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INFERTILITY PowerPoint PPT Presentation


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INFERTILITY. Assessment and treatment of patients with fertility problems Dr Nitu Raje-Ghatge. Why learn about it?. Its in the curriculum ! Infertility – primary/ secondary Investigations eg hormone tests Knowledge of subfertility

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Infertility l.jpg

INFERTILITY

  • Assessment and treatment of patients with fertility problems

    Dr Nitu Raje-Ghatge


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Why learn about it?

Its in the curriculum !

Infertility – primary/ secondary

Investigations eg hormone tests

Knowledge of subfertility

secondary care investigations

Primary care management

Knowledge of specialist treatments

and surgical procedures


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Why learn about it..

Expectations from secondary care services!

Inappropriate timing of referrals (early/late)

Incomplete /inadequate investigations


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What is infertility?

  • NICE:

    Failure to conceive after regular UPSI for 2 years in the absence of reproductive pathology.

    P.S NICE suggests offer clinical investigations if failure to conceive after 1 year of UPSI.

  • GP NOTEBOOK:

    Infertility is the failure of conception in a couple having regular, unprotected coitus for 1 year, provided that normal intercourse is occurring not less than twice weekly.


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Natural conception rates:

80% of couples will be pregnant after 12

cycles.

50% of remaining will conceive during a

2nd year ( hence cumulative rate 90%)

50% in the following 4 years.


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PRIMARY/SECONDARY INFERTILITY

  • PRIMARY – Couple without a prior pregnancy

  • SECONDARY – Couple with previous pregnancy including miscarriage/ectopic.


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Etiology:

  • Male factors

  • Female factors

  • Unexplained -20%

  • Mixed – 15%


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Male

Account for 25%

  • Hypogonadotrophic hypogonadism

  • Obstructive azoospermia

    Surgery

  • Erectile dysfunction

  • Anatomical

    - Hypospadias

    - Undescended/

    maldescended testis


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Female

  • Peritoneal factors 40%,

    - Endometriosis.

  • Tubal blockage 20%.


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Etiology (female)

  • Ovulatory dysfunction 15-20%

    - Hypothalamic/hypogonadotrophic

    hypogonadism

    - Hypothalamic pituitary dysfunction

    (PCOS)

    - Ovarian failure

  • Uterine cavity abnormalities

    - Asherman's syndrome

    - Uterine fibroids.

  • Cervical hostility 5-10%,

    - Infection

    - Female sperm antibodies.


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Fertility may be impaired in poorly controlled diabetes.


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History taking (female)

  • Symptoms (past or present)

    - P I D / STD,

    - dysparenuria

    - galactorrhoea,

    - thyroid symptoms

  • Obstetric history


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History taking (female)

  • Menstrual history

    - irregularities

  • Surgical history

    – D & C, abdominal/pelvic surgery

  • Contraception

    - IUCDs

  • Cervical smear


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History taking (male)

  • Symptoms

    h/o genital tract infection e.g. mumps orchitis, prostatitis

  • Surgical history

    - Hernia repair

    - Testicular surgery for torsion/ undescended /maldescended

    testis

    - Prostate surgery


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History taking (male)

  • Trauma to the male genital or inguinal region

  • Occupational history

    - exposure to lead, cadmium

  • Drug history

    - Sulphasalazine – impairs spermatogenesis

    - Phenothiazines/ typical antipsychotics/ metoclopramide

    increase prolactin levels

    - Immunosuppresants


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IN BOTH

  • Smoking

  • Alcohol intake

  • Psychological factors


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EXAMINATION

  • General health and nutritional status

  • BMI

    <19 (F)

    > 29.(M/F)

  • SSC


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Female:

  • Hirsuitism, galactorrhoea

  • Bimanual examination

    - adnexal masses (tubo/ovarian, ovarian cyst)

    - tenderness (PID/ endometriosis)

    - Uterine fibroids


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Male

  • Hypospadias

  • Size and consistency of each testicle and epididymis;

  • Presence of varicocele or hernia;

  • Size of prostate.

  • Gynaecomastia


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Now what??

Investigate

Or

Refer


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Female

Age >35 years

Amenorrhoea/ oligo menorrhoea

PID

Abnormal pelvic exam

Male

Undescended testes

Previous genital pathology

Previous urogenital surgery

In Both

Prior treatment for cancer

HIV, Hep B, Hep C

Early referral if..


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Primary care

Female

Assess ovulation.

