بسم الله الرحمن الرحیم
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بسم الله الرحمن الرحیم. به کانفرانس علمی عقامت خوش آمدید ترتیب کننده : پوهنمل دوکتور محمد حسن فرید. In the name of god.

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1834993

بسم الله الرحمن الرحیم

  • به کانفرانس علمی عقامت خوش آمدید

  • ترتیب کننده : پوهنمل دوکتور محمد حسن فرید


In the name of god

In the name of god

Definition : if a young couple did not get pregnancy during one year with at least two time intercourse per week ،without using any contraception method ، means infertility

75 - 80 % of couple got pregnancy in 1 year , 20 - 25 % needs more intervention , but around 10 % of these remained infertile.


Most important things for fertility are

Most important things for fertility are ..

In Men

  • Normal spermatogenesis production .

  • Open way for the passage of spermatozoa from testes to the orifice of urethral ( epidydemes , ductus deferent and ductus ejaculatory ).

    In Women

  • Normal oovogenesis.

  • Open way .

  • Normal development of functional endometrial layer ( compact , spongiosa and basal ) .

    Any problems interfere in this 5 maintained procedure can change the condition form fertility to infertility . it is effective from 1 - 100 %. absolutely belongs to the intensity ,location , kind of pathology duration and kind of treatment .


Percentage of getting pregnancy

Percentage of getting pregnancy

  • 25 % in 1 month after marriage

  • 63 % in 6 month after marriage

  • 75 % in 9 “ ‘” “

  • 80 % in 12 “ “ “

  • 90 % in 18 “ “ “

  • 10% rest infertil .

  • 1/3 cases belongs to the men .

  • 1/3 = = = women.

    1/3 = = = both partner (treatment is verey dificult )


Normal semen analysis

Normal semen analysis

  • Volume 2 - 5 ml ( greish , white or yellow ).

  • PH 7.2 - 7 .8 .

  • Sperm count > 20 mil / ml ( 80 - 100 favorable ).

  • Viability > 50 %.

  • Morphology > 50 % normal.

  • Leukocyte < 10 pus cell / ml.

  • Fructose 13 μ mol per ejaculation .


Terminology

Terminology

  • Aspermia : No semen.

  • Azoospermia : Not sperm in the semen.

  • Oligospermia : Low sperm count .

  • Asthenospermia : No motile sperm.

  • Teratospermia : Abnormal sperms .


Favorable condition to take semen

Favorable condition to take semen.

  • 2 -3 days abstinence intercourse.

  • Semen take with masturbation .

  • Within ½ - 2 h must be exam .

  • Don’t use condom .

  • 2-3 time should be exam .

  • Collecting in clean container ( jar )


Male infertility factor

Male infertility factor

A – Defective spermatogenesis

  • Hypothalamus Pituitary failure .

  • Testicular failure: undesending TesTes, agenesis , cryptorachidism , Damage of the T T by radiation, chemotherapy,orchitis (Mumps,T B,Syphlis)& tumors .

  • Exposure of T T to heat (NL<2c ).

  • The T TVaricocle , trauma ,androgen receptor abnormality ,chromosomal abnormality . Enzyme deficiency

    B - Obstruction in the passage :

  • Congenital absents of vas .

  • Block vas due to infection .

  • Block vas due to herniorrhaphy .


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C-- Ejaculatory problems

  • Frequency and timing of intercourse .

  • Hypospadiasis and phymosis .

  • Impotence ( erectile dysfunction ).

  • Premature or retrograde ejaculation.

    D – immunological problems

  • Spermal ab.

  • Cervical mucosa ab.


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E - Medical diseases

  • Diabetes , Thyroid disorders

  • TB , Mumps .

  • Hypertension.

  • Intoxication .

  • Deficiency of vitamins and minerals.

    F – Other factor

  • Smoking .

  • Alcohol.

  • Drugs .

  • Environmental.

  • Age >40 year for male , age > 30 year for female.

  • Cirrhosis.


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  • History

  • Examination

  • Semen analysis

    I-- History

  • Time of ovulation and frequent coitus on that time.

