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Sub-fertility Causes &Management. Dr. Yousef Gadmour Professor, Al-fateh university Senior consultant, Al-Jalla Hospital Tripoli , Libya. Definitions:. Sub fertility- Involuntary failure to conceive within 12 months of commencing unprotected sexual intercourse.

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Sub fertility causes management

Sub-fertilityCauses &Management

Dr. Yousef Gadmour Professor, Al-fateh university

Senior consultant, Al-Jalla Hospital

Tripoli , Libya


Definitions
Definitions:

  • Sub fertility- Involuntary failure to conceive within 12 months of commencing unprotected sexual intercourse.

  • Primary infertility - No previous pregnancy.

  • Secondary infertility- previous pregnancy. (whatever the outcome)


Causes and approximate incidence
Causes(and approximate incidence)

1. Idiopathic - 25 per cent

2. Sperm defects or functional disorder - 25 per cent

3. Ovulation failure - 20 per cent

4. Tubal damage - 15 per cent

5. Endometriosis - 5 per cent

6. Coital failure - 5 per cent

7. Cervical mucus defect - 3 per cent

8. Obstruction of sperm ducts - 2 per cent


Principles of management
Principles of management:

  • Deal with the sub fertile couple together.

  • No one is at fault or to blame.

  • Give good explanations of causes , prognosis and outline of treatment of sub fertility.

  • Carry out investigations and treatments consistency in proper sequence.


History general
History - General

  • Both couples should be present.

  • Age.

  • Previous pregnancies by each partner.

  • Length of time without pregnancy.

  • Sexual history :

    • Frequency and timing of intercourse

    • Use of lubricants

    • Impotence, anorgasmia, dysparunia

    • Contraceptive history


History male
History - Male

  • Infections; gonorrhea , tuberculosis.

  • Radiation, toxic exposures ,drugs.

  • Mumps orchitis.

  • Testicular injury/surgery.

  • occupation (Excessive heat exposure).

  • Smoking.

  • Diabetes mellitus.


History female
History - Female

  • Detailed menstrual history ; Irregular menses, amenorrhea.

  • Hirsutism.

  • Galactorrhoea.

  • Previous pregnancies and mode of deliveries.

  • Ectopic pregnancy history.

  • PID.


History female1
History - Female

  • Appendicitis.

  • IUCD use.

  • Endometriosis.

  • Stress.

  • Weight changes.

  • Excessive exercise.

  • Cervical and uterine surgery.


Physical examination male
Physical Examination - Male

  • Weight & Height (BMI).

  • Size of testicles (orchidometry).

  • Testicular descent.

  • Varicocele.

  • Outflow abnormalities (hypospadias, etc).

  • General look- Klinefelter syndrome (47XXY).

  • Weight & Height (BMI).

  • Size of testicles (orchidometry).

  • Testicular descent.

  • Varicocele.

  • Outflow abnormalities (hypospadias, etc).

  • General look- Klinefelter syndrome (47XXY).

  • Kallmann syndrome (hypothalamichypogonadism) (delayed puberty ,normal stature, no smell ).


Physical examination female
Physical Examination - Female

  • Weight & Height (BMI)

  • Hirsutism

  • Thyroid examination

  • Abdominal examination

  • Speculum examination - HVS, endocervical swap

  • Vaginal examination- Uterosacral nodularity, Uterine mobility

  • USS-(Vaginal)


General laboratory investigations
General laboratory investigations:

Female

  • FBS(GTT).

  • TFT.

  • chlamydial antibody titer.

  • Rubella antibody titer (If negative, immunize and advise not to try for pregnancy for 3 months).

  • HIV,HBV,HCV.


General laboratory investigations1
General laboratory investigations:

Female

  • Day 2 FSH, LH.

  • Serum prolactin (fasting).

  • Day 21 serum progesterone.


General laboratory investigations2
General laboratory investigations:

Male

  • HIV,HBV,HCV.

  • FBS (GTT).

