6. Infertility is a disease or dysfunction of
the reproductive system defined by the
failure to achieve a clinical pregnancy
after 12 months or more of regular
unprotected sexual intercourse.
7.
8. Infertility
- Primary 40% a couple that has never
conceived.
- Secondary 60% infertility that occurs after
previous pregnancy regardless of outcome.
9. No major change in prevalence but
Apparent:
Scope of investigation and treatment are now easily available at affordable cost.
Real:
Advanced age at marriage of both partners.
» Male: Telomaric deletion of chromosome this may reduce chromosomal
integrity affecting spermatozoa viability.
» Female: Inverse correction between age and female fertility.
Life time quota of follicle in female is established at birth.
Changing life style and dietary habits.
Stress of modern society.
Use of synthetic dyes in green vegetable.
Consumption poultry chickens fattened with estrogen.
10. Fewer than 1% of teenage girls are infertile.
30% of women in their mid 30s are infertile.
90% of women past 40s are infertile.
11. Fertility is a
two person phenomenon
Male and Female.
In Bangladesh – everybody blame
female.
12. Successful conception depends on many complicated
events including.
1. Satisfactory sexual and ejaculatory function.
2. Appropriate timing and a complex set of interaction
between male and female reproductive tracts.
13. Explosion of knowledge about human reproduction and
a greater understanding has increased our scope of
applying ART for providing solution to a great number
of infertile couple.
14. ART have disadvantages…
• Costly
• Not easily available
• Invasive
• OHSS
• Multiple birth
• Ovulation inducing drug may increase the risk of
ovarian carcinoma.
• Single shot
15. Success of ART depends on…
• Age of female partner
• Cause of infertility
• ART lab
16. Aim…
•Allow for natural conception
•Reduce the risk of ART
•She may produce number of child in repeated attempt.
17. ART is the end point for many causes of infertility
but should not be abused or embarked upon too
early on the other way not too late.
18. Patient selection for referral to ART
should be based on the cause of infertility
and age of the couple.
19.
20. General recommendation…
1.Privacy and sufficient clinical time.
2.Counseling is very important and essential.
3.Environment factors can affect fertility and therefore an
occupational history should be taken.
4.Each of the investigation and treatment of infertility
should be fully explained to the couple.
5.Couple should be fully involved in decision making
regarding their treatment.
6. Management individualized not general.
21. Evaluation both male and female
History
Examination
Laboratory studies
Evaluation should be
proceed simultaneously of
male and female partner.
22. The main goal of evaluation are to detect correctable
causes of infertility and help the couple to conceive by
most natural & least invasive way.
NOT BY ART…..
23. Evaluation of male:
History
- Age
- Childhood illness
Mumps
Orchidopexy
Cancer
- Respiratory tract infection
- Sexually transmitted diseases.
Genitourinary Tuberculosis
24. A history of inguinal, scrotal or retro peritoneal surgery.
Duration of marriage.
Previous pregnancies by him.
Sexual history
Inadequate frequency or timing of intercourse.
Sexual dysfunction.
Lubricant use- Commercially available lubricants are
spermicidal.
25. Most men of reproductive age do not have
significant medical history but the risk factors has
to be identified.
27. Anti psychotic and antidepresent
- Ercetile dysfunction
- Loss of libido
- Hyper protectincemia
impair sexual function.
Abnormal semen quality.
Chemotherapeutic agent
- Almost all agent are gonadotoxic
- Chance of recovery is poor after : - Bleomycin, Etoposide ,Cisplatin,
Vincristin
Other drugs : Cimetidine, Colchicine, Statins
28. Environmental toxin
- Work environment
Welding
Ceramics
Factory worker
Life style factors
- Excess stress
- Long distance cycling
29. Physical examination
Build
Height
Certain chromosomal abnormality can be detected
by
looking over all appearance.
30. Local examination
- Presence of testis in scrotum.
- Size of testing
- Volume-20 Cm3
- Length- 4cm in greatest dimension.
- Varicocele
- Absent of vas deference.
- Thickening epididymis- obstruction.
USG
31. Perfect normal semen analysis report
generally precludes a significant
male factor infertility.
