INFERTILITY Presented by,Mrs.Kavitha Jasmine,Asst. Prof, Obstetrics & Gynecology Department,Annammal College Of Nursing, Kuzhithurai.
INFERTILITY Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus.
TYPES Primary Infertility Secondary Infertility PRIMARY INFERTILITY: It denotes those patients who have never conceived. SECONDARY INFERTILITY: It indicates previous pregnancy but failure to conceive subsequently.
INCIDENCE Eighty percent of the couples achieve conception if they so desire,within one year of having regular intercourse with adequate frequency(4-5 times a week).Another 10 percent will achieve the objective by the end of second year.As such,10 percent remain infertile by the end of second year.
CAUSES OF INFERTILITY MALE FACTORS FEMALEFACTORS Defective spermatogenesis Obstruction of efferent duct system. Failureto deposit sperm high in vagina. Errors in seminal fluid. Ovarian factor. Tubal & peritoneal factors. Uterine factors. Cervical factors. Vaginal factors. Combined factors.
DEFECTIVE SPERMATOGENESIS • CONGENITAL FACTORS • UNDESCENDED TESTES • KARTARGENER SYNDROME • HYPOSPADIAS • THERMAL FACTORS • INFECTION • GENERAL FACTORS • ENDOCRINE FACTORS • GENETIC FACTORS • IMMUNOLOGIC FACTORS
CONGENITAL FACTORS: • Undescended testes- The hormone secretion remains unaffected, but spermatogenesis is depressed.Vas deferens is absent in about 1-2 percent males. • Kartagener syndrome- It is an autosomal disease in which there is loss of ciliary function and sperm motility. • Hypospadiasis- Causes failure to deposit sperm high in vagina.
THERMAL FACTOR: Scrotal temperature is raised in conditions such as varicocele,bighydrocele or filariasis. Other causes are using tight under garments or working in hot sun. In all these cases the depressed spermatogenesis may be temporary and reversible. INFECTION: Infections like mumps, bronchiectasis bacterial or viral infection of SEMINAL VESICLE OR PROSTATE depresses sperm count.
GENERALFACTORS: Chronic diseases,malnutrition or heavy smoking reduce spermatogenesis.Alcohol also has the same effect. IATROGENIC: Radiation,cytotoxic drugs, nitro-furantoin,cimetidine, β- blockers, anti hypertensives,anticonvulsants and antidepressant drugs are likely to hinder spermatogenesis.
OBSTRUCTION OF EFFERENT DUCTS The efferent ducts may be obstructed by infection like tubercular , gonococcal or by surgical trauma(herniorraphy) following vasectomy. FAILURE TO DEPOSIT SPERM HIGH IN VAGINA Ercetile dysfunction, Ejaculatory defect-premature ejaculation, retrograde or absence of ejaculation. Hypospadias: A developmental anomaly in the male in which the urethra opens on the underside of penis or in the perineum.
ERRORS IN SEMINAL FLUID 1.Usually high or low volume of ejaculate. 2.Low fructose content. 3.High prostaglandin count. 4.Undue varicosity.
OVARIANFACTORS • ANOVULATION • OLIGOOVULATION • LUTEAL PHASE DEFECT • LUTEINISED UNRUPTURED FOLLICULAR SYNDROME
ANOVULATION OR OLIGO-OVULATION: Ovarian function is likely to be linked with disturbed hypothalamo-pituitary-ovarian axis either primary or secondary from thyroid or adrenal dysfunction. Thus, the disturbance may result in anovulation, or even amenorrhoea.As there is no ovulation, there is no corpus luteum formation.
LUTEAL PHASE DEFECT(LFD): In this condition there is inadequate growth and functioning of corpus luteum. There is inadequate progesterone secretion.The life span of corpus luteum is reduced to 10 days.As a result,there is inadequate secretory changes in the endometrium which hinders implantation Drug induced ovulation,decreased level of FSH and LH, elevated prolactin,subclinicalhypothyroidism,olderwomen,pelvicendometriosis,dysfunctional uterine bleeding are the important causes.
LUTEINISE UNRUPTURED FOLLICULAR SYNDROME (trappedovum): In this condition the ovum is trapped inside the follicle which gets luteinized.The causes may be associated with pelvic endometriosis or with hyperprolactineamia.