  • Coital difficulty like premature and retrograde ejaculation .

  • Taking drugs like : antihypertensive , antipsychotic , cimetidine ,spirinolacton , oestrogen , excess ( testosterone , smoking , alcohol) and working in hot place can interfere or diminish sperms .

    4 Medical illnesses ( D.M , hypertension , thyroid disease , mumps etc ).


Ii examination a general

II - ExaminationA - General

  • Height : Excess height ( kallman & kalinfelters syndrome ) .

  • Obesity : Hormonal disorder .

  • Secondry sex characters examined any abnormality must be noted .

  • Thyroid gland enlargement .

  • Medical diseases ( D.M , HP , ect ). Must be palpated by special examination to identify it .


B local examination

B - local examination

  • Volume of the T.T ( normal 15 – 35 ml) .

  • Hernia or herniorrhaphy scar .

  • Hydrocele .

  • Testicular , descent , volume ,mobility & consistency.

  • Epididymis ,vas deferent ,Prostate by TR.


C psychological factor

C - Psychological factor

Psychological distress

a -fallopian tube

spasm

Exacerbate angry b –deficiency of g gammete

c – decreased coital f frequency

d – impotence

e - ejaculation p problems

Infertility


Fertilization

Fertilization

  • Sperm passes C.R.

  • Sperm penetrates Z.P by acrosomal reaction & release hyaloronidase ( zonal reaction = ZR ).

  • Z.R inhibits the entry of other sperm .

  • Secondary oocyte is formed by second meiotic division mature ovum come out , called female pronucleous .

  • Within the oocyte the sperm tail degenerated and male pronucleous formed.

  • pronuclie of male and female mixed and zygote formed with 46 chromosome ( sex belongs to the Y chromosome).


Different tests

Different tests

  • PCT (Post coital test) : gives information on immunological aspects and cervical mucosa quality .

    Procedure :

    Intercourse abstinence 2 -3 days . after intercourse specimen aspirated form cervical canal and posterior fornix separately . 10 or > motile sperm forward movement PCT is ok .abnormal PCT 3 - 5 % .

    Another specimen collected from posterior fornix acts as a control .


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  • Sperm cervical mucus penetration test (S.C.P.T): the semen and C.M placed side by side to form interface . the sperm should penetrated > 3 cm of cervical mucus at the end of 2h (ok )

    3 – sperm cervical mucus contact test (S.C.C.T) : Equal amount of semen and C.M mixed. if > 25 % of sperm show jerky movement after 30 min immunological factor is positive (we need control specimen from the semen) .


4 other new tests

4 Other new tests

When above 3 mintioned test & semen count are normal the problem may be on fertilization process must be do it:

  • Zona free egg penetration test : depends upon ability of the sperm to penetrate the zona . free hamster egg more than 10 % penetration considered normal . this test is vary expensive

  • Acrosin reaction ,sperm zona binding are the new technique to study the fertilizing potential of the sperm.

  • U/S & Doppler study show scrotal volum and varicocele

  • Testicular biopsy is indicated in :

    A - In high F.S.H level primary T.T failure is suspected.

    B - when TB of the T.T is suspected .

    C - To study histopathology in presence of oligospermia & abnormal semen parameter .

    D- In azoospermia to distinguish testicular failure from blockage of the vas deferent or unability of the T T.


Advantage of t t biopsy

Advantage of T.T Biopsy

  • Chromosomal study .

  • Cryopreservation of spermatids & sperms can be useful in therapeutic.

  • 5 - intracytoplasmic sperm insemination

  • ( I.C.S.I ) technology .


  • Management

    Management

    • General .

    • Hormonal.

    • Surgical .

    • New teqnique.


    1 general

    1 - General

    • Treat the cause .

    • Improve time & frequency of coitus in the ovulation phase .

    • Scrotal hyperthermia avoided & use ( cold bath & loose undergarment ).

    • Limited alcohol and smoking.

    • Treated medical disorders .

