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Human Reproductive Disorder. Xulan Dept. of G & O, the First Affiliated Hospital of Shantou University Medical College. Introduction of Infertility ※ Definition Fecund: the ability to reproduce, typically used in context of women to become pregnant.

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human reproductive disorder
Human Reproductive Disorder

Xulan

Dept. of G & O, the First Affiliated Hospital of Shantou University Medical College

slide2
Introduction of Infertility

※ Definition

  • Fecund: the ability to reproduce, typically used in context of women to become pregnant.
  • Infertility: the inability to conceive after two years or more of trying with unprotected intercourse for couples.

( WHO, one year)

slide3
Primary infertility: no previous pregnancies have occurred
  • Secondary infertility: a prior pregnancy has occurred, but inability to conceive again for two or more years exposure to intercourse, no matter how the result of the pregnancy is.
slide4
What are the chances of a fertile couple actively seeking pregnant in a single month or cycle? 10%-20%
  • The accumulated pregnancy rate during two years

__chances of conceiving by 6 months: 75%

__chances of conceiving by 1 year:90%

__10%-15%of couples will require longer than one year to conceive.

slide5
Epidemiology and etiology of infertility

Causes Percentage

Female factors 30-50 %

Male factors 30 %

Both male and

female factors 20 %

unexplained factors 10 %

So, the initial evaluation should include both the partners.

slide6
※ Female Infertility
  • Causes
  • Ovulatory dysfunction: 25%.
  • Tubal factors: 30%-50%

3. Pelvic factors

4. Cervical factors

5. Extra-genital tract factors

6. Others

female factors
Female Factors

Hypothalamus

Pituitary

Follopian tube

Uterine

ovary oocyte

Cervix

Extra-genital tract

Fig.1sperm

Thyroid

Adrenal

slide8
Ovulatory dysfunction

1. Hypothalamus: amenarrhea or mensrtual disorder

-- Emotional depress

-- Psychological trauma

-- Environmental and Climate changes

2. Pituitary diseases:

--Sheehan’s syndrome

-- Pituitary tumor: Hyperprolactinemia,

-- Empty sella syndrome

slide9
Ovary diseases:

1. Congenital dysformation:

Turner’s syndrome(45,XO)

2. Polycystic syndrom(PCO)

3. Premature ovary failure(POF)

4. Ovary functional tumors

5. Insensitive to follicle stimulating hormones(FSH).

6. Other endocrinologic diseases: adrenal or thyroid dysfunction

slide11
● Pelvic Factors

Tubal factors: tubal blokage, adhension and hydrosalpinx

1. Inflammations

--Chlamydia

--Gonorrhea

--Tubercle bacillus and so on

2. Tubal dysformation

3. Pelvic adhension: endometriosis

4. Abdominal or pelvic surgery

5. Ectopic pregnancy

slide13
●Pelvic factors

Pelvic Adhension

1.Inflammations:

--Chlamydia, turbercle bacillum, gonorrhea, staphylococci and so on

2. Pelvic endometriosis

3. Pelvic surgery

●Reproductive system dysformation

-- Mayer-Rokitansky- Kuster-Hauser syndrome: no uterus and vagina

slide14
-- Uterus didelphys

-- Uterus bicornis

-- Uterus septus

-- Uterus unicornis

-- Rudimentary horn of uterus

-- others

slide25

Fig.13-1

Fig.13-2

slide26
Cervical factors

-- Cervicitis :

cervical erosion,

cervical polyps,

cervical hyperplasia

-- cervical stenosis

-- Cervical tumors: leiomyoma

-- Cervical cancer

slide27
●Extra-genital factors

-- Vulvo-vaginalitis

-- Vulvo-tumors

● Others

--Immunological factors:

autoimmune response;

auto-antibodies: AsAb, ACA, ANA, etc.

-- Genetic factors

-- Psychological factors:

-- Unexplained causes

slide28
Evaluation and diagnosis

Initial evaluation

The initial visit is the most important; the infertility is a problem of both of the couple; so, the male partner should be present at the beginning.

slide29
1. Taking history:

-- marriage, menarche, menstruation

-- duration of sexual relationships with or without birth control

-- methods of birth control

-- reproductive history of both partners (ie: children with previous partners/marriages)

slide30
2. Physical examination (PE)

--General development

-- Secondary sexual characteristics

3. Pelvic examination (PV)

-- Bimanual exam

-- Rectal-vaginal exam

slide31
4. Breast exam: masses and galactorrhea

5. Laboratory:

-- hormonal testing:

-- urinary LH surge test

-- vaginal shedding cells test

-- cervical mucus test

-- post-coital sperm—cervical mucus test

6. Assisted imaging examination

-- Ultrasound B continuous monitoring

-- HSG

-- Hysteroscopy

-- Laparoscopy

slide32
Treatment for female fertility
  • General therapy

-- Watchful waiting (provide more time for unassisted conception)

-- more frequent intercourse at mid-cycle

-- emotional support

slide33
2. Special therapy

-- treatment of pelvic inflammation disease(PID)

-- hydrotubation:

-- selective salpingogram and recanalization: to make the obstructed site of the tube reopen under X-ray guidance

-- hysteroscopy:removal of submucous leiomyoma, endometrial polyps, complete or incomplete uterus septum and separation of the cavity adhension.

