Infertility
Download
1 / 55

Infertility - PowerPoint PPT Presentation


  • 157 Views
  • Uploaded on

Infertility. Chairman of the Indian College of Obstetricians & Gynecologists (ICOG) Past President of the Federation of Obstetric & Gynecological Societies of India (FOGSI) 2006 Honorary Fellow of the Royal College of Obstetricians & Gynecologists

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Infertility' - naida-charles


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  • Chairman of the Indian College of Obstetricians & Gynecologists (ICOG)

  • Past President of the Federation of Obstetric & Gynecological Societies of India (FOGSI) 2006

  • Honorary Fellow of the Royal College of Obstetricians & Gynecologists

  • Prof. and Cons. Obs. & Gyn,Breach Candy Hospital, Jaslok Hospital,

    Sir H.N. Hospital Mumbai, India.


Causes of infertility
Causes of Infertility

Couples (Speroff & Fritz, 2005)


Causes of infertility continued
Causes of Infertility(Continued)

Women (Speroff & Fritz, 2005)


Introduction
Introduction

  • Primary infertility The inability to conceive after 1 year of unprotected intercourse for a woman younger than 35, or after 6 months of unprotected intercourse for a woman 35 or older (Speroff & Fritz, 2005).

  • Secondary infertility The inability of a woman to conceive who previously was able to do so (Speroff & Fritz, 2005).


Unexplained infertility
Unexplained Infertility

Clinical Definition : Absence of a definable cause fora couple’s failure to achieve pregnancy after 12 months of attempting conception despite a thorough evaluation

Sub-fertility :Any form of reduced fertility withprolonged time of unwantednon-conception.


First visit
First visit

  • Have both come to all visits

  • Get a complete history

  • Sexual history

  • Educate


Visit 1 male history
Visit 1: Male History

Past medical history

  • Fathered previous pregnancies within 3 years

  • Genital trauma or surgery

  • Genital infections; GC, Chlamydia, mumps

  • Environmental heat: spa, pants, sitting time

    Coital factors

  • Coital frequency

  • Coital technique, esp ejaculation factors


Visit 1 male history1
Visit 1: Male History

Current exposures

  • Drugs: b-blockers, Ca channel

    blockers,cimetidine, HMG-CoAreductase

    inhibitors

  • Toxic chemicals, esp. metals and dyes

  • Street drug and alcohol use

  • Cigarette smoking


Visit 1 male examination
Visit 1: Male Examination

Utility is controversial

  • “Preferable” to do exam, but little contribution If semen analysis is normal

    Male examination

  • Masculine traits

  • Varicocoele

  • Hypospadias

  • Urethral discharge

  • Prostatitis


Visit 1 female history
Visit 1: Female History

  • Prior infertility; evaluation, treatments

  • Hx of PID; postpartum/ postTB infection

  • Pelvic pain, dysmenorrhea; endometriosis

  • Medical: diabetes, thyroid; pelvic surgery

  • Medications, alcohol, street drugs

Contd….


Visit 1 female history1
Visit 1: Female History

  • Cigarette smoking

  • Galactorrhea

  • Menstrual patterns

  • Cycle length range (best 25-35 days apart)

  • Moliminal symptoms (if present, ovulating)


Visit 1 female examination
Visit 1: Female Examination

  • Weight, BMI, waist circumference (PCOS)

  • Skin: axial hirsuitism, acne, male-pattern balding (PCOS)

  • Breasts: galactorrhea ( ▲prolactin)

  • Cervix: mucus, friability (infection)

  • Uterine corpus

  • Size, shape (fibroids, uterine anomalies)

  • Corpus tenderness (PID)

  • Fixed retroflexion (EM)

  • Adnexa: tenderness (PID, EM), mass (EM, tumor)


Visit 1 pelvic ultrasound
Visit 1: Pelvic Ultrasound

  • Diagnostic pelvic ultrasound

  • >10 to 12 follicles per ovary (PCOS)

  • Persistent hemorrhagic cysts with low-level echoes (endometriosis)

  • Anatomical conditions: fibroids, polyps, and

  • Müllerian anomalies (uterine septum)

  • Decreased ovarian volume and reduced antral follicle count associated with reduced fertility

  • Serial TV ultrasound used to document ovulation


Visit 1 laboratory
Visit 1: Laboratory

Women

  • CBC, ESR

  • TSH, prolactin

  • Ovarian reserve testing (if indicated)

  • Screen for gonorrhea, chlamydia (if indicated)

  • Microscopy of cervical mucus


Visit 1 laboratory1
Visit 1: Laboratory

Men

  • Semen analysis if has not fathered children

  • Fresh sample (to lab within 30 mins.) –most sperm in initial ejaculate

  • Male should be abstinent for 48 to 72 hours


Visit 1 counseling
Visit 1: Counseling

  • Time intercourse just before ovulation

  • Use menstrual calendar to predict ovulation

  • Shortest cycle length minus 14 days

  • Ovulation prediction kit to confirm ovulation


Coital frequency and technique
Coital frequency and Technique

  • Every other day intercourse starting 4-5 days

    before expected ovulation

  • Lay supine with knees up x 20 minutes after intercourse

  • No sperm-toxic lubricants


Visit 1 counseling1
Visit 1: Counseling

  • Stop smoking (both partners)

  • If BMI > 30, recommend/assist with weight loss

  • Preconceptional care

    Folic acid 400 mcg PO per day

    Rubella serology; immunize if seronegative

Contd…..


