Management of Female infertility


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Management of
Female infertility

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Management of Female infertility

  1. 1. Benha University Hospital, Egypt Aboubakr Elnashar
  2. 2. When to refer a couple for investigations? Not conceived with unprotected sexual intercourse Age <36 y Absence of any known cause of infertility After one year Age >36 y known clinical cause of infertility history of predisposing factors for infertility Earlier Aboubakr Elnashar
  3. 3. Incidence 1 in 7 couples Main causes Male factors: 30% Female: 45% • Tubal: 20% • Ovulatory disorders: 25% • Uterine: 10% • Endometriosis: 5% Unexplained: 25% Combined male and female: 40% Aboubakr Elnashar
  4. 4. Investigations (ESHRE, 2000) I. Tests that have an established association with pregnancy: Conventional semen analysis HSG Midluteal progesterone Aboubakr Elnashar
  5. 5. II. Tests that are not consistently associated with pregnancy: Post-coital test Antisperm antibody tests Zona-free hamster egg penetration test III. Tests that have no association with pregnancy: Endometrial biopsy Varicocele assessment Chlamydia testing Aboubakr Elnashar
  6. 6. Aboubakr Elnashar
  7. 7. Investigations 1. HSG No co morbidities: PID Previous ectopic pregnancy or Endometriosis {reliable test for ruling out tubal occlusion less invasive makes more efficient use of resources than laparoscopy} Aboubakr Elnashar
  8. 8. Aboubakr Elnashar
  9. 9. HS-contrast-US experience effective alternative to HSG Prophylactic antibiotics before uterine instrumentation if screening for CT has not been carried out. Aboubakr Elnashar
  10. 10. HS-contrast-US Free fluid collection in the cul-de-sac following successful demonstration of oviductal patency. Oviductal fimbria are clearly observed in the collected fluid. Aboubakr Elnashar
  11. 11. 2. Laparoscopy and dye test Co morbidities {tubal and other pelvic pathology can be assessed at the same time}. Aboubakr Elnashar
  12. 12. 3. Hysteroscopy Not an initial investigation unless clinically indicated {effectiveness of surgical treatment of uterine abnormalities on improving pregnancy rates has not been established}. Aboubakr Elnashar
  13. 13. Classification of Tubal disease British Fertility Society Minor Proximal occlusion without tubal fibrosis Distal occlusion without tubal distension Healthy mucosal appearance at HSG, salpingoscopy Flimsy peritubal/ovarian adhesions. Intermediate Unilateral severe tubal damage Limited dense adhesions of tubes & ovaries Severe Bilateral severe tubal damage Extensive tubal fibrosis Tubal distension >1.5 cm Abnormal mucosal appearance Bipolar occlusion Extensive dense adhesion Aboubakr Elnashar
  14. 14. Hydrosalpinx well-constrained fluid accumulation in the adnexae. In some cases, adhesions between the oviduct and ovary may be visualized. Aboubakr Elnashar
  15. 15. Treatment I. IVF: 1. Moderate to severe tubal disease 2. Other factors e.g A. Sperm dysfunction B. Age >36 yr Aboubakr Elnashar
  16. 16. Hydrosalpinges salpingectomy, preferably by laparoscopy, before IVF treatment {improves the chance of a live birth}. Aboubakr Elnashar
  17. 17. II. Laparoscopic surgery: mild tubal disease appropriate expertise Aboubakr Elnashar
  18. 18. III. Selective salpingography plus tubal catheterisation, or hysteroscopic tubal cannulation Proximal tubal disease If pregnancy has not occurred within 12 mo of surgery: IVF Aboubakr Elnashar
  19. 19. Aboubakr Elnashar
  20. 20. Investigations 1. Midluteal progesterone in regular and irregular cycles {confirm ovulation} In irregular prolonged cycles Depending upon the timing of menstrual periods, conducted later in the cycle (for example day 28 of a 35-day cycle) and repeated weekly thereafter until the next menstrual cycle starts 2. Basal FSH and LH • Only in irregular prolonged cycles Aboubakr Elnashar