    • Treated infection with antibiotic

    • Immunological factor:

      a – Corticosteroid : 50 mg/d prednisolon.

      b – use condom 3 - 6 months .

      the above 2 mentioned things eliminate antibodies 30 - 40 % .

      c -- Sildenafil ( Viagra ) 25 -100 mg one hour before intercourse, improve erectile function .other method of treatment vacuum pump , local penile implants and local injection . ( have own disadvantage ).


    2 hormonal therapy

    2 - Hormonal therapy

    • low dose testosterone 25 m g / day improve spermatogenesis ( height dose suppresses ).

    • Clomiphene citrate 25 mg /d for 25 days in each month for 6 month .

    • F.S.H / hCG :in pituitary hypofunction. ( FSH 37,5 iu /im twice weekly & increase to 75 iu / im .hCG 2000 iu /im 1 -2 time / weekly continues 6 –12 month ( improvement 60 to 70 %. ( pregnancy 50 - 60 %) .

    • GnRH 50 ng / kg by intervals within infusion pump or 200 mg / day intranasally in hypothalamus dysfunction.

    • Thyroid hormones in hypothyroidism.

    • Bromocryptin in hyper prolactinaemia .

      Note : these drugs must be used at least for 3 month because spermatogenesis process take 72 days time and passage from the T.T takes 2 weeks more time .


    3 surgical

    3 - Surgical

    • Vas vasostomy.

    • Rectified undescended T.T in child hood (in adult results is not good) .

    • Surgery of varicocele ( if the sperm count is abnormal ).

    • Herniorrhaphy .


    4 newer technologies

    4 - Newer technologies

    • Aspermia due to retrograde ejaculation is corrected by giving alpha adrenergic & anticholinergic drugs . Note : urine can be centrifuged & sperm insemination at ovulation time

    • Artificial insemination ( AI ).

    • In vitro fertilization ( IVF )

    • ICSI ,GIFT , ZIFT & IUI

    • Micromanipulation technique : such as zona pilloceda dissection , drilling .

    • Testicular and epidydimal aspiration of sperms when vas is blocked

    • Donor insemination


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    Detail the newer therapeutic technology in male infertility

    • AI

    • IVF.

    • GIFT.

    • ZIFT.

    • Micromanipulation such as zona pillucida dissection drilling .

    • ICSI.

    • IUI.

      Testicular and epididymal aspiration of sperm when vas is blocked .


    Artificial insemination ai indication

    Artificial insemination ( AI) indication:

    • Impotence & hypospadia .

    • Premature & retrograde ejaculation .

    • CMA ( cervical mucosa antibodies) & spermal antibodies .

    • Oligospermia .

    • Unexplained infertility .


    Important factor in female infertility

    Important factor in female infertility

    • H.P.O axis factor .(schedul )

    • Ovarian factor .

    • Tubal factor .

    • Uterine factor.

    • Cervical mucosal factor .

    • Vaginal factor .

    • General factor .

      8. Pshycological factor .


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    Ovarian factor

    • Ovarian agenesis & hypoplasia .

    • Ovarectomy .

    • Impaired ovaries function by radiation , infection etc.

    • Ovarian , cyst.

    • O.Tumor ( granulosal C T & theaca C T).

    • Intractable ovaries to effect of GhRH .


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    Suspected ovulation

    • Monophasic BBT ( must be biphasic ).

    • Vaginal cytology .

    • Vaginal PH .

    • Cervical mucus changes ( fern test +).

    • Endometrial biopsy ( secretary phase + ).

    • Level of progesterone in luteal phase .( high + )

    • Level of pregnandiol in urine

    • Level of 17 hydroxy progesterone .

    • Ostradiol level of plasma.

    • Saliva glucose level .

    • Saliva esterase level.

    • Alkaline phosphates .

    • Normal and regular cycle ( + ).

    • Collapse and shrinking follicle . u/s

    • Collection of fluid in D.G pouch .u/s

    • Corpus luteum formed. u/s


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    Tubal factor

    Important function of the tube are :

    • Transfer released ovum from ovaries to the uterine cavity

    • Permit entry of the sperm from uterus to the tube .