CERVICAL FACTORS OVARIAN & TUBAL FACTORS
Tubal factors: Are responsible for about 30-40 percent cases of female infertility. It is due to obstruction in the tube due to; 1.Peritubal adhesions 2.Endosalpingeal damage 3.Previous tubal surgery or sterilization 4.Salpingitis 5.Tubal endometriosis 6.Polyps or mucous debris in the tubal lumen 7.Tubal spasm Peritoneal causes: Minimal endometriosis, dyspareunia, abnormal peritoneal fluid are the peritoneal factors.
Uterine factors: The endometrium must be sufficiently receptive enough for effective nidation and growth of fertilized ovum.The possible factors that hinders nidation are:- 1.Uterine hypoplasia 2.Inadequate secretoryendometrium 3.Fibroid uterus 4.Congenital malformation of the uterus Cervical factors: Congenital elongation of cervix,second degree uterine prolapse,acuteretroverteduterus,abnormal composition of cervical mucous.
Vaginal factors: It includes; 1.Atresia vagina 2.Transevrse vaginal septum 3. Septate vagina 4. Narrow introitus
COMBINED FACTORS • Apareunia And Dyspareunia • Anxiety And Apprehension • Use Of Lubricants During Intercourse Which Are Spermicidal • Immunologic Factors
Combined factors: • These include the presence of factors both in male and female partners causing infertility. • General factors: • Advanced age of wife beyond 35 is related but spermatogenesis continues throughout life although ageing reduces the fertility in males. • Infrequent intercourse, lack of knowledge of coital technique and timing of coitus to utilize the fertile period are common even among the literate couples. • Apareunia and dyspareunia • Anxiety and apprehension • Use of lubricants during intercourse which may be spermicidal.
INVESTIGATIONS OF INFERTILITY OBJECTIVES ; 1.To detect the etiological factors. 2.To rectify the abnormality in an attempt to improve the fertility. 3.To give assurance with explanation to the couples, if no abnormality is detected.
INVESTIGATION IN MALES • History collection: • Age, duration of marriage,history of previous marriage,and proven fertility if any,are to be noted. • A general medical history should be taken with special reference to sexually transmitted diseases,mumpsorchitis after puberty, diabetes,& recurrent chest infection. • Relevant surgeries such as herniorrhaphy, surgeries on testes or genital area are to be enquired. • Occupational history should be directed towards exposure to excessive heat or radiation.Socialhabits,particularly heavy smoking and alcohol is to be collected.
Examination: • A full physical examination is to be performed to determine the general health condition. • Examination of reproductive system includes inspection and palpation of genitalia. • Presence of varicocele should be elicited in upright position.
A.Routine Investigations include urine and blood examination including postprandial sugar. B.Seminal Fluid Analysis: This should be the first step in investigation because if some gross are detected like absence of sperm,the couple should be counselled for the need of assisted reproductive therapy. C.Collection: Collection of semen is done by masturbation failing which by coitus interruptus.The semen is collected in a clean wide mouthed jar.The sample must be send to lab as early as possible so that examination is conducted witnin 2 hours.
INDEPTH EVALUATION: • These are needed for the cases of –a)Azoospermia b)Oligospermia c)Low volume ejaculate d)Problems of sexual potency etc. • .SERUM FSH,LH, TESTOSTERONE,PROLACTIN & TSH: Testicular hypogonadotropichypogonadism.Elevatedprolactin due to pituitary adenoma may cause impotency. • .FRUCTOSE CONTENT IN SEMINAL FLUID: Its absence suggest congenital absence of seminal vesicle or portion of ductal system or both. • .TESTICULAR BIOPSY: It is done to differentiate primary testicular failure from obstruction as a course of azoospermia or severe oligospermia.The biopsy material is to be sent in Bouin’s solution.
Transrectal Ultrasound(TRUS): is done to visualize the seminal vesicles, prostate and ejaculatory duct obstruction. Indications of TRUS are-Azoospermia or oligospermia, abnormal digital examination, ejaculatory duct abnormality and genital abnormality like hypospadias. Vasogram: is a radiographic study done to evaluate the ejaculatory duct obstruction.It is mostly replaced by TRUS. karyotype analysis: This is done in case with azoospermia or severe oligospermia and raised FSH.Klinefelter’s syndrome (XXY) is the commonest.
