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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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Presentation Transcript
slide1
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 .
slide9
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.
slide10

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.
slide11
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 .

slide17
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
slide25
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 .

slide28

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 .
slide29

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
slide30

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 .
slide31

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
slide32

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.
slide35
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.

slide36
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.
slide37
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 :
slide45
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 .

slide46
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 .

slide48
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.
slide54
Note : counseling a couple is essential & prognosis at each treatment should be discussed the last choice of adoption should be left to their decision .
slide55
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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