Laboratory studies
Semen analysis, central part of evaluation of
male infertility.
32. If the only evaluation is a semen analysis underlying
pathology may be missed.
Evaluation may uncover significant underlying medical
or genetic pathology that could affect the patients
health & that his offspring.
33. Routine semen analysis
A .Background data
- Abstinence- 2-5 days.
- Method of collection
How - Masturbation
Place - Adjacent to lab
Container - wide mouth jar which is made of
poly-propylene .
Outside collection – collect in media. Kept in
body temperature reach within 45 minute.
34. B. Physical examination-
- Temporary coagulation
- Liquefactions 20-30 minutes
- Viscous
- Volume: 1.5-5ml
- PH: 7.2-7.5
- Color : Opaque or Grayish.
C. Microscopic examination-
- Sperm count
- Motility
- Morphology
- Pus cell
36. Normal Values for SA
Volume
Sperm Concentration
Motility
Viscosity
Morphology
pH
WBC
– 1.5 ml (1.4-1.7)
– 15 million/ml (12-16)
– 40% (38-42)
32% forward progression
– Liquification in 30-60 min
– 4.0 % (3-4)
– 7.2-7.8
– Fewer than 1 million/ml
37. Causes for male infertility
• 42% varicocele – repair if there is a low count or
decreased motility
• 22% idiopathic
• 14% obstruction
• 20% other (genetic abnormalities)
38. Number of sperm per ml & motility are important in assessing a
man’s fertility potential.
The morphology is a measurement of the percentage of normal
shaped sperm.
Morphology correlated with success of in-vitro-fertilization.
The significance of morphology in estimating the chance for
natural conception is less clear.
39. Pregnancies can be established with
subnormal parameters of semen analysis
if the female partners fertility potential is
high.
40. Terminology Inference
Oligozoospermia Sperm concentration < 15
million/ml severe: < 5
million/ml)
Azoospermia Absence of motile/viable sperm
in the semen.
Aspermia Absence of ejaculate/semen
Asthenozoospermia Reduced sperm motility <40%
Teratozoospermia Spermatozoa with reduced
proportion of normal morphology
(< 4%)
Leukocytospermia >1 million white blood cells/ml of
semen
Oligoasthenoteratozoospermia All sperm variables are abnormal
Necrozoospermia All sperms are non-motile or non-
viable
Type of abnormality that are commonly encounter-
42. In practice
Sperm count less then <10 million/ml
Serum testosterone
FSH
Total Testosterone normal – No endocrine test is needed.
Total testosterone low – LH & Prolactin
FSH level
Low – Hypogonadotrophic hypogonodism
High – Testicular failure
Semen volume less than 1ml - Retrograde ejaculation.
43. Azoospermia – FNAC
Failure/ Non obstructive
Obstructive
Azoospermia and severe oligozoospermia
a) Karyotype : Chromosomal Ab
Sex – 4.2%
Autosomal 1.5%
Numerical – XXY
Structural – Balanced translocation.
b) Y chromosome micro deletion.-13% of men with
nonobstructive azoospermia
Any male off spring also suffer from infertility.
c) Mutation CFTR gene (cystic fibrosis transmembrane
conductance regulator gene) 70% of CAVD are carriers of this mutant
gene.
44. A significant proportion of male sub fertility currently
is unexplained.
50% of male infertility is potentially correctable.
45. Treatment of correctable male factor pathology is :
- Cost effective
- Does not increase the risk of multiple birth.
- Can spare the women invasive procedure and
potential complications associated with ART.
46.
47. With the advancement of technique of ICSI only one
viable sperm per egg is required for ICSI and to
achieve conception.
Precise diagnosis is not required.
48. Female
History
- Age – single predominant factor for infertility ( Inversely proportional)
- Duration of infertility
- Menstrual history
Age of menarche
Cycle length, Dysmenorrhoea, menstrual flow.
- Coital frequency and sexual dysfunction.
- Use of any contraception.
Reproductive outcome
- Number of pregnancy
- Pregnancy outcome
- Associated complication
49. Medical history
- Not only fertility
- She can carry the pregnancy
- Prepare for pregnancy before fertility treatment.
