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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
slide15
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.
slide32
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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