Visit 1 counseling2
Visit 1: Counseling

  • Change medications to safer FDA pregnancy

    category

    »Antihypertensives

    »Anti-epileptic drugs

  • Blood glucose control in diabetics


Sperm count
Sperm Count

  • Fresh sample (to lab within 30 mins.) –most sperm in initial ejaculate

  • Male should be abstinent for 48 to 72 hours


Sperm analysis
Sperm Analysis

  • Volume - : 2.0ml or more

  • pH : 7.2- 8.0

  • sperm concentration : 20 x 10 spermatozoa/ml

    or more

  • total sperm count : 40 x 10 spermatozoa

    per ejaculate or more

  • motility : 50% or more with forward

    progression (categories a and b)

    or 25% or more with ra (category a )

    within 60 minutes of ejaculation

Contd.....


Sperm analysis1
Sperm Analysis

  • Morphology : 30% or more with normal forms

  • Vitality : 75% or more live, ie. Excluding dye

  • White blood cells : fewer that 1 x 106/ ml

  • Immunobead test : fewer than 20% spermatozoa with

    adherent particles

  • MAR test : fewer than 10% spermatozoa with

    adherent particles


Sperm terms

Normozoospermia

Normal ejaculate

Asthenozoospermia

Teratozoospermia

Azoospermia

Aspermia

Normal ejaculate

Sperm concentration <20 × 106 /ml

<50% spermatozoa with forward progression

<30% spermatozoa with normal morphology

No spermatozoa in the ejaculate

No ejaculate

Sperm Terms


Tests for the lady
Tests for the lady

  • Thyroid

  • Midcycle progesterone level &/or luteal phase progesterone level

  • FSH/ LH

  • Cortisol

  • Hystersalpingogram

  • Laporoscopy/hysteroscopy

  • Postcoital Test


Markers of ovarian reserve
Markers Of Ovarian Reserve

  • Baseline hormones- FSH - Estradiol - Inhibin B - Antimullerian hormone

  • Ultrasound parameters- Antral follicle count- Ovarian volume- Ovarian Stromal Blood Flow

Contd..


Markers of ovarian reserve1
Markers Of Ovarian Reserve

  • Dynamic tests.-Clomiphene citrate challenge test (CCCT)- Exogenous FSH ovarian reserve test (EFFORT)- GnRH agonist stimulation test (GAST)


Clomiphene citrate challenge test
Clomiphene Citrate Challenge Test

Clomiphene citrate ( 100mg OD ) from D – 5 to D – 9 of the cycle

FSH measured on Day – 3 and Day – 10

An abnormally high value ( cut – off point 10 – 26 mIU / ml ) indicates diminished ovarian reserve


Exogenous fsh ovarian reserve test efort
Exogenous FSH Ovarian Reserve Test ( EFORT )

Day 3 – Inhibin B to be done ( Pre )

Administer 300 IU FSH

After 24 hrs – Inhibin B to be repeated ( Post )

EFORT Values= Post Inhibin B – Pre Inhibin B

< 78.6 : patient is poor responder

78.6 – 110.4 : patient is borderline

> 110.4 : patient is good responder


Gnrh agonist stimulation test gast
GnRH Agonist Stimulation Test ( GAST )

GnRH agonist down regulation

Administration of 100 mcg baserelin every 4 hrs for a total daily dose of 1200mcg

OR

Every 6 hrs for a total dose of 800mcg

S – FSH and S – estradiol to be measured before and after 24 hrs of treatment

Change in estradiol less than 180 pg/ml and / or FSH 9.5 IU/L predicts poor oocyte response


Documentation of ovulation
Documentation of Ovulation

  • Regular menstrual cycles with molimia

  • Mid-luteal phase progesterone > 9 ng/ml

  • BBT

  • LH surge: positive ovulation prediction kit

  • Pelvic ultrasound evidence of ovulation

  • Secretoryendometrium on endometrial biopsy


Tests of tubal patency
Tests of Tubal Patency

  • Hysterosalpingography

  • Hydrohysterosonography

  • Sonosalpingography

  • Hydrogynecography or sion procedure

  • Redionucleide HSG

  • Selective salpingography

  • Hysterosalpingographic fallopian tube recanalization.


Role of laparoscopy

Role of Laparoscopy

Controversial as to whether to include it in the basic evaluation or not

Studies indicate that it may demonstrate previously undetected stage I or II endometriosis, periovarian or peritubal adhesions

Contd…..