  • TFT.

  • Serum Testosterone, FSH, PRL levels.


Routine investigation in the female
Routine investigation in the female

Assessment of Ovulation

  • Basal body temperature

  • Mid luteal serum progesterone

  • Endometrial biopsy

  • Ultrasound monitoring of ovulation


BBT

Cheap and easy, but…

  • Inconsistent results.

  • Provides evidence after the fact.

  • May delay timely diagnosis and treatment;

    98% of women will ovulate within 3 days of the nadir.

  • Biphasic profiles can also be seen with LUF syndrome.


Luteal phase progesterone
Luteal Phase Progesterone

  • Pulsatile release, thus single level may not be useful unless elevated.

  • Performed 7 days after presumptive ovulation ( day 21 ).

  • If done properly , level >15 ng/ml consistent with ovulation.


Endometrial biopsy
Endometrial Biopsy

  • Invasive, but the only reliable way to diagnose luteal phase defect (LPD).

  • Performed around 2 days before expected menstruation (= day 28 by definition).

  • Lag of >2 days is consistent with LPD.

  • Must be done in two different cycles to confirm diagnosis of LPD.

  • Controversy exists over the relevance of luteal phase defect as a cause of infertility and the accuracy of the endometrial biopsy in assessing the delay.


Postcoital test pk tests
Postcoital test (PK tests)

  • Scheduled around 1-2d before ovulation (increased estrogen effect)

  • 48hours of male abstinence before test

  • No lubricants

  • Evaluate 8-12h after coitus (overnight is ok!)

  • Remove mucus from cervix (forceps, syringe)


Postcoital test pk test
Postcoital test (PK test)

  • PK (normal values in yellow)

    • Quantity (very subjective)

    • Quality (spinnbarkeit) (>8 cm)

    • Clarity (clear)

    • Ferning (branched)

    • Viscosity (thin)

    • WBC’s (~0)

    • progressively motile sperm/hpf (5-10/hpf)


Problems with the pk test
Problems with the PK test

  • Subjective.

  • Timing varies; may need to be repeated.

  • In some studies, “infertile” couples with an abnormal PK conceived successfully during that same cycle.


Tubal function
Tubal Function

  • Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition.

  • Tests:

    • HSG

    • Laparoscopy

    • Falloposcopy (not widely available)


Hysterosalpingography hsg
Hysterosalpingography (HSG)

  • Can be uncomfortable.

  • Done at the end of menses.

  • Can detect intrauterine and tubal disorders but not always definitive.


Laparoscopy
Laparoscopy

  • Invasive; requires OT or office setting.

  • Can offer diagnosis and treatment in one sitting.

  • Not necessary in all patients.

  • Uses (examples):

    • Lysis of adhesions

    • Diagnosis and excision of endometriosis

    • Myomectomy

    • Tubal reconstructive surgery

    • Test of tubal patency by dye test


Falloposcopy
Falloposcopy

  • Hysteroscopic procedure with cannulation of the Fallopian tubes.

  • Can be useful for diagnosis of intraluminal pathology.

  • Promising technique but not yet widespread.


Assessment of uterine cavity
Assessment of uterine cavity

Hysteroscopy

  • It is advisable to assess the uterine cavity pathology as submucous fibroid, polyps, uterine malformation, and others .

  • Outpatient hysteroscopy, hysterosalpingography are equivalent regarding evaluation of uterine cavity pathology


Routine investigation in the male
Routine investigation in the male

Semen analysis

  • Test after (~3) days abstinence from intercourse.

  • If abnormal parameters, repeat twice, 2 weeks apart

  • Normal values:

    Volume: 2 to 6 ml

    Density: 20 to 250 million /ml

    Motility: > 50 % with forward motion within 2 hours

    Morphology: > 50 % normal sperm


Other male investigation
Other Male Investigation

  • Doppler USS (varicocele).

  • Testicular Biopsy.