    • Transportation zygote onward the uterus .

    • Creation favorable environment for growth ,development and division of zygote

      The most important defect of the tube are :

    • Tubal aplasia & dysplasia .

    • Tubal blockage congenitally.

    • Tubal complete or incomplete block by infection disease ,XR & etc .

    • Bilateral tuballigation .

    • Tubal adhesion by TB & Chronic PID .


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    Endometrial or uterus factor

    Rule of the uterus in productive process

    • Favorable & appropriate environment for zygote , implantation & development .

    • Protection embryo & fetus from external effect ( trauma , etc ).

      these following factors are interfere in the process of infertility

    • Uterus aplasia .

    • Uterus hypoplasia .

    • Rudimentary uterus.

    • Infantile uterus .

    • Small uterus .

    • Over retroverted or anteflexed uterus.

    • Sub mucosal polyps and fibroma .

    • Acute and specially chronic endometritis.

    • Destroyed endometrium by radiation ,curettage , chemical or burned material.

    • Dfd…..

    • Hysterectomy


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    Cervical factor

    • Absence of mucus by operation procedure like: amputation of cervix ,cone biopsy & diathermy etc &polyps.

    • Miss direction like : Retroversion prolapsus of cervix or uterus .

    • Closed or pin hole cervix .


    Vaginal factor

    Vaginal factor

    • Vaginal aplasia .

    • Vaginal displasia .

    • Vaginal atrophy .

    • Vaginal prolapsus &Tomurs .

    • All kind of vaginitis .

      General factor

      Most of medical diseases ( DM , aneamia , vitamins deficiency , hormonal problems .etc ) have own effects on infertility in both partners.


    Examination

    Examination

    • Height and weight .

    • Secondary sexual organs development.

    • Hirsutisum and PCOD .

    • Presence of glactorrhea .

    • Pelvic examination :( size ,mobility, consistency, location , tenderness , position of the uterus .adnexal masses .

      Investigation

    • Menstrual history .

    • BBT .

    • Cervical Mucosa Test.

    • Progestin level .

    • Endometrial study .

    • U/S.

    • Hormonal assay: FSH , LH , Prolactin , thyroid profile.


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    • U/S

      a – Safe ,non invasive & reliable methods .

      b – Serial u/s monitoring shows growth ,development & rupture of F.du .Graff

      c – Endometrial growth : Normal endometrial growth before ovulation 8- 10 mm thick. normal growth rate 1 -2 mm /d , reaches around 20 mm or more at ovulation time. After ovulation follicle du graff shrink and fluid can be found in Douglas pouch.

      d – By u/s we can precise ovulation days .

      e – dictate administration of hCG .

      f – Retrieval of ova in IVF process.

      g – Also recognized PCOD.


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    Explaination

    • Regular mucus suggest intact H.P.O axis .

    • BBT explained before .

    • Serum progesterone level in 22 – 23 days of the cycle 10 - 15 ng / ml < 5 ng / ml CLPD ( corpus Luteal phase defect )

    • Endometrial biopsy for histopathology examination( TB CLPD, ovulatory phase ) & invasive process.

    • Cervical mucus ( C.M).: Examine for spinnbarkeit test (10 cm stretching in proliferation phase . but in secretary phase cervical mucosa become tenacious and thick. it is unfavorable for sperm to pass it.


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    • Hormonal level

      FSH,LH & prolactine levels can indicates normal or HPO axise dysfunction & or primary ovarian failure.

      A – high LH level in PCOD.

      B – High FSH level inhypothyroidism &hyperprolactenemia.

      C – Low estrogen level in ovarian failure

      D - low progesterone level in L Phase , shows CLP Dificiency.

      E - prolactine more than 25 ng /ml is high.

      schedual


    Tubal test

    Tubal test

    • HSG.

    • Laparoscopic chromotubation .

    • Sonosalpingography .

    • Falloscopy .

    • Salpingoscopy.

    • Insufflation test.

      I - HSG

      I - HSG

      thefirst important diagnostic method for evaluation of tubes. its must be done in 8 – 10 days of cycle .

