Management of Infertile Couple

8/9/2019 Management of Infertile Couple

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Management of

infertile couple

Dr. Salma Kafeel QureshiConsultant obstetrician & Gynecologist

MBBS (Pb) !"C#G ($K)Sonologist %i'ural secialist ($K)! secialist (Sy'ney *ustralia)+#D Quai',e,*-am nternational +osital


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Infertility

Dening infertility * oman of rero'ucti/e age ho has

not concei/e' after 0 year ofunrotecte' /aginal se1ual intercoursein the absence of any 2non cause ofinfertility shoul' be o3ere' further

clinical assessment an' in/estigationalong ith her artner.

4 5C%6ne 7809:


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Oer an earlier referral forspecialist

consultation the oman is age' 9; years or o/er

there is a 2non clinical cause ofinfertility or a history of re'isosingfactors for infertility.

45C% 6 ne 7809:


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Incidence of infertility

nfertility is a common clinicalroblem. t a3ects 09< to 0=< ofcoules orl'i'e

Pre/alence of infertility in Pa2istanisaro1imately 77< rimary nfertility0?< secon'ary infertility

5eelofar S @a-een SA The cultural politics of gender for infertile

women in Karachi, Pakistan nGender Studies Conference

. South*frica6 788;


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Multiple "auses of Infertility#$lo%al

Causes ofnfertility

Centers for Disease Control an' Pre/ention. 788; *ssiste' "ero'ucti/e @echnology Success "atesA 5ational Summary an'!ertility Clinic "eorts. 788?. httA.c'c.go/*"@*"@788;=8?PD!788;*"@.'f. *ccesse' *ril 78 788.


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"auses of Infertility#Pakistan

Tu%al %locked& '()

O*ulatory failur& '+)

seual dysfunction& -)

.ndometriosis& /)

Mucus hostility& ')

tu%o#o*arian mass& ')

0neplained& +)

Multiple factors 1female only2& '')

Multiple factors 1male 3 female2& '4)

Multile factors

(male E female)

6haheen et al, Pakistan. /ol. >7(>) . 9?,99 7808.


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Minimal In*estigation

@ests establishe' correlation ithinfertility

Semen *nalysisMi' Futeal rogesterone o/ulation

'iagnosis@ubal Patency test (+SG or

Faroscoy)


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7istory#taking

!ocuse' history ta2ing ,infertilecoule.

Goo' history is Gol' stan'ar' toin/estigate un'erlying roblem!emale PartnerAPresent history menstrual history obstetric

contraceti/esurgeries or serious illness se1ual history !amily history

Male PartnerAPresent history contraceti/e surgeries or serious illness

!amily history se1ual history


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8ocused clinicaleamination

8emale Partner9:asic In*estigation9General %1amination

*b'ominal %1aminationBreast %1aminationGenital %1amination+ormonal assay;d*anced In*estigations

@rans/aginal ultrasonograhy+ysterosalingograhy or+ysterosalingocontrast,sonograhyFaaroscoy+ysteroscoy


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0ltrasound ofendometrium

lutealluteal

early follicular

triple line


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Laparoscopy

Looking inside the abdominal cavity


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.ctopic

*Prof " Gyaneshar 09


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Pel*ic Infection and Tu%alDisease

*Prof " Gyaneshar 0>


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Pel*ic Infection and Tu%alDisease

*Prof " Gyaneshar 0=


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.ndometriosis

*Prof " Gyaneshar 0;


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Hysteroscopy

Looking inside the uterus


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1 2

3 4


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Investigation of suspected tubal and uterine abnormalities:

2. Hysterosalpingo-contrast-ultrasonography

- TVS scan during which air and saline or a solution of D-galactose is

infused into the uterine cavity and observed to flow along the fallopian

tubes.- Requires ore e!pertise.

- "ess invasive.

Hysterosalpingo-contrast-ultrasonography


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8ocused clinicaleamination

Male Partner9General %1amination

Semen analysis*nti,serm antibo'ies;d*anced In*estigations+ormonal assay

@esticular biosy


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Male Infertility

olumeA 7,=ml +A H.7,H.?

FiIuefaction timeA ithin >8 mins. Serm CountA ,78,078 millionml

(J+# Criteria) Serm motilityA =8< after L hour.

Serm MorhologyA =8< normal.