Other hormonal tests

Tests for PID

Male

Sperm analysis

Secondary care

Tubal patency

Uterine abnormality

Investigations


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Assessing ovulation

Do if

  • regular cycles with > 1 year of infertility

  • irregular cycles

    1) Serum progesterone

    2) LH/FSH levels


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INVESTIGATIONS (Female)

1) Serum progesterone

(mid luteal phase ie day 21 of 28 week cycle)

Timing is important!!!

  • Regular cycles - 7 days before next MP

  • Irregular cycles - day 28/35 wk then weekly

    till menstruation occurs


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Interpretation of test


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Assessing ovulation

2) LH/FSH levels

High levels – poor ovarian function

High LH compared to FSH -PCOS


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Other hormonal tests

  • E2, Testosterone levels – PCOS

  • Prolactin ONLY if

    - ovulation problems

    - galactorrhoea,

    - pituitary problem.


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Other hormonal tests

  • Thyroid tests

    - only with symptoms/ signs

  • Other androgen profile (DHEAS,

    Androstenedione, SBHG)

    – as per etiology


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Tests for PID

  • HVS

  • Chlamydia screening


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Don’t forget!!

  • Rubella status

    - check immunity

    - Vaccinate if non immune, avoid conception for 3 months


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Cervical hostility

  • Post coital test

    - no longer recommended by NICE

  • Mucus invasion test

    - doubtful significance


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Investigations (Male)

Semen analysis

  • Needs prior appointment with lab

  • Abstinence for atleast 3 days

  • Transport to lab in 30- 60 min

  • Repeat abnormal test in next 3 months, earlier if gross abnormality


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Semen analysis- interpretation (WHO values)

  • Volume 2 mls or more

  • Sperm concentration - 20 million/ml

  • Sperm morphology - atleast 30% normal

  • Sperm number - 40 million/ ejaculate

  • Sperm motility – 50%

  • Vitality – 75%

  • WBC - <1 million/ml

    Anti sperm antibody tests- not recommended by NICE


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Investigations in secondary care


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Tests for uterine/tubal problems

  • HSG/hystero salpingo-contrast USG

  • Laparoscopy + dye test

    Done only when ovulation tests/Sperm tests normal.

    Choice of tests depends upon co morbidities


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Management in primary care

Principles of care

  • Couple centred management

  • Access to evidence based information

  • Counselling (third person)

  • Contact with fertility support groups

  • Specialist teams


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Positive approach

Reassure about cumulative pregnancy rates


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Lifestyle changes

- Weight reduction,

BMI 19-29

- Smoking cessation- offer support groups

- Alcohol reduction

<1-2 units/week for women

<3-4 units/week for men

- S I every 2-3 days

- Information about OTC/ recreational drugs

Management in primary care


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Management in primary care

  • Pre conceptual advice

    - Folic acid supplementation

    - Rubella status

    - Cervical screening

  • Management of erectile dysfunction

    - psychosexual couselling

    - drugs


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Management in secondary care

  • Depends upon the etiology..


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Hypogonadotrophic hypogonadism

  • Pulsatile GnRH

  • Gonadotrophins with LH activity

  • Bromocriptine ( for hyperprolactinaemia)


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Ovarian dysfunction ( hypothalamic dysfunction)

1) Anti- oestrogens eg Clomiphene/ Tamoxifen

- 1st line

- use for atleast 12 months if ovulating

- initiated in secondary care

- under USG guidance ( to adjust dose)

- shared care when dose established

- S/E risk of multiple pregnancy, OHSS


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Ovulatory dysfunction- treatment

2) Metformin

- not licensed for ovulatory disorders in UK

- used 2nd line with Clomiphene in

- anovulatory women with PCOD

+ BMI >25

+ no response to CC


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Others…

3) Gonadotrophins

4) Luteal phase support –

- progesterone,

- clomiphene

5) Laparoscopic ovarian drilling


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Peritoneal problems (endometriosis)

  • Laparoscopic surgical ablation/ resection of endometriosis + adhesiolysis

  • If ovarian endometriomas, laparoscopic cystectomy


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Uterine/ tubal factors

  • Tubal factors:

    - Laparoscopic tubal surgery/ tubal microsurgery

    - Salpingography + tubal catheteristion

    - Hysteroscopic tubal cannulation

  • Uterine factors

    - hysteroscopic adhesiolysis

    - myomectomy


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Assisted reproduction techniques

  • Intra uterine insemination (IUI)


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In vitrio fertilisation

  • Intracytoplasmic sperm injection (ICSI)

  • Donor insemination

  • Oocyte donation


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ACON at CRH

  • Satellite IVF unit

  • Counselling, monitoring and most of treatment , except egg retrieval and embryo transfer.


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Central unit

  • Clarendon Wing, LGI

  • SJUH, Leeds

  • CARE, Manchester


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Questions…..zzzz??


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