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Infertility and Family planning

Lecture Petrenko N.V., MD, PhD, assistant professor of obstetric and gynecology department № 2. Infertility and Family planning. Film fertilization. Requirements for Conception. Three general strategies: Generation of ovum and sperm (spermatogenesis, ovulation);

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Infertility and Family planning

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  1. Lecture Petrenko N.V., MD, PhD, assistant professor of obstetric and gynecology department № 2 Infertility and Family planning

  2. Film fertilization

  3. Requirements for Conception • Three general strategies: • Generation of ovum and sperm (spermatogenesis, ovulation); • Fertilization (union of gametes: sperm & ovum). • Implantation in the uterus.

  4. Definition • Infertility - the inability to conceive following unprotected sexual intercourse during • 1 year (age < 35) • 6 months (age >35) • Primary infertility • Secondary infertility • Subfertility – reduced fertility decreased fertility or a decreased chance of getting pregnant, but not a complete inability to get pregnant. • Sterility – inability to conceive

  5. Infertility Causes

  6. Male infertility

  7. Normal spermatogenesis Sperm is constantly produced by the germinal epithelium of the testicle Sperm generation time 73 days Travel to epididymis to mature Sperm exit through vas deferens Semen produced in prostate gland, seminal glands, cowpers glands Sperm only 5% of ejaculation Sperm can live 5-7 days

  8. Cause of Male Infertility • STRUCTURAL OR HORMONAL DISORDERS • Undescended testes • Hypospadias • Testicular damage caused by mumps • Varicocele • Low testosterone levels

  9. Cause of Male Infertility • SUBSTANCE ABUSE • Changes in sperm (Smoking, heroin, marijuana, amyl nitrate, butyl nitrate, ethyl chloride, methaqualone, Monoamine oxidase) • Decrease in sperm (Hypopituitarism, Debilitating or chronic disease, Trauma, Gonadotropic inadequacy, • Decrease in libido (Heroin, methadone, selective serotonin reuptake in­hibitors, and barbiturates) • Impotence (Alcohol, Antihypertensive medications)

  10. Cause of Male Infertility • OBSTRUCTIVE LESIONS OF THE EPIDIDYMIS AND VAS DEFERENS • NUTRITIONAL DEFICIENCIES • OTHER FACTORS • Endocrine disorders • Genetic disorders • Psychologic disorders • Sexually transmitted infections • Exposure of scrotum to high temperatures • Exposure to workplace hazards such as radiation or toxic substances

  11. Assessment of Male Infertility • Laboratory data • Routine urinary test, Gonorrhea and Chlamidia tests, serologic test for syphilis • Complete semen analysis • Additional lab studies • Basic endocrine studies indicated in men with oligospermia or aspermia • FSH, LH, testosteron • T3, T4, TSH • Test for sperm antibodies • 17-hydroxycorticoids and 17 ketosteroids • Buccal smear and chromosome studies (e.g. Klinefelter syndrome, XXY sex chromosomes • Testicular biopsy where correct interpretation is available, vasography • Ultarasonography

  12. Assessment of Male Infertility • Physical examination • General • Complete physical examination, with special attention given to physical condition and fat and hair distribution • Genital tract • Assessment of penis and urethra, scrotal size, position, size, and consistency of testes, epididimides and vasa deferentia, prostate size and consistency • Careful search for varicocele with man in both supine and upright position

  13. Semen Analysis (SA) • Obtained by masturbation after 2 to 5 days of abstinence from ejaculation

  14. Azoospermia (No sperm in semen) Klinefelter’s syndrome Sertoli only syndrome Ductal obstruction Hypogonadotropic- hypogonadism Oligozoospermia (Few sperm in semen) Genetic disorder Endocrinopathies Varicocele Exogenous (e.g., Heat) Abnormal Volume No ejaculate Ductal obstruction Retrograde ejaculation Ejaculatory failure Hypogonadism Semen Analysis. Abnormal Morphology Varicocele Stress Infection (mumps) Asthenozoospermia (Abnormal Motility) Immunologic factors Infection Defect in sperm structure Poor liquefaction Varicocele • Low Volume • Obstruction of ducts • Absence of vas deferens • Absence of seminal vesicle • Partial retrograde ejaculation • Infection

  15. Male Infertility If SA is abnormal: • lab test • US and referral to urologist or sexopatologist

  16. Female infertility

  17. Female Reproductive System • Ovaries • Two organs that produce eggs • Eggs can live for 12-24 hours • Uterine tubes • Two tubes allow union egg and sperm • Uterus • Pear shape organ that receive fertilized egg

  18. Menstrual function

  19. Cause of Female Infertility • Congenital or developmental factors • Hormonal factors • Tubal/Peritoneal factors • Uterine factors

  20. Cause of Female Infertility 1 • CONGENITAL OR DEVELOPMENTAL FACTORS • Abnormal external genitals • Absence of internal reproductive structures

  21. Cause of Female Infertility 2 • HORMONAL FACTORS • Anovulation-primary • Pituitary or hypothalamic hormone disorder • Adrenal gland disorder • Congenital adrenal hyperplasia • Anovulation-secondary • Disruption of hypothalamic-pituitary-ovarian axis • Early menopause • Amenorrhea after discontinuing OCP • Increased prolactin levels

