders:
▫Stenosis: Congenital or acquired.▫Tumor or polypi, benign or malignant
tumors.▫Infections: chlamydia & mycoplasma
infections.•Functional disorders of the cervical
mucus:▫Quantitative: Inadequate cervical mucus
secondary to cauterization or to antiestrogenic drugs as clomiphene citrate.
▫Qualitative: hostile mucous due to presence of antisperm antibodies.
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Evaluation of the cervical factor:• History & examination: cervical stenosis, infection or
cervical tumors.• Post-coital test PCT(Sims-Huhner Test):
N.B.: regarding evidence-based medicine the role of the PCT has been questioned and its use has become controversial.
Evaluation of the cervical mucus score:• 4 parameters are graded (Each parameter is given a degree
from 0-3):- Amount.- Stretchability.- Ferning.- Degree of opening of the external os.
-Cervical mucus score < 8 weak estrogenic stimulus.-Cervical mucus score > 8 considered normal.The number & motility of sperm in the cervical mucus (by high
power field):
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Results of PCT:Positive post-coital test: > 5 motile sperm/HPF with
progressive motility.• A positive PCT means that there is:
▫Normal spermatogenesis.▫Normal coitus.▫Normal ejaculation & adequate cervical mucus.
Non-conclusive PCT: 1-5 motile sperm/ HPF usually indicate oligospermia.
Negative post-coital test : • Negative PCT if:
▫No sperms in cervical mucus either azoospermia or a coital-ejaculatory defect.
▫ Immobile or agglutinated sperms presence of antisperm antibodies in the cervical mucus (i.e. immunological infertility).
▫False negative.
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Post Coital Test
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IV- Antisperm antibodies test:•To detect antisperm antibodies in serum
or in cervical mucus.V- Culture & sensitivity test of the
cervical mucus:•To detect the chlamydia, mycoplasma or
other cervical infections.
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Treatment of cervical factor:IUI is the most common treatment
modality for cervical factor whatever the cause
Treatment of cervical infections: •By proper antibiotics after culture &
sensitivity. Treatment of insufficient, viscid cervical
mucus:•Oral doses of ethinyl estradiol 10 µg 3
times daily for 3 days from day 11-13 of the cycle may improve the cervical mucus quality.
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•Treatment of immunological infertility:▫Condom used for 6 months then coitus is
allowed without condom during the fertile period of the woman.
▫Corticosteroid: results are controversial.•Surgical treatment of organic cervical
disorders: Cervical dilatation in cases of congenital or
acquired cervical stenosis. Surgical removal of cervical tumors.
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Tubal factor of infertilityFunctions of fallopian tubes:•Pick up & transport of the ovum to the
site of fertilization.•Capacitation of the sperm & its transport
to the site of fertilization.•Nourishment & maturation of the oocyte.•Transport of the fertilized ovum to the
uterine cavity.Incidence:•Tubal factor of infertility is responsible for
30-40 % of the female infertility.
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Etiology:Bilateral tubal obstruction:• Congenital tubal aplasia or atresia (rare).• Salpingitis: the commonest cause of tubal obstruction, it may
be caused by specific organisms (gonococcus- chlamydia or tuberculosis) or by non-specific bacteria following childbirth, abortion or the use of IUDS.
• Previous surgery on or near the fallopian tubes.• Tumors of the uterus (fibromyomata) or broad ligament cysts
or tumors.Pelvic adhesions secondary to:• Pelvic peritonitis, appendicitis or diverticulitis.• Pelvic endometriosis.• Pelvic & peri-tubal adhesions may interfere with the pick up
of the ovum either mechanically or by biochemical substances (PGs & interleukins) that affect tubal motility.
• Pelvic adhesions & pelvic endometriosis are referred to as peritoneal factor of infertility.
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Tubal patency is evaluated using one or more of the following methods:
a- Tubal insufflation or Rubin's test (not done, only for historical interest)
b- Hysterosalpingography (HSG)c- Laparoscopy.
