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Understanding Infertility Basic Sciences. A/Prof R Gyaneshwar FRANZCOG, MH.Ed Clinical Director of Obstetrics & Gynaecology Liverpool Health Service Conjoint Associate Professor University of New South Wales. Acknowledgement. Dr Antony Lighten – IVF Australia Dr Derek Lok – Sydney IVF.

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understanding infertility basic sciences

Understanding InfertilityBasic Sciences

A/Prof R Gyaneshwar

FRANZCOG, MH.Ed

Clinical Director of Obstetrics & Gynaecology

Liverpool Health Service

Conjoint Associate Professor

University of New South Wales

acknowledgement
Acknowledgement
  • Dr Antony Lighten – IVF Australia
  • Dr Derek Lok – Sydney IVF

A/Prof R Gyaneshwar

reproductive physiology
Reproductive Physiology

A/Prof R Gyaneshwar

slide5

Blocked or damaged Fallopian tubes eg Ectopic pregnancy

Fibroids

Endometriosis

Miscarriage

Polycystic Ovarian Syndrome

Failure of Ovulation

A/Prof R Gyaneshwar

causes of infertility
Causes of Infertility

A/Prof R Gyaneshwar

the causes of infertility and their approximate frequency adapted from hull et al 1985
The Causes of Infertility and their Approximate Frequency (adapted from Hull et al 1985)

A/Prof R Gyaneshwar

infertility
Infertility
  • Definition
    • 12 months of attempting to conceive
      • Incidence 1 in 6 couples
      • Incidence increases with age

A/Prof R Gyaneshwar

natural cumulative pregnancy rate

24

90

12

80

11

% pregnant/month

10

70

9

8

7

60

6

5

50

4

40

3

30

2

20

1

10

0

1

2

3

4

5

6

7

8

9

10

11

12

24

Natural Cumulative Pregnancy Rate

Months of trying

A/Prof R Gyaneshwar

natural pregnancy rate
Natural Pregnancy Rate

A/Prof R Gyaneshwar

ovarian reserve
Ovarian Reserve

A/Prof R Gyaneshwar

anovulation

LHRH

LH

FSH

Anovulation

A/Prof R Gyaneshwar

the clues

LHRH

LH

FSH

The Clues

A/Prof R Gyaneshwar

tubal factor
Tubal Factor
  • Peristalsis
  • Ciliary dysfunction
  • Narrowing
  • Blockage

A/Prof R Gyaneshwar

lap dye
Lap / Dye

A/Prof R Gyaneshwar

ectopic
Ectopic

A/Prof R Gyaneshwar

endometriosis
Endometriosis

A/Prof R Gyaneshwar

minimal mild endometriosis
Minimal / Mild Endometriosis

Monthly fecundity rate 6.1 (laparoscopic surgery) vs 3.2 (diagnostic laparoscopy) per 100 person month

The Canadian Collaborative Group on Endometriosis 1997 NEJM 337:217

A/Prof R Gyaneshwar

hysteroscopy
Hysteroscopy

A/Prof R Gyaneshwar

slide23

Septate uterus

A/Prof R Gyaneshwar

slide24

Congenital Anomalies

A/Prof R Gyaneshwar

slide25

Blocked/absent vas deferens

Low sperm numbers and/or poor sperm movement

High numbers of abnormal shaped sperm

Failure of sperm production

Antisperm antibodies

Erectile dysfunction

A/Prof R Gyaneshwar

male factor
Male Factor
  • Primary Testicular Disease
    • Most common cause of male factor infertility
    • Aetiology
      • 66% unknown
      • 20% testicular maldescent
      • 7% trauma and torsion
      • 5% Klinefelter’s Syndrome
      • 1% mumps orchitis
      • 1% chemo

A/Prof R Gyaneshwar

male factor27
Male Factor
  • Endocrine causes
    • Hyperprolactinaemia
    • Hypogonadotrophic hypogonadism
    • Hypothrooidism
      • Rare
      • Present with sexual dysfunction

A/Prof R Gyaneshwar

sperm count
Sperm Count
  • Volume 2 – 5 mls
  • Density/Concentration > 20 mill/ml
  • Motility > 50%
  • Morphology > 14% normal

A/Prof R Gyaneshwar

male infertility
Male Infertility
  • Semen Analysis (WHO 1999)
    • 3 days of abstinence, collection technique, 72 days for sperm to be ejaculated
    • Vol > 1 ml
    • Concentration > 20 x 106 / mL
    • Motility > 50%
    • Morphology (WHO Strict Criteria 99) > 15% normal
    • Note: SA best performed in andrology lab; If abnormalalways repeat

A/Prof R Gyaneshwar

important concepts
Important Concepts
  • Age
  • Duration of infertility
  • Primary versus secondary infertility
  • Multiple causes of infertility
  • Sub-fertility versus sterility