      Action mechanism

    • Atropine injection to avoid tubal spasm .

    • Folli catheter must be use .

    • Wilkenson or Rubin cannules is used.

    • Water soluble dye better from oil media because of ( chemical peritonitis , granuloma and delayed spillage ) .


    With hsg we can recognized

    With HSG we can recognized

    • Septet uterus .

    • Bicornuate uterus.

    • Unicornuate uterus.

    • Asheerman syndrome.

    • Sub mucosal fibroid .

    • Patency or blockage of tubes .

      falls negative : Tubal spasm like block .

      falls positive : Hydrosalpinx like spellage .

      Tubercular salpingitis : it is cause extravasations of the

      dye and show bilateral corneal block .

      Complication

    • PID.

    • Allergic reaction .

    • Dislodgment of pregnancy.

      Advantages

    • Its a permanent record.

    • Its shows the site of blockage .


    Laparoscopy

    Laparoscopy

    Laparoscopy is indicated if :

    • HSG reported abnormal .

    • Pelvic adhesion suspected .

    • Endometriosis suspected .

      Show that

    • Patency of tube tested ( chromotubation ).

    • External adhesion of tubes.

    • Position of tubo ovarian fimberia.

      We can help these therapy processes

    • Adhisiolysis .

    • Endometriosis ablation.

    • Fimberioplasty .

    • LSC + salpingoscopy.


    Sonosalpingography ssg

    Sonosalpingography ( SSG)

    100 cc serum saline + small amount of air injected transcervical in the cavity of uterus .U/S can screen the movement of the bubble & determined blockage of tube (free fluid in the Douglas pouch indicated patency of the tube in this procedure no risk of x ray & allergic reaction)

    Hysteroscopy falloscopy ( HF)

    • For uterine abnormality pathology of corneal end of fallopian tube .

    • Tubal polyp detection .

    • In this procedure we can do it cannulation & breaking of flimsy adhesions within the lumen

      Salpingoscopy

    • Visualized the fimberial & ampullary portion of the F.T laparascopically.

    • Peritoneal infertility causes can be detected during salpingoscopy .


    Treatment

    Treatment

    A-Treat an ovulation

    • Clomephine citrate 50 mg /d from second day of the cycle . monitoring growth of F Du Graff by U/S until the follicular size reaches 20 m m .the dose may have to increased gradually up to 200mg/d in the non responders. From hyper stimulation syndrome with hCG &antiostrogenic side effect by changing over to letrozal 2.5 mg / d instead of clomephine .When follicular size reaches 20 mm , hCG 5000 iu / im give it. after 36 - 40 hour the follicular ruptured . intercourse must be arranged timely. this regime is given for 6 - 8 month .if the above regime fails following the :


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    • Human menopausal gonadotrophin ( containing FSH) is given in a dose of 75 - 150 iu onward . recombination HMG is expensive but more effective .

    • GnRh sub cutaneous or intranasal in hypothalamic disorder

      Multiple pregnancy (MP)with clomephin & FSH 10 %.

      MP with GnRH 1 % .

      If failed medical therapy , donor egg or adopts with this condition .


    1834993

    POCD responds to clomephen or gonadotrophin stimulation , but hyperstimulation must be watched , if it occur hCG should be withheld in the cycle. If failed medical therapy calls for laparoscopic drilling of the cyst or cauterized.

    • Hyperprolactemia : Hypothyroidism & pituitary adenoma should be excluded or threaded .bromocryptine 1.25 mg TID & increased to 5 mg TID.

    • (CLPD) corpus luteal phase deficiency is rectified by progesterone or hCG in the leuteal phase .


    Tubal infertility treatment

    Tubal infertility treatment

    • Tubal microsurgery ( tubo plasty ).

    • Laparoscopic T adhesiolysis and fimberioplasty .

    • Balloon tuboplasty and canulation through hysteroscopy ( HBT ).

    • IVF ( In Vetro Fertilization ).

      I - Tuboplasty : Excising the blocked portion & anastomosis. success depending on the sit of blockage. ( fimb 25 % , cornual end 50 % , isthemic isthmus anastomosis 60 - 70 %).