-- laparoscopy: adhension separation, ovarian tumors and leiomyoma removal

slide34
Surgical approaches:

-- ovary cysts and tumors

-- severe pelvic adhension

-- Leiomyomas out of uterus wall

  • Physical treatment for cervical erosion:

-- laser light

-- crpyotherapy

-- electrotherapy

  • Anti-tuberculosis:

-- endometrial tuberculosis

-- salpingotuberculosis.

slide35
Medication therapy
  • Ovulation induction
  • Clomiphene citrate(CC)

M5 50-150mg qn×5

2. CC/HMG/HCG

M5-9 CC 50-150mg

M10-11 HMG 75IU qd

3. LHRH pulsive therapy

4. Bromocriptine---hyperprolactinemia

5. Metformin---PCO

slide36
6. HMG/HCG

M3 HMG 75IU qd

F 18-25mm, EN 8-10mm

HCG10000IU qd

● Progesterone supplement

1. Post-ovulation, progesterone 10-20mg

qd×7-10 days

2. HCG 2000IU-5000IUq3d82

3. Low dosage thyroid 20mg qd

● Assisted reproductive technology (not discussed here)

slide37
Methods to monitor ovulation

-- Luteinizing Hormone monitoring:

LH surge-- ovulation occurs after 34-36 hr,

BBT--simple, cheap, biphasic pattern,

-- Mid-luteal serum progesterone: > 15.7nmol/mL, peak;

-- Premenstrual molimina: 95% presence,

-- Mucus change: thick and cellular, no crystalline fern,

-- Ultrasound monitoring: follicle size 21-23 mm,

fluid in the cul-de-sac.

slide38
※ Male infertility
  • Causes

1. PRE-TESTICULAR CAUSES OF INFERTILITY

a. Hypothalamic disease

  • Isolated gonadotropin deficiency (Kallmann\'s syndrome) 
  • Isolated LH deficiency ("Fertile eunuch") 
  • Isolated FSH deficiency Congenital hypogonadrotropic syndromes
slide39
b. Pituitary disease
  • Pituitary insufficiency (tumors, infiltrative processes, operation, radiation) 
  • Hyperprolactinemia 
  • Hemochromatosis 
  • Exogenous hormones (estrogen-androgen excess, glucocorticoid excess, hyper and hypothyroidism).
slide40
2. TESTICULAR CAUSES OF INFERTILITY
  • Chromosomal abnormalities: Klinefelter\'s syndrome (XXY, karayotype), XX disorder (sex reversal syndrome), XYY syndrome
  • Noonan\'s syndrome (male Turner\'s syndrome)
  • Myotonic dystrophy- Bilateral anorchia (vanishing testes syndrome)
  • Sertoli-cell-only syndrome (germinal cell aplasia)
slide41
Gonadotoxins (drugs, radiation)
  • Orchitis
  • Trauma
  • Systemic disease (renal failure, hepatic disease, sickle cell disease)
  • Defective androgen synthesis or action
  • Cryptorchidism
  • Varicocele
slide42
3. POST-TESTICULAR CAUSES OF INFERTILITY

a. Disorders of sperm transport

● Congenital disorders 

● Acquired disorders 

● Functional disorders

b. Disorders of sperm motility or function

● Congenital defects of the sperm tail 

● Maturation defects 

● Immunologic disorders 

● Infection

3. Sexual dysfunction

slide47
● Evaluation and diagnoses

1.History collection:

-- period of infertility without protected intercourse

-- present and previous marriage,

-- previous fertile history with partners,

-- frequency of intercourse,

-- method of birth control,

-- harmful habits: cigarette, alcohol, drug-injection

slide48
2. Physical examination

-- development of body: height and ratio of

upper body sigment to low body sigment

-- Secondary sexual characteristics

Inadequate body hair

atypical genital hair distribution

gynecomastia

slide49
-- Exam of reproductive system

Size, masses (length, volume and mass) of scrotum

Use orchidometer if possible

Epididymis for scarring ,absence or induration

Vas deferense for absence or nodules

Varicocele

3. Laboratory test

-- Semen analysis

-- Karyotype (chromosome)

slide50
Normal Values for Semen Analysis

Volume > 2.0 mL

Sperm concentration > 20 million/mL

Motility >50 %

A >25%

A+B >50%

morphology >30 % normal

Data from WHO, 1992

slide51
Abnormal Values for Semen Analysis

azoospermia—no sperm found under microscope for at twice SA at two weeks interval

oligospermia—sperm count less than 20 million per 1mL

asthenospermia—the percentage of normal morphology sperm less than 30%

slide52
-- Endocrine test: <3%

FSH,LH,T,PRL,E2,T3,T4,ACTH,TSH,GH

hyperprolactinemia--MR

-- Blood biochemistry

Liver enzymes and blood lipid

-- Immunologic antibody: AsAb

-- Special and sperm function tests

Sperm-Cervical mucus interaction

Sperm penetration assays

Acrosome evaluation

Hypoosmotis swelling

slide53
-- Bacteriologic test

Bacterial culture for urine or prostate gland fluid

and drug sensitive test

Chlamydia trachomatis

Mycoplasma hominus

Ureaplasma urealyticulum

● Treatment

1. Surgical measures

-- Varicocelectomy—varicocele

-- Transurethral resection of ejaculatory duct

slide54
-- Microsurgical epididymal sperm aspiration

-- Ablation of pituitory Adenomas

-- Prophylactic surgical measures—undescended testes

2. Medical measures

--Endocine therapy

HMG,HCG,CC,Bromocriptine

-- Treatment of infection

antibiotics

-- Empiric therapy—herbal treatment

3. Assisted reproductive techniques treatment

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