A/Prof R Gyaneshwar

history
History
  • Duration
  • Previous pregnancies
  • Wt / Ht / BMI
  • Full menstrual history
  • Androgenising signs
  • Pelvic pain
  • Previous investigations
  • Past medical history
  • Past surgical history
  • Medications / cigarettes / alcohol

A/Prof R Gyaneshwar

history34
History
  • Previous paternities
  • Sexual dysfunction
  • Mumps / STD
  • Trauma
  • Undescended testes
  • Previous investigations
  • Past medical history
  • Past surgical history
  • Medications / cigarettes/ alcohol

A/Prof R Gyaneshwar

ranzcog statement c obs 3 march 2004
RANZCOG Statement C-Obs 3 March 2004
  • Tests recommended at the first antenatal visit of each pregnancy:
    • Blood group and antibody screen
    • Full blood examination
    • Rubella Antibody status
    • Syphilis serology
    • Hepatitis B serology
    • Midstream urine examination by culture: eg dipslide
    • HIV serology
    • Hepatitis C serology
    • Cervical cytology

A/Prof R Gyaneshwar

prognostic factors
Prognostic Factors
  • Age
  • Duration of infertility
  • Primary versus secondary infertility
  • Multiple causes of infertility
  • Sub-fertility versus sterility

A/Prof R Gyaneshwar

duration of infertility
Duration of Infertility
  • The longer the duration of infertility, the greater the likelihood of a cause of infertility; ie the less likely that the situation is due to bad luck
  • Treatment is more successful in patients where a specific treatable cause is found

A/Prof R Gyaneshwar

prognosis
Prognosis

A/Prof R Gyaneshwar

investigations
Tubal Patency

HSG

Lap & Dye

Ovulation

Midluteal P4

Testosterone, TSH,Prolactin, LH, FSH asindicated

Rubella, Varicella

Hep B, C, HIV, VDRL

Semen Analysis

LH, FSH, Prolactin as indicated

Karyotype

Hep B, C, HIV, VDRL

Investigations

A/Prof R Gyaneshwar

hormone ovulatory tests
Hormone / Ovulatory Tests
  • Day 2-3 hormones
    • FSH, LH, Oestradiol
    • Testosterone, SHBG
    • Others:
      • 17-OH P, DHEAS, Androstenedione, cortisol
      • TSH, prolactin
      • 75g GTT & fasting insulin
  • Luteal Progesterone
    • 7 days prior to estimated date of period if regular
    • If irregular, start 7 days prior to shortest cycle date and repeat every 5-7 days till next period arrives

A/Prof R Gyaneshwar

treatment options
Treatment Options

A/Prof R Gyaneshwar

ovulation induction
Ovulation Induction

PCOS

1st line

Clomiphene – 60% pregnant after 6 months

2nd line

Metformin

FSH

Surgical Ovarian Drilling

A/Prof R Gyaneshwar

ovarian drilling
Ovarian Drilling

A/Prof R Gyaneshwar

ovarian induction
Ovarian Induction

Hypothalamic amenorrhoea

FSH

Pulsatile GnRH

Hyperprolactinaemia

Carbergolide

A/Prof R Gyaneshwar

intrauterine insemination
Intrauterine Insemination

Indications

Unexplained

Mild male factor

Success/Cycle

Natural 10-15%

Stimulated 15-20%

A/Prof R Gyaneshwar

in vitro fertilisation
In Vitro Fertilisation

Indications

Prolonged unexplained

Tubal factor

Severe male factor

Unsuccessful OI / IUI / fertility surgery

A/Prof R Gyaneshwar

in vitro fertilisation48
In Vitro Fertilisation

Success / Cycle

40 – 5-%

Single embryo transfer

Now gold standard

Twin rate 1%

A/Prof R Gyaneshwar

slide49

Sperm Preparation

49

A/Prof R Gyaneshwar

slide50

50

A/Prof R Gyaneshwar

slide51

51

A/Prof R Gyaneshwar

slide52

52

A/Prof R Gyaneshwar

slide53

Day surgery for egg collection

53

A/Prof R Gyaneshwar

slide55

IVF(In Vitro Fertilisation

55

A/Prof R Gyaneshwar

slide57

Fertilisation

Day 2

Day 3

Day 5

Blastocyst

Day 5

Blastocyst

Day 4

A/Prof R Gyaneshwar

slide59

Embryo transfer

59

A/Prof R Gyaneshwar

slide60

Pregnancy blood test

2 weeks after embryo transfer

60

A/Prof R Gyaneshwar

slide61

Embryo freezing

61

A/Prof R Gyaneshwar

oocyte cryopreservation
Oocyte Cryopreservation

Jain. Fertil Steril 2006

62

A/Prof R Gyaneshwar

slide63

Any Questions?

63

A/Prof R Gyaneshwar

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