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;%normal 6emenParameters#ligosermiaA , serm count 78

millionmlMil'A ,08,78 millionml

Mo'erateA ,=,08millionmlSe/ereA ,= millionml.

*-oosermiaA , *bsence of singleserm in eNaculate.

*sthenosermiaA ,Serm motility=8< normal

serms associate' ith oor fertility


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:uilding %urden#infertility

Quac2s +a2eems

Dayaa ne1erience' ractitioners


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Treatment Options forInfertile couple

8emale Partner5on,n/asi/e @reatment Counseling

n'uction of #/ulation ntra,uterine nsemination ($) n/asi/e @reatment @ubal surgery

n,/itro !ertili-ation (!) an' %mbryo

transfer(%@) G!@ O!@


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Treatment Options forInfertile couple

Male Partner5on,n/asi/e @reatment

Counselling ntra,uterinensemination ($) n/asi/e @reatment Surgical restoration of 'uct

atencyntra,cytolasmic Serm

nNection (CS) PGD.

@%S% P%S% @%S* M%S*.


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O*arian 6timulation

>oung PatientMinimal StimulationCC or letro-ole

Poor responder or poor o*arianreser*e=;ge ?@- years

(melatonin D+%* %C%F)nN. F+ !S+ H=$Poly"ysticO*aries 1P"O2Diane,9=an'rogenFe-ranN. r!S+ H=$


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OA0


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"lomiphene "itrate

DoseA =8,088 mg.'ay. starting 'ay 79> or = for = 'ays.

Monitoring conRrm o/ulationA ultrasoun' F+ 2its F+ serum le/els 'ay 70 rogesterone.


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"" Pathways


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h"$ *s


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;no*ulatory cycles

Clomihene citrate (all 'oses) as associate' ithan increase' regnancy rate er treatment cycle

f still ano/ulatoryafter ; months of continuous use

the case is consi'ere' clomihene resistantT

Meta,analysis by +ughes et al 7800


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The ;romatase Inhi%itors

Fetro-ole (F%O"* 7.= mg)

e3ecti/e inano/ulatory infertility.

t has the folloinga'/antagesA

0, t re'uce %7 le/el.7, t a/oi's the

unfa/orable e3ectson the en'ometriumfreIuently seen ithCC


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Pregnancies an' li/e births are achie/e' moree3ecti/ely an' faster after # ith lo,'ose !S+

than ith CC.

@his result has to be balance' by con/eniencean' cost in fa/our of CC.

!S+ may be an aroriate Rrst,line treatmentfor some omen ith PC#S an' ano/ulatoryinfertility articularly ol'er atients.

+omburg et al 7807

CC or low-dose FSH for the first-line treatment of

infertile women with PCOS:


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Metformin

@he a''ition of metformin in the CC,resistant atient is highly e3ecti/e in

achie/ing o/ulation in'uction.

Meta,analysis by Siebert et al 7809

P l ti 5 d i


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Prolactin 5educingMedications

, !or +yerrolactinaemia associate'infertility.

CausesA Pituitary a'enoma (rolactinoma). +yeracti/e lactotrohs. Me'icationsA tranIuili-ers hallucinogens ain2illers

alcohol..

Diseases of the 2i'ney or thyroi' glan'.

Doamine agonistA , Bromocritine.

, Quinagoli'e.

, Cabergoline

$ d t i


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$onadotropins 9Indications

n'icationsA ,!ailure to reson' to antiestrogen

theray *t least 9 cycles of C.C. an' no o/ulation DoseA 8,788mg'ay for H 'ays.

*t least ; #/ulatory cycles an' not concei/e'.

,Si'e e3ects to antiestrogen therayirresecti/e of o/ulation

,@o or more miscarriage after C.theray.


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"" =


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Hypothalamus

Late follicular and

luteal phases

1

1

2 2

2

3

4

5

5

6

8

8

7

Slightly

elevated

estrogenand rising

inhibin

levels.

Positive

feedbac e!erted

by large inestrogen

output.

"ature follicleCorpus luteum

Ovulated

secondary

oocyte

#uptured

follicle

$H surgeProgesterone%strogen

&nhibin

Hypothalamus

Early and midfollicular phases

'ravels via

portal blood

(ranulosa

cells

&nhibin

)ndrogens

Convert

androgens to

estrogens

'hecalcells

)nterior pituitary

(n#H

FSH $H


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Thank you

Management of Infertile Couple

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