female infertility

1. FEMALE INFERTILITY
Akshai George Paul

2. For convenience, the treatment modalities in female
infertility are grouped as follows according to the
disorders identified:
• Ovulatory.
• Tubal.
• Associated disorders like endometriosis,
infections or endocrinopathy.
• Cervical.
• Immunological.
• Unexplained infertility.
• Uterovaginal canal.

3. OVULATORY DYSFUNCTION
1.PCOS
a)Lifestyle modifications
Weight loss,
Dietary modifications
Exercise

4. b)Ovulation induction

5. i)Clomiphene citrate
SERM
It binds to estrogen receptor
It make hypothalamus to be unable to recognize the endogenous
estrogen levels
It interferes with the negative feed back resulting in increased GnRH
and FSH

6. DOSAGE AND MONITORING
Clomiphene therapy is simple, safe and at the
same time cost-effective.
Most centers use an initial
dose of 50 mg daily.
Dose is increased in 50 mg
steps to a maximum 250 mg daily, if ovulation is not
induced by the lower dose.

7. The actual starting day
of its administration in the follicular phase varies
between day 2 and day 5 and therapy is given for 5
days.
Ovulation is expected to occur about 5–7 days
after the last day of therapy. Therapy for six cycle is
generally given.

8. SIDE EFFECTS:
Hot flushes, nausea, vomiting,
headache , visual symptoms and ovarian
hyperstimulation (rare).
Incidence of abortion and
congenital fetal malformations are not increased

9. Ovarian hyperstimulation syndrome
Life threatening complication
Abnormal accumulation of fluid in third space-
pleural,pericardial,peritoneal.

10. ii)Aromatase inhibitor
Letrozole,anastrozole
iii)Gonadotrophins
It is given in combination with clomiphene or letrozole
iv)Laparoscopic ovarian drilling -rule of 4
4 punctures,four seconds,forty watt,4 mm depth
v)Insulin sensitisers
Metformin 1-1.5 gm in divided doses

11. 2.Hyperprolactinemia
Bromocryptine or cabergoline
3.Hypothyroidsm
Treated with thyroxine
4.Hypegonadotrophic Amenorrhoea
Gonadotrophins can be used
5.Hypergonadotrophic amenorrhoea
Ovum donation and IVF

12. LUTEAL PHASE DEFECT (LPD)
The following treatment may be of help
in the idiopathic groups:
Natural progesterone as vaginal suppositories 100
mg thrice daily starting from the day of ovulation is
effective.
It should be continued until mens begins.
If mens fails to appear after 14 days, pregnancy
test is to be done

13. If the test is positive, it should
be continued upto 10th week of pregnancy.
hCG is a potent luteotropic hormone, however, the
response of LPD to hCG is unpredictable.
In unresponsive cases, clomiphene citrate may
be tried.
It increases FSH which may improve
folliculogenesis and normal corpus luteum formation
with adequate production of progesterone. In
refractory cases, IVF may be tried.

14. LUTEINIZED UNRUPTURED FOLLICLE (LUF)
Defective folliculogenesis or inadequate LH surge
may be corrected with:
Optimally timed intramuscular injection of hCG
5000–10,000 IU.
Administration of ovulation inducing drugs in
the follicular phase followed by ovulatory hCG
(5000–10000 IU).
Bromocriptine therapy, if associated with
hyperprolactinemia

15. TUBOPERITONEAL FACTORS
i.Peritubal adhesions: Correction is done by
salpingo-ovariolysis either by laparoscopy or by
laparotomy.
ii. Proximal tubal block: Salpingography under
fluroscopy may be helpful to remove any block
due to mucus plugging. Otherwise proximal tubal
cannulation with a guide wire under hysteroscopic
guidance is done. In about 85 percent cases, tubal
patency can be restored and over all pregnancy rate
of about 45–60 percent is reported. Cannulation
and balloon tuboplasty can avoid the need of
ART which is expensive.

16. iii. Distal tubal block:
(a) Fimbrioplasty/fimbriolysis—
release of fimbrial adhesions and/or dilatation of
fimbrial phimosis.
(b) Neosalpingostomy—to create
a new tubal opening in an occluded tube.

17. iv. Mid tubal block: Reversal of tubal ligation—
pregnancy rates after this procedure varies
between 50–82 percent. Success rate depends
on—
(a) age,
(b) the method of sterilization
(Pomeroy’s, Fallope rings, Diathermy, etc.),
(c) site of anastomosis (isthmic-isthmic or
isthmic-cornual),
(d) final length of reconstructed
tube. Risk of ectopic pregnancy following tubal
reanastomosis is 3–7 percent.

19. UTERINE FACTOR
• Polyps can be removed hysteroscopically
• Submucous Fibroids also can be removed hysteroscopically
• Laparoscopy
• Myomectecomy
• Metroplasty in removing septae
• Adhesiolysis for synechiae

20. CERVICAL AND IMMUNOLOGICAL FACTORS
Cervical mucus protects sperm from the hostile
environment of the vagina and also from phagocytosis.
The cervical mucus quality can be improved by
conjugated estrogen 1.25 mg orally daily starting on
day eight for 5 days.
In proved cases of Cl. trachomatis or M. hominis,
doxycycline 100 mg twice daily for 14 days is to be
given to both the partners. Cervical factor when
cannot be treated, is overcome by ART procedures
like lUI, IVF or GIFT

21. IMMUNOLOGICAL FACTOR
In the presence of antisperm antibodies in the
cervical mucus, dexamethasone 0.5 mg at bed time
in the follicular phase may be given. As there is
no distinct benefit of such treatment in antisperm
antibody positive patients, COH and IUI or IVF
or ICSI is recommended.

22. UNEXPLAINED FACTORS
a)Gonadotrophins and IUI
Controlled ovarian stimulation followed by IUI
b)In vitro fertilisation

23. ASSISTED REPRODUCTIVE
TECHNOLOGY(ART)

25. THANK YOU