      Risk

    • Failure to restore the patency of tube.

    • Reblockage .

    • Ectopic pregnancy.

      two weeks after do it this procedure , needs hydrotubation also .


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    II -Laparoscopy : we can do it :

    • Fimberioplasty.

    • Adhesiolysis .

    • PCOD can be dealt.

    • Endometriosis nodules cauterization .

      III_ Balloon tuboplasty & cannulation .

      Medical end blocked by flimsy adhesion ( 40 % pregnancy occured )

      IV - IVF : we don in :

    • Extensive Tubal damage.

    • Failed tuboplasty .


    Unexplained infertility

    Unexplained infertility

    When all investigation in both male & female are normal we used this term.

    • Counseled on adoption.

    • Used newer technologies are :

      a - IUI ( AI ).

      b - IVF.

      c - ZIFT.

      d - GIFT.

      e - Cryopreservation technique .

      f - ICSI.


    1 iui or iti

    1 – IUI or ITI

    Indication :

    • Male infertility.

    • Cervical mucus hostility with ab.

    • Unexplained infertility .

      Action mechanism :

      ovulation induction . intra uterine or fallopian insemination of washed sperms at ovulation time ( 3 - 4 cycle attempted 30 - 40 % success ).


    2 ivf

    2 - IVF

    Indication

    • Tubal infertility.

    • Male infertility .

    • Cervical factor .

    • Unexplained infertility.

      Action mechanism

    • Induction of multiple ovulation .

    • Under u/s guidance retrieval oocyte.

    • Invitro fertilized with washed sperms .

    • 2 -3 fertilized egg or embryo transfer to uterine .

    • Success rate 20 - 30 % .

      Complication

    • High failure rate.

    • High cost of IVF.

    • High abortion rate.

    • Multiple pregnancy.

    • Ectopic pregnancy .

    • Psychological trauma to the couple if IVF fails.


    3 gift gammete intra fallopian transfer

    3 - GIFT ( gammete intra fallopian transfer )

    Action mechanism

    • Induction of multiple ovulation .

    • Oocyte retrieval .

    • Placement of two oocytes & 50 000 washed sperm in each ampullary portion laparascopically .

    • 30 - 40 % success .

      4 - Cryopreservation :

      Lately it has been possible to caryopreserve the sperm , ova and embryos .( to avoid of invasive procedure time by time and reduced cost ).


    5 insuffilation

    5 – insuffilation

    Passage of co2 with Rubin‘s machine in the uterine cavity .

    A – complication

    • Collapse .

    • Shock in death.

    • Embolic ( interavasition ).

    • Peritoneal reaction .

    • Salpangitis .

    • Sensetivity to drugs ( if we want to use drugs instead of air).

    • Abortion ( if she is pregnant ).

      B - Contraindication

    • During of immediately after menstruation.

    • After curettage .

    • After salpangitis .

    • Active TB .

    • Cervicitis , vaginitis , etc.


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    Note : counseling a couple is essential & prognosis at each treatment should be discussed the last choice of adoption should be left to their decision .


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    C – Four important following criteria shows open tubes

    • Change compression in machines .

    • Ascultation of the gas sound during passed from the tube .

    • Felling pain in the right shoulder.

    • Free air in the abdominal cavity.


    Infertility factor in woman

    Infertility factor in woman

    • H.P.O axis factor .

    • Ovarian factor .

    • Tubal factor .

    • Uterine factor.

    • Cervical mucosal factor.

    • Vaginal factor .

    • General factor .

    • Dysparonia ,PID ,Endometriosis.

    • Unfrequent & untimely intercourse.

    • Duration of infertility & user of contraception.

    • History of TB or contact T B patient , D M , etc .

    • Menstrual irregularity , ovaries dysfunction & non ovulation in PCOD.

    • Previous history of PID & ectopic pregnancy suggest tubal damage.

    • In secondary infertility P.P infection , PPH (Sheehan's syndrome ) prolonged lactation is very important .


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