Current medication
- Past surgery
Procedure
Indications
Outcomes
Previous abnormal pap’s smear and any subsequent treatment.
53. Ovulatory disorder
Causes of anovulation
- Polycystic ovary
- Obesity
- Weight gain or loss
- Strenous exercise
- Thyroid dysfunction
- Hyper prolactinaemia.
54. Assessment of ovulation
Menstrual history
Regular cyclical menstruation - 90% ovulation.
Premenstrual monilima - indicates ovulation.
Serum progesterone assessment (P4) - Greater than 3.0ngm/ml
in between 19-23 days
Urinary luteinizing hormone (LH) - Ovulation kits can identify the
midcycle LH surge that proceeds ovulation by one to two days.
Urinary LH detects – indirect evidence of ovulation.
Helps to define the interval of greatest fertility.
The day of the LH surge and the following two days.
55. Follicle Tracking by TVS
Presumptive evidence of ovulation:
- Size and number of follicles.
- Progressive follicular growth
- Sudden collapse of the pre ovulatory follicle.
- Loss of clearly defined follicular margins.
- Appearance of internal echoes.
- Fluid in cul -de-sec.
56. Serum TSH and Prolactin
Thyroid dysfunction
Hyper prolactinaemia.
57. In women with amenorrhoea
- FSH and oestradiol (E2)
Ovarian failure (FSH E2)
Hypothalamus and pituitary failure (FSH, E2)
58. Assessment of ovarian reserve
Number and quality of remaining Oocyte
Decrease ovarian reserve (DOR):
Women of reproductive age having regular menses
whose response to ovarian stimulation is reduced
compared to those women of comparable age.
59. Women are increase risk of diminished ovarian reserve.
- Age more than 35 years
- Family H/O early menopause.
- Single ovary, H/O previous ovarian surgery.
- Chemotherapy or pelvic radio therapy.
- Poor response to gonadotrophin stimulation.
- Unexplained infertility.
60. Ovarian reserve can be assessed with
1.D3 – FSH, E2
2. AMH
3.Antral follicle count (AFC)
FSH – 10-20mIu/L.
AFC – 3-10 total antral follicle(Follicle in both ovaries)
AMH – < 1 ngm/ml
Poor responses to ovarian stimulation
poor embryo quality and poor pregnancy outcome
in IVF.
65. 2. Postcoital test : Direct analysis of sperm and cervical mucus
interaction and provides a rough estimate of sperm quality.
D12 – D14 of 28-30 days of menstrual cycle (after 48 hours of
abstinence) when maximum estrogen secretion is present.
The mucus is examined within 2-8 hours (at least 5 motile sperm
per high power field is considered normal)
3. Cervical stenosis
67. Pelvic ultrasound detects - organic ,anatomic and endocrine
abnormality of genital tract .
- Cervix
- Utero cervical canal
Direction
Continuity
- Endometrial pattern in relation to menstruation.
- Endometrial cavity
68. - Myometrium
- Ovary
Position of ovary
Endometriotic cyst or any other cyst
AFC.
- Tube : Hydrosalphinx
Laparoscopy and hysteroscopy
1. Symptomatic
2.Risk factors or abnormal HSG
3.Abnormal USG
4. Unexplained.
69. Favorable Unfavorable
Age < 35yrs > 35 years
Duration of marriage < 7 years > 7 years
Type of defect single multiple
Treatment Treatable Untreatable
Baseline FSH < 10mIV/L > 10mIU/L
AFC >6 <6
Pelvic adhesion minimum or none Moderate to extensive
Uterine shape
size of cavity Normal Distorted and enlarged
70. Any gynaecologist not specially trained in the
subspecialty of infertility care can complete this
investigation.
Based on the result of these investigations couple should
be referred.
72. Criteria for straight – ART(IVF/ICSI)
Age-> 38 years
Both fallopian tubes block
Decrease ovarian reserve(>35years with AFC<5)
Advance endometriosis
Abnormal pelvis not amenable to Microsurgical repair
Male factor-Azoospermia, Severe oligozoospermia
Genetic screening
73. ART gives hope to couple to fulfill the dream by producing
child.