  21. 21. 3. Prolactin Only in ovulatory disorder galactorrhoea or pituitary tumour 4. TSH: only if symptoms of thyroid disease Endometrial biopsy To evaluate the luteal phase: No {no evidence that medical tt of luteal phase defect improves pregnancy rates] Aboubakr Elnashar
  22. 22. 5. Ovarian reserve testing  Woman’s age: An initial predictor of overall chance of success through natural conception or with IVF  Predictors of ovarian response to Gnt stimulation in IVF: High responseLow response 16 or more4 or lessTotal AFC 3.5 or more 25 0.8 or less 5.5 AMH ng/ml pmol/l Conversion ratio:7 4 or less8.9 or moreFSH IU/L Aboubakr Elnashar
  23. 23. • Do not use 1. ovarian volume 2. ovarian blood flow 3. inhibin B 4. E2 Aboubakr Elnashar
  24. 24. WHO: I. Hypothalamic pituitary failure II. Hypothalamic pituitary dysfunction III. Ovarian failure Aboubakr Elnashar
  25. 25. Amenorrhea or severe oligomenorrhea FSH & LH: low Prolactin: normal Aboubakr Elnashar
  26. 26. 1. Reverse the life style factors: Increase wt if BMI <19 Moderating exercise if high levels of exercise. Treat stress 2. Gonadotrphins with LH activity or Pulsatile GnRH (pump)  CC: not effective Aboubakr Elnashar
  27. 27. PCOS 2 of 3 (Noterdam definition,2003): •U/S PCO •Hyperandrogenism (Clinical or Laboratory) •Irregular or absent ovulation Aboubakr Elnashar
  28. 28. PCO Multiple peripheral subcentimetric follicles (arrow). Aboubakr Elnashar
  29. 29. OVULATION INDUCTION IN PCOS NICE, 2013 1. Weigh loss: If BMI >30 K/m2  alone may restore ovulation  improve response to ovulation induction agents,  positive impact on pregnancy outcomes Aboubakr Elnashar
  30. 30. 2. One of the following taking into account •potential adverse effects •ease and mode of use •BMI •monitoring needed: CC: (not more than 6 m) or Metformin or CC + Metformin Aboubakr Elnashar
  31. 31. 3. CC resistance: one of the following 2nd line tt, depending on •clinical circumstances •woman's preference: CC and met if not already offered as1st line tt or LOD or Gnt US monitoring {measure follicular size and number {reduce the risk of multiple pregnancy and OHSS} Aboubakr Elnashar
  32. 32. Aboubakr Elnashar
  33. 33. Hyperprolactinaemia I. Idiopathic .Dopamine agonist (anxiety, pregnancy ). Stop during pregnancy II. Microadenoma . Dopamine agonist (anxiety, pregnancy). Stop after 2-3 yr. . Surgery (rapid growth). III. Macroadenoma . Dopamine agonist: long term . Surgery (No response, suprasellar extension, pregnancy).Aboubakr Elnashar
  34. 34. < 40 yr, 2ndry amenorrhea Repeated FSH > 20 IU/L Causes 1. Idiopathic. 2. Genetic. 3. Autoimmune 3. Viral/bacterial infection 4. Pelvic surgery, chemotherapy 5. Galactosemia Aboubakr Elnashar
  35. 35. POF. Only the stroma of the ovary is identified. A very few follicles of less than 1 mm on the inferior aspect of the ovary. Aboubakr Elnashar
  36. 36. 1. Oral contraceptive suppression of gonadotrpins followed by discontinuation to allow a rebound in gonadotropins & ovarian function. 2. GnRH agonist suppression of gonadotropins secretion followed by high dose gonadotropin injection 3. Glucocorticoids suppression of immune system. Non of these tts has demonstrated efficacy in RCT (van Kastren et al, 1995) Aboubakr Elnashar
  37. 37. Aboubakr Elnashar
  38. 38. Aboubakr Elnashar
  39. 39. Aboubakr Elnashar
  40. 40. Infertility workup 1. Ovarian reserve 2. Semen analysis 3. F tubes Compromised: IVF Not compromised: surgery Allow 6-18 month No pregnancy: IVF No surgery before IVF except: Large endometrioma , hydrosalpinx, pelvic pain de Ziegler et al, 2010Aboubakr Elnashar
  41. 41. I. Minimal and mild (Aboulghar,2003): • Medical treatment does not enhance fertility & should not be offered • Expectant treatment. • ±COH/IUI. • Surgical ablation* • IVF. *Minimal or mild endometriosis who undergo laparoscopy should be offered surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis • {improves the chance of pregnancy}. Aboubakr Elnashar