  22. Cause of Female InfertilityTUBAL/PERITONEAL FACTORS • Absence of fimbriated end of tube • Tubal motility reduced • Absence of a tube • Inflammation within the tube • Tubal adhesions

  23. Cause of Female Infertility 3 • UTERINE FACTORS • Developmental anomalies • Endometrial and myometrial tumors • Asherman syndrome (uterine adhesions or scar tissue)

  24. Cause of Female InfertilityDevelopmental anomaliesof uterus

  25. Cause of Female Infertility Developmental anomaliesof uterus

  26. Cause of Female Infertility Developmental anomaliesof uterus

  27. Cause of Female Infertility Developmental anomaliesof uterus

  28. Cause of Female Infertility Endometrial and myometrial tumors

  29. Causeof Female Infertility Endometrial and myometrial tumors Endometrial tumor

  30. Cause of Female Infertility Asherman syndrome

  31. Assessment of Female Infertility • Physical examination • General • Complete physical examination • Genital tract • State of hymen (full penetration) • Clitoris • Vaginal infection (trichomoniasis, candidiasis) • Cervical tears, polyps, infection, patency of os, accessibility to insemination • Uterus (size, position, mobility) • Adnexae (tumor, evidence of endometriosis)

  32. Assessment of Female Infertility • Laboratory data • Chlamidia test and gonorrhea culture • For woman with irregular menstrual cycle or amonorrhea • Serum prolactin level with tomographic radiographs of skull • FSH,LH, serum progesteron and estrogen determanation, 17-ketosteroid assay test, 17-hydroxycorticosteroid test, glucose tolerance test • T3, T4, TSH • Endometrial biopsy • US • Hysterosalpingography • Laparoscopy, hysteroscopy

  33. Hysterosalpingography An X-ray that evaluates the internal female genital tract uterine cavity and tubes after instillation of radiopaque contrast material through the cervix Performed between the 7th and 11th day of the cycle Diagnostic accuracy of 70%

  34. Hysterosalpingography It is possible to see abnormalities of uterus Congenital defect, submucous myomas, endometrial polyps Distortions of uterine cavity o uterine tubes can be a result of current or past PID Scar tissue and adhesions from inflammatory process can immobilize the uterus and tubes, kink the tubes and surround the ovaries

  35. Hysterosalpingography

  36. Detection of Ovulation • Basal body temperature • Cervical mucus characteristic • Endometrial biopsy • US • Serum progesterone level • Urinary ovulation-detection kits

  37. Basal Body Temperature • Excellent screening tool for ovulation • Biphasic shift occurs in 90% of ovulating women • Temperature • drops at the time of menses • rises two days after the lutenizing hormone (LH) surge • Ovum released one day prior to the first rise • Temperature elevation of more than 16 days suggests pregnancy

  38. Basal Body Temperature

  39. Cervical mucus • requires that the woman recognize and interpret the cyclic changes in the amount and consistency of cervical mucus that characterize her own unique pattern of changes • Postmenstrual mucos: scant • Preovulational mucus: cloudy, yellow, or white, sticky • Ovulation mucus: clear, wet, sticky, slippery • Right before ovulation, the watery, thin, clear mucus becomes more abundantand thick. It can be stretched 5+ cm between the thumb and forefinger. This indicates the period of maximal fertility • Postovulation fertile mucus: thick, cloudy, sticky • Postovulation, postfertile mucus: scant

  40. Cervical mucus Ovulation-Detection Method

  41. Predictor test for ovulation • detects the sudden surge of luteinizing hormone (LH) that occurs approximately 12 to 24 hours before ovulation. Unlike BBT, the test is not affected by illness, emotional upset, or physical activity

  42. Serum Progesterone • Progesterone starts rising with the LH surge • drawn between day 21-24 • Mid-luteal phase • >10 ng/ml suggests ovulation

  43. Endometrial biopsy • Check endometrial response to progesteron and adequacy of luteal phase • Late (21-27 days) of menstrual cycle? 2-3 days before expected menses

  44. Ultrasonography • Collapse of follicle after ovulation • 7, 14, 21 days of menstrual cycle

  45. Laparoscopy • Allow good visualization of internal pelvic structures • Small endoscope is inserted through small incision in the anterior abdominal wall • General anesthetic is usually given • Laparoscopy reveal endometriosis, pelvic adhesions, tubal occlusion, leyomiomas or polycyclic ovaries • Possible procedure • fulguration (destruction of tissue by means of elctricity) of small endometrial implants, • lysis of adhesions • tacking ovarian biopsies

  46. Hysteroscopy • is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention

  47. Postcoital test • PCT used to test for adequacy of coital technique, cervical mucus, sperm and degree of sperm penetration through cervical mucus • Test is performed within several hours after ejaculation of semen into vagina • A specimen of cervical mucus obtained from the cervical os and examined under a microscope • The quality of mucus and the number of forward-moving sperm are noted

  48. ???Unexplained infertility??? • 10% of infertile couples will have a completely normal workup • Pregnancy rates in unexplained infertility • no treatment 1.3-4.1% • clomid and intrauterine insemination 8.3% • gonadotropins and intrauterine insemination 17.1% ???

  49. Treatment

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