Ovarian disorders
Ovarian Disorders

Anovulation

  • Clomiphene Citrate (CC) ± hCG

  • Human Menopausal Gonadotropin (hMG)

  • Pure FSH

    Central amenorrhea

  • CC first, then hMG

  • Pulsatile GnRH


Ovarian disorders1
Ovarian Disorders

Hyperprolactinaemia:

  • Drugs :Bromocriptin, Carbegoline(Dostinex), Quinagolide (Norprolac)

  • Surgery if macroadenoma

    Premature ovarian failure :

  • ? high-dose hMG (not very effective)

    Luteal phase defect:

    • Progesterone suppositories during luteal phase

    • CC ± hCG


Ovulation induction
Ovulation Induction

  • Clomiphene Citrate

    • Compete with natural oestrogens by blocking receptors in target organs including the pituitary, leading to increased FHS levels.

    • 70% induction rate, ~40% pregnancy rate.

    • Patients should typically be normoestrogenic.

    • Induce menses and start on day 2 for 5 days.

    • With high dosages, antiestrogen effect dominate.

    • Multiple pregnancy rates 5-10%.

    • Monitor effects with USS & D21 progesterone.


hMG

  • LH +FSH (also FSH alone = Metrodin)

  • For patients with hypogonadotrophic hypoestrogenism or normal FSH and E2 levels

  • Close monitoring essential, including estradiol levels & USS

  • 60-80% pregnancy rates overall, lower for PCOS patients

  • 10-15% multiple pregnancy rate


Risks

CC

Vasomotor symptoms

Ovarian enlargement

Multiple gestation

NO risk of malformations

hMG

Multiple gestation

OHSS (~1%)

Can often be managed as outpatient

Diuresis

Severe cases fatal if untreated in ICU setting

Risks


Fallopian tubes
Fallopian Tubes

  • Tuboplasty

  • IVF


Corpus
Corpus

  • Asherman syndrome

    • Hysteroscopic Lysis of adhesions (scissor)

    • Postop. ; IUCD, E2

  • Fibroids (rarely need treatment)

    • Myomectomy ( hysteroscopic, laparoscopic, open)

    • ??Uterine artery embolization.

  • Uterine anomalies (rarely need treatment)

    • Metroplasty.


Peritoneum endometriosis
Peritoneum (Endometriosis)

  • From a fertility standpoint, excision beats medical management (Laser therapy ).

  • Lysis of adhesions.

  • GnRH-a (Not a cure and has side effects & expensive).

  • Danazol (side effects, cost).

  • Continuous OCP’s ( poor fertility rates ).

  • Chances of pregnancy highest within 6 -12 months after treatment.


Male factor
Male Factor

  • Hypogonadotrophism

    • hMG

    • GnRH

    • CC, hCG ( results poor )

  • Varicocoele

    • Ligation? ( No definitive data yet )

  • Retrograde ejaculation

    • Ephedrine, imipramine

    • AIH with recovered sperm


Male factor1
Male Factor

  • Idiopathic oligospermia

    • No effective medical treatment

    • IVF (in-vitro fertilization)

    • ICSI ( Intra- cytoplasmic sperm injection )

    • TESE( Testicular Sperm Extraction )

    • MESA(Microsurgical Epididymal Sperm Aspiration)

    • ?? donor insemination


Unexplained infertility
Unexplained Infertility

  • 15-20% of couples

  • Consider PRL, laparoscopy, other hormonal tests, cultures, Antisperm Abs. testing, sperm penetration assay if not done.

  • Review previous tests for validity.

  • Empirical treatment:

    • Ovulation induction

    • IUI

    • Consider IVF and its variants

  • Adoption


Summary
Summary

  • Sub fertility is a common problem.

  • Sub fertility is a disease of couples.

  • Evaluation must be thorough, but individualized.

  • Treatment is available, including IVF, but can be expensive, invasive, and of limited efficacy in some cases.

  • Consultation with a reproductive endocrinologist is advisable.



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