  42. 42. II. Moderate & severe • IVF: Treatment of choice (Aboulghar, 2003). • Postoperative medical treatment does not improve pregnancy rate & not recommended Moderate or severe: surgical treatment {improves the chance of pregnancy}. Aboubakr Elnashar
  43. 43. • Endometrioma: Laparoscopic cystectomy {improves the chance of pregnancy} Aboubakr Elnashar
  44. 44. Aboubakr Elnashar
  45. 45. 1. Uterine myoma Aboubakr Elnashar
  46. 46. Myomectomy: -Indications: 1. Distorting the uterine cavity  Submucous: interfere with fertility and should be removed in infertile patients, regardless of the size or presence of symptoms (Gambadauro,2012).  Intramural: distorting: reduce the chances of conception not distorting: controversial results.  Subserosal: No evidence supports removal in asymptomatic, infertile 3. >5-7cm 4. Multiple >3 (3-5 cm) (Bajekal & Li, 2000) Aboubakr Elnashar
  47. 47. Aboubakr Elnashar
  48. 48. Intramural fibroid Examples of fibroids which compromise the contours of the endometrial cavity. Refraction artifacts {tissue density interfaces and the texture of the fibroids} often aid in their identification. Aboubakr Elnashar
  49. 49. Fibroid 1. Cavity Distorted Not distorted 2. Size >7 cm <7 cm 3. Number (3-5 cm) >3 <3Aboubakr Elnashar
  50. 50. A. Open myomectomy (Bajekal & Li, 2000) The route of choice: Large SS or IM(>7 cm) Multiple fibroids (>5) When entry into uterine cavity is to be expected Aboubakr Elnashar
  51. 51. B. Hysteroscopic myomectomy: The route of choice: SM fibroids. Compared to laparotomy, it is associated with a lower risk of scar rupture & no pelvic adhesion (Bajekal & Li, 2000) Large (>5 cm) type II SM fibroids may be unsuitable for hysteroscopic surgery. A significant benefit of removing SM fibroid >2cm (Varasteh et al, 1999)Aboubakr Elnashar
  52. 52. Aboubakr Elnashar
  53. 53. C. Laparoscopic myomectomy:  Pedunculated or SS: not candidate for removal {not the cause of infertility or recurrent miscarriage} (Bajekal & Li, 2000). IM:  Very experienced laparoscopic surgeon  Uterine rupture: 2 reports both at 34 w {inability to effectively close the myometrium laparoscopically} Uterine indentation Uterine fistula Aboubakr Elnashar
  54. 54. Aboubakr Elnashar
  55. 55. 2. Septate uterus Not increased among women with infertility compared with other women (2–3%). More common: RM or PTL. Hysteroscopic metroplasty: No increase pregnancy rates in women with infertility [Evidence level 2b–3] Aboubakr Elnashar
  56. 56. Aboubakr Elnashar
  57. 57. 3. Intrauterine adhesions with amenorrhoea hysteroscopic adhesiolysis {restore menstruation and improve the chance of pregnancy}. (C) Aboubakr Elnashar
  58. 58. IU adhesions Bright (hyperechoic) uterine lining - scar tissue in uterine cavity Aboubakr Elnashar
  59. 59. Aboubakr Elnashar
  60. 60. Inability to conceive after one year with routine (standard, basic) investigations of infertility showing no abnormality. (RCOG guidelines,1998; Randolph,2000) Dependent on: Availability of resources , Patients’ age Duration of infertility. IUI: ESHRE (2004) indicated as empiric treatment Aboubakr Elnashar
  61. 61.  Protocol for Management (Ray et al, 2012)
  62. 62.  Cochrane (2012) • IUI with OH increases the live birth rate compared to IUI alone. • The likelihood of pregnancy was also increased for treatment with IUI compared to TI in stimulated cycles Aboubakr Elnashar
  63. 63. • NICE, 2013  Do not offer oral ovarian stimulation agents (such as clomifene citrate, or letrozole). {no increase the chances of a pregnancy or a live birth}.  Offer IVF after 2 years  IUI:  when social, cultural or religious objections to IVF without stimulation: no better than expectant management. with stimulation: better than expectant management Aboubakr Elnashar
  64. 64. Benha University Hospital, Egypt E-mail: Aboubakr Elnashar Aboubakr Elnashar