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• b- Hysterosalpingography (HSG):Technique: By injecting a radio-opaque dye through the
cervix.Timing: Post-menstrual (last day of menstruation) to ensure
open cervix and exclude pregnancy.Criteria of tubal patency:• Both tubes are finely delineated.• Free peritoneal spill in the second X-ray filmAdvantages:• Outline the uterine cavity detect congenital uterine
anomalies, submucous fibromyomata & intrauterine adhesions.
• Tubal patency: the site of the tubal block can be determined.• Other tubal pathology: hydrosalpinx, tuberculous salpingitis. • Peritoneal or peri-tubal adhesions.Disadvantages:• Ascending Infection.• Allergic reactions.
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c- Laparoscopy:• It is the method of choice in investigating the tubal
& peritoneal factors of infertility.Advantages: can reveal :
▫Tubal patency (chromopertubation). ▫Pelvic & peritoneal adhesions.▫Ovarian & pelvic endometriosis.▫Pathological lesions of the uterus (congenital
anomalies- fibromyomata ) or the ovaries (PCOS. Tumors or rndometriosis)
d- Others• Culdoscopy (transvaginal laparoscopy).• Salpingoscopy.• Falloposcopy.• Hysteroscopic tubal cannulation.
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Treatment of defective tubal or peritoneal factors
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A. Tubal surgery:Tubal surgery is also of limited value in tubal infertility:B. Laparoscopic:• Adhesiolysis: dissection & cutting of pelvic adhesions or
peri-tubal adhesions.• Fimbrioplasty: in cases of distal tubal block.• Tubal anastomosis: in cases of segmental tubal block.C- Hysteroscopic or ultrasound tubal cannulation:• In case of corneal tubal block. D. ART: (IVF-ET):
The line of management of choice in tubal factor of infertility
• Success rate is high (30-40 %).• N.B.: it may be necessary to remove a damaged
fallopian tube (e.g.: hydrosalpinx) by operative laparoscopy to increase the success rate of IVF-ET.
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Uterine factor of infertilityEtiology: •Uterine aplasia, rudimentary or hypoplastic
uterus.•Uterine anomalies as septate, subseptate,
bicornuate uterus....•Refractory or non-responsive endometrium to
ovarian steroid hormone.• Intrauterine synechia (Asherman's syndrome).•Tuberculous endometritis.•Uterine fibromyomata.•Adenomyosis.
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Diagnosis:•History.•Examination.•Investigations:
▫Endometrial biopsy: Reveals the responsiveness of the
endometrium to ovarian hormones & tuberculous endometritis.
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▫Ultrasound:▫2D Transvaginal:
Uterine size, position, congenital anomalies & tumors of the uterus.
Uterine index: gives an idea about the degree of development of the uterus.
Others▫SIS.▫3&4D US
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▫HSG: To diagnose uterine congenital anomalies,
intrauterine adhesions, submucous fibromyomata..
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▫Hysteroscopy: For direct visualization of the interior of the
uterus, diagnosis and surgical correction of intrauterine adhesions, uterine anomalies & submucous fibromyomata.
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Treatment of uterine infertility:i. Medical treatment:• Antituberculous therapy for 12-18 months is
beneficial for tuberculous endometritis.• Estrogen hormonal therapy may be of value in
case of uterine hypoplasia.ii. Hysteroscopic surgery:• Resection of the uterine septum, intrauterine
adhesions or submucous fibromyomata.iii. Myomectomy:• Indicated in cases of submucous fibromyomata
causing repeated pregnancy loss or fibromyoma compressing the cervical canal or the interstitial part of the fallopian tubes .
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Unexplained infertilityDefinition: • Failure of a couple to conceive with no identifiable cause &
the investigations of infertility reveals no abnormalities.
• Before considering infertility as an unexplained problem the following criteria should be present:▫ No identifiable cause could be detected by clinical
examination of both partners.▫ Normal semen parameters by analysis of two specimens.▫ Normal ovulation & adequate luteinization.▫ Positive post-coital test.▫ Patent & functioning fallopian tubes.▫ Normal uterine factor by HSG, HSK & endometrial biopsy.
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•Treatment of unexplained infertility:•Unexplained infertility should be
managed by assisted reproductive techniques:▫Controlled ovarian hyperstimulation +
IUI: This procedure has to be repeated for 3 trials.
▫IVF-ET.▫ICSI.
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THANKS