Subfertility presentation

1. SUBFERTILITY
Azan Rid
Batch 15th
Roll No.: 100

2. SUBFERTILITY
• Failure to conceive after 12 months of regular
unprotected intercourse is called subfertility.
• Incidence = 1 in 7 heterosexual couples.
• Types
Primary- Couples have never conceived.
• Secondary- Couples have previously conceived.

3. CAUSES

4. WHAT IS INFERTILITY?
• Infertility is synonymous to subfertility and is defined
as either 1 year of unprotected coitus without
conception in a female younger than 35 years or 6
months in a female older than 35 years.
• In subfertility couples have a good chance of
conceiving on their own whereas infertility needs
medical help for conceiving.

5. NATURAL CONCEPTION
• Fecundability is the probability of achieving
pregnancy in a single menstrual cycle.
 18-20% chance of conceiving in a single menstrual
cycle.
Percentage of conception;
70% within 6 months
80% within 12 months
90% within 24 months

6. FACTORS AFFECTING FERTILITY
• Female age – Most important factor affecting fertility.
• Male age
• Frequency and timing of intercourse.
• Smoking
• Stress
• Alcohol and caffeine (not proved)
• Abnormal BMI (outside the range 20-30)

7. FEMALE SUBFERTILITY
Female subfertility can be due to;
 Disorders of ovulation
 Impaired oocyte production
 Tubal dysfunction
 Uterine problems

8. OVULATORY DISORDERS
Polycystic Ovary Syndrome (PCOS) => Commonest
problem
Hypothalamic disorders (e.g. Hypothalamic
hypogonadism)
Pituitary disease (e.g. Hyperprolactinemia)
Endocrine abnormalities (e.g. Thyroid disease)

9. TUBAL FACTOR
• Pelvic Inflammatory Disease (PID)
• Endometriosis
• Chlamydial infections
• Previous pelvic or abdominal surgery

10. UTERINE PROBLEMS
• Fibroids
1. Submucosal = Direct impact on embryo implantation.
2. Intramural = Reduce fertility if larger than 5cm.
• Endometrial polyp
• Asherman’s syndrome

11. INVESTIGATIONS
• Female Investigations: Blood hormone profile. In woman with
regular menstrual cycles FSH, oestrdiol and LH.
• AMH for ovarian reserve.
• Mid luteal progesterone measurement to confirm ovulation.
• In a woman with irregular menstrual cycle thyroid function,
prolactin and testosterone can prove useful.
• Chlamydia, HIV, Hepatitis B and C testing.
• TVUSS
• Tubal assessment by Hysterosalpingography (HSG) using X-
Ray, Hysterocontrast synography using ultrasound or more
recently 3D hysterocontrast synography.

13. MALE FACTOR
Male subfertility can be due to;
 Aging
 Inflammation – Orchitis, epididymitis
 Testicular trauma
 Varicocele
 Pelvic radiotherapy
 Genetics: Klinefelter syndrome
 Ejaculatory dysfunction
 Medical conditions: DM
 Occupational: Radiation and Chemical exposure

14. MALE INVESTIGATIONS
• Semen Fluid Analysis (SFA)
• Abnormal SFA – perform serum FSH, LH and
testosterone.
• Karyotyping if Klinefelter suspected.
• Cystic fibrosis screening if clinically indicated.

16. MANAGEMENT
• Ovulation Induction
• Surgery
• Intrauterine insemination
• In vitro fertilization

17. Ovulation Induction: First line of management for PCOS patients.
 Antioestrogen Clomiphene citrate is the most common ovulation induction agent.
In Clomiphene resistant women,
Augmentation with Metformin
Use of Aromatase inhibitors
Injectable gonadotropins
Laparoscopic Ovarian Drilling (LOD)

18. Surgery:
 Laparoscopy
 Hysteroscopy
 Laparoscopic ablation of endometriosis
Intrauterine insemination (IUI): Intrauterine
insemination is performed by introducing a small sample of
prepared sperm into the uterine cavity with a fine uterine
catheter.
IUI preceded by several days of mild stimulation with
subcutaneous injections daily of exogenous FSH, for
stimulating ovaries to produce 2-3 mature
follicles is called stimulated IUI.
In-vitro fertilization: Steptoe and Edwards
performed the first successful case in 1978.
It involves extraction of oocytes, fertilization in laboratory,
and trans-cervical transfer of embryo into nucleus.

19. Principle steps of IVF
1. Pituitary down-regulation
2. Controlled ovarian stimulation
3. Inhibition of premature ovulation
4. hCG trigger
5. Egg collection
6. Fertilization
7. Embryo culture
8. Embryo transfer
9. Embryo cryopreservation
10. Luteal phase support

20. ART SUCCESS RATES
• In young patients under the age of 35yr – 40-45%
• Over 40 yr – below 15%
Complications:
• Ovarian hypermature stimulation syndrome (OHSS) – 1-3%
• Miscarriage
• Ectopic pregnancy