INVESTIGATION IN FEMALES • HISTORY COLLECTION • EXAMINATIONS • SPECIAL INVESTIGATIONS -INDIRECT DIAGNOSIS OF OVULATION -DIRECT DIAGNOSIS OF OVULATION
DIAGNOSIS OF OVULATION • 1.Direct method • 2.Indirect method • Indirect method includes collection of menstrual history, Basal body temperature, Cervical mucous study,endometrial pH and hormone study. • Directmethod includes • Laparoscopy • Dilatation & Insufflation Test • Hysterosalphingography • Laparoscopy &Chromopertubation • Sonohysterosalphingography
LAPAROSCOPY; Laparoscopic visualization of recent corpus luteum or detection of ovum from the aspirated peritoneal fluid from the pouch of douglas is the only direct evidence of ovulation. The scope of diagnostic laparoscopy has been widened.It is an invasive investigation,so this is done after male factor and ovulatory functions have been fonud normal or corrected. The indications of its use are; a.Abnormal HSG findings. b.Failure to conceive after reasonable period(6 months) even with normal HSG. c.Unexplained infertility. d.Age above 35 years.
INDICATIONS FOR LAPAROSCOPY IN INFERTILITY Diagnostic - Age above 35 years. - Abnormal HSG. - Failure to conceive after reasonable period with normal HSG. - Unexplained infertility. Operative Gift & Zift Procedures. -Ovarian diathermy -Reconstructive tubal surgery. - Fulguration of endometriotic implants.
PROTOCOLS: A double puncture technique is to be applied.All the pelvic organs are to be properly visualized,of particular importance is to note the fimbrial end of fallopian tubes and their relation with the ovaries.Proper documentation with the aid of diagram is mandatory. Advantages Over Hsg: It can precisely diagnose peritubaladhesions,pelvic endometriosis or evidence of ovulation.Chromopertubation with methylene blue cannot only reveal patency of the tube but the nature of tubal motility. Drawbacks: It is more invasive than HSG.It cannot detect abnormality in the uterine cavity or lumen of tube. When to be done? It is preferably done in the secretoryphase.Recent corpus luteum may be visualized and endometrial biopsy can be taken in the same setting.
DILATATIONAND INSUFFLATION TEST(RUBIN’S TEST) Principle: The underlying principle lies with the fact that cervical canal is in continuity with the peritoneal cavity through the tubes.As such entry of air or CO2 into the peritoneal cavity when pushed transcervically under pressure gives evidence of tubal patency. When to be done? It should be done in the post menstrual phase atleast 2 days stopping of menstrual bleeding. LIMITATION: It should not be done in the presence of pelvic infection. OBSERVATIONS: The patency of the tube is confirmed by: 1.Fall in pressure when raised above 120mm hg. 2.Hissing sound heard on auscultation on eithr iliac fossa. 3.Shoulder pain experienced by the patient. Drawbacks: In about one third of cases it gives a false negative findings due to corneal spasm.It also cannot identify the side and site of block in the tube.
HYSTEROSALPHINGOGRAPHY Principle: The principle is sams as that of insufflationtest,instead of air or CO2,dye is instilled transcervically. When to be done? 2 days after stopping of menstrual bleeding. Advantages: It has got many advantages over insufflations test.It can precisely detect the side and site of block in the tube.It can reveal any abnormality in the uterus like congenital anomalies,fibroid etc.
SONOHYSTEROSALPHINGOGRAPHY • Normal saline is pushed within the uterine cavity with a paediatric Foley catheter.The catheter balloon is inflated at the level of cervix to prevent fluid leak.USG of the uterus and fallopie tube is done.Ultrasound can follow the fluid through the tubes up to the peritoneal cavity and in the pouch of Douglas. • Advantages: • It is a non-invasive method . • It can detect uterine abnormality and polyps. • Tubal Pathology could be detected. • There is no radiation exposture.
PREVENTION OF INFERTILITY • Assurance To The Couples • Body Weight Should Be Adequate • Smoking & Alcoholism Is Prevented • Managing Coital Problems
1.ASSURANCE: The infertile couples remains psychologically disturbed right from the beginning, more so as the investigations proceeds.The couple in such cases should be tactfully handled to minimize psychologic upset. When minor defects are detected in both the husband and the wife,each of which alone could not cause infertility but in combination,they significantly reduce the fertility potential.Assuch,the faults should be treated simultaneously and not one afer the other. 2.BODY WEIGHT: Overweight or underweight of any partner should be adequately dealt with to obtain an optimal weight.Body mass of index of 20-24 is optimum.