Role of laparoscopy1

Role of Laparoscopy

This may alter treatment plans such as surgery for endometriosis or directly IVF for peritubal adhesion

Can be avoided in women with a normal HSG in patients who may need IVF


Laproscopy findings
Laproscopy findings

  • Uterus ---- fibroids

    uterine anamoly

  • Tubes --- patency

    hydrosalpinx

  • Ovaries --- PCOS

    chocolate cyst

  • POD --- endometriosis

    adhesions


Hysteroscopy findings
Hysteroscopy findings

  • Cervical canal --- polyps

  • Uterine cavity --- adhesions

    polyps

    fibroids

    uterine anamoly

  • Endometrium --- proliferative/ hyperplastic

  • Tubal ostium --- visualised or not


Post coital test
Post coital test

Technique

  • No longer routine, since subjective interpretation

    and poor correlation with pregnancy rates

  • Evaluates sperm-cervical mucus interaction

  • Schedule 1-3 days before expected ovulation

  • Abstain x 48o, then intercourse 2-8 hrs before PCT

  • Retrieve mucus with cytobrush or cannula


Post coital test1
Post coital test

Normal findings

  • Quant (+4), clarity (clear) , SBK (>8 cm), fern (+4)

  • Mucus WBC count (<5 wbc/ HPF)

  • Sperm quantity ( > 20/ HPF correlates >20 million/ cc)

  • Sperm motility (> 1-3 progressively motile/ HPF)


Fertility treatment goals
Fertility Treatment: Goals

  • To ensure patient safety

  • To help a couple experience a healthy pregnancy and birth or an alternative way to build a family

  • To use as little of a couple’s resources as necessary


Fertility treatment options
Fertility Treatment: Options

  • Correct ovulatory dysfunction

  • Correct tubal or uterine abnormalities

  • Overcome subfertile sperm parameters

  • ART


Ovulation induction

Serum TSH

Serum Prolactin

Anovulatory

Ovulatory

Specific treatment

Prog C.T.

Dysovulatory

Infertility

Negative

Positive

Unexplained

Infertility

Serum FSH

N

LPD

Pre Luteinasation

LH surge Absent

PCOD

No

PCOD

Low

High

CC

CC + HMG

HMG/FSH

Brom/cabergolin

Corticosteroids

Metformin (Insulin sensitizers)

Letrozol (Aromatase inhibitor)

Surgical treatment (Ovarian Drilling)

Hypo pit.

hypogonadism

POF

Superovulation IUI

CC

CC + HMG

HMG/FSH

HMG

OC

GnRHa + HMG

No success

Associated tubal / male factor

ART

Ovulation Induction

CC

GnRH + HMG

CC+HMG/FSH


Clomiphene citrate
Clomiphene Citrate

+ HMG / FSH

OR CC 100mg

D5 to D9

CC 100mg

D3 to D7

Inj. HCG 10,000 IU

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Clomiphene Citrate dose

Day of cycle

Contd...


Clomiphene Citrate

Antiestrogenic effect on hypothalamus

Increase in GnRh

Increase in LH & FSH

Development of follicles

Increase in E2

Increase in LH

OVULATION


Letrozole
Letrozole

Letrozole 2.5mg bd

D3 to D7

Inj. HCG 10,000 IU

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Letrozole

dose

Day of cycle

Contd...


Tamoxifen
Tamoxifen

Taxomifen 50 –

100mg / day

Inj. HCG 10,000 IU

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Tamoxifen

dose

Day of cycle

Contd...


Cc gonadotropins
CC + Gonadotropins

FSH + HMG

CC

Inj. HCG 10,000 IU

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

16

18

Tamoxifen

Day of cycle

Contd...


Gonadotropins step up regimen

HMG / FSH Ampoules / day

3

2

1

0

5

10

15

Gonadotropins (Step up Regimen)

Day of cycle


Gonadotropins step down regimen
Gonadotropins (Step down Regimen)

HMG / FSH Ampoules / day

3

225 IU

150 IU

2

75 IU

1

2

10

12

14

16

0

4

8

6

Day of cycle


Gnrh agonist short protocol
GnRH Agonist Short Protocol

HMG 225

IU

HMG 150 IU

HMG 75 IU

Inj. HCG 10,000 IU

Lupride 1mg

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

16

18

Day of cycle

Contd...


Gnrh agonist long protocol
GnRH Agonist Long Protocol

HMG 600

IU

HMG 450 IU

HMG 300 IU

Lupride 1mg

Lupride 0.5mg

20

22

24

26

28

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

16

Previous cycle Day of cycle

Contd...


Luteal support
Luteal Support

Tab. Progynova 2mg

twice a day

OR

Inj. HCG 5000 IU

twice weekly

Vaginal progesterone 400mg/day /

Inj. Progesterone 100mg/day

Inj. HCG 10,000 IU

RF

S. B HCG

Positive

0

14

16

18

20

22

24

26

28

12 to 14 weeks of pregnancy

Day of cycle

Contd...




Management of infertility in women 30 years
Management of infertility in women >30 years

Conservative

Active

  • Ovarian stimulation with IUI

  • Ovarian stimulation with IVF (own eggs)

  • Ovarian stimulation with IVF (donor eggs)

  • Surrogacy

  • Adoption

For couples who do not desire medical intervention


ad