Subfertility - Failure to conceive within 12 months of regular sexual intercourse without any form of contraception. Woman older than 35 years -- have not conceived during a 6-month period of trying.

1. Evaluation and options in
Managing Subfertile Couple
Dr Edawati Dahrawi Edrus
Obstetrics dan Gynaecology
Hospital Umum Sarawak

2. MARRIED COUPLE

3. Not Pregnant ?

4. Subfertility
Failure to conceive within 12 months of
regular sexual intercourse without any form
of contraception.
Woman older than 35 years -- have not
conceived during a 6-month period of trying.

5. Average incidence globally: 15% (varies in different
population)

6. Conception & Subfertility
•The chances of spontaneously conceiving at any
given menstrual cycle is 20%
• Main event leading to pregnancy is ovulation,
fertilization & implantation THUS any event
interfering with these results in subfertility

7. • The single most important determinant of a
couple’s fertility is the age of the female partner:
• At the age of up to 25 years CCR is 60% at six
months and 85% at one year
• At the age of 35 years or more the CCR is 60%
at one year and 85% at two years
CCR – Cumulative Conception Rate

8. • About 84% of couples would conceive
within one year of trying for a pregnancy
• Another 8% would conceive in the next year
giving a cumulative pregnancy rate of 92%
at the end of two years

9. NORMAL
• Female reproductive
organ

10. • Menstrual cycle

11. NORMAL
• Male reproductive
organ

12. Male spermatogenesis

14. Factor for Infertility
30-40%
UNEXPLAINED 5-15%
Couple does not conceive and no definite of
infertility can be diagnosed after a complete
evaluationcause

15. FEMALE FACTOR

16. OVARIAN FACTOR
• Anovulation

17. Anovulation
• Hyperprolactinaemia
• Obesity

18. Ovarian Failure
• Repeated surgery on
ovaries
• Chemoradiation
• Primary Ovarian Failure
• Pemature Menopause

19. TUBAL FACTOR
Endometriosis

20. Pelvic Inflammatory
Disease (PID)

21. • Tubal block
• Previous tubal
surgery/Ectopic
pregnancy

22. • Uterine Factor
• Uterine Fibroid

23. • Adenomyosis

24. • Uterine Septum

25. • Uterine polyp

26. • Submucosa Fibroid

27. • Uterine adhesions

28. • Transcervical Resection
• TCRF (firbroid)
• TCRP (polyp)

29. MALE FACTOR

30. NORMAL SPERM COUNT
• Parameter WHO 1999 WHO 2010
• Volume 2 ml 1.5 ml
• Concentration 20 million/ml 15 million/ml
• Progressive motility 50% 32%
• Normal forms 14% 4%

31. MALE FACTOR
• Oligospermia

32. • Asthenospermia

33. • Teratozoospermia

34. • SUPPLEMENT FOR
oligoasthenoteratozoos
permia

35. • CLOMID
• HCG and MENOPUR
injection

36. • Azoospermia

37. SURGICAL MANAGEMNT FOR
AZOOSPERMIA
• PERCUTANEOUS SPERM
ASPIRATION (PESA)
• Testicular Biopsy
(TESE/TESA)

38. Assessment of Subfertility Patient
Assessment of Female and Male partner
Female – Ovulation , Tubal Patency
Male – Sperm Analysis

39. Investigation
FEMALE
• Hormone
Regular menses
D2-D5 FSH/LH
D21 Progesterone
Irregular menses
D2-D5/Random FSH/LH
Serum Prolactin
Thyroid Function Test
FEMALE
PCOS
Testosterone
Fasting lipid profile
Fasting blood sugar/MOGTT
Tubal Patency
Hysterosalphingogram (HSG)
Laparoscopic Dye Insufflation

40. Female
• Infective screening
- Hepatitis B/C/HIV/VDRL
- Rubella Ig G
Male
• Semen Analysis
• Infective screening
- Hepatitis B/C/HIV/VDRL

41. HYSTEROSALPINGOGRAM (HSG)

42. GENERAL ADVICE

43. Management of Infertility
• Timed Sexual
Intercourse (TSI)
• Intrauterine
Insemination (IUI)
• Invitro Fertilization
(IVF)/Intracytoplasmic
Sperm Insemination
(ICSI)

44. OVULATION INDUCTION

46. Timed SI
• Cumulative pregnancy
rate 40% in 4 attempts
• May try for 3-6 cycles
depends on patient age,
duration of infertility
and response to
ovulation induction.
Suitable for
• Anovulatory cycle
• Patent tubes
• Mild male factor

47. IUI
• Available in Hospital
Umum Sarawak
• Success rate 10-15 %
Suitable for
• Mild male factor
- Sperm > 10 million /ml
- Motility > 40%
• Anovulation
• Patent tube/tubes
• Failed Times SI – 2-4
times

48. • IUI

49. IVF VS ICSI

50. IVF VS ICSI
IVF
Blocked tubes
Moderate to severe
endometriosis
Sperm count > 10 million/ml
Sperm motility >40%
Failed IUI treatment
ICSI
Male factor
-moderate to severe
oligospermia
- Poor motility sperm
- Immotile sperm
- Azoospermia but sperm
available through
PESA/TESE/TESA

51. IVF/ICSI
• IVF/ICSI stimulation

52. IVF stimulation
Transvaginal scan (TVS)

53. OOCYTE RETRIEVAL (OR)

54. EMBRYO TRANSFER(ET)

55. EMBRYO TRANSFER (ET)
DAY 2/3/5

56. Luteal Support

57. Post Embryo Transfer

58. Succcess Rate
Depends on Factor of
Infertility and maternal age
Factors lower success rate
1. Advanced age
2. Poor responder
3. Endometriosis
4. Adenomyosis
5. PID with Hydrosalphinx
6. Male Factor

59. COMPLICATIONS
• OHSS
• Injury to bowel ,
bladder
• Injury to vessel
• Puncture site
bleeding/haematoma
• Pelvic Infection
• Multiple Pregnancy
• Failed IVF
• Miscarriage
• Ectopic Pregnancy
• Damage to stored
embryos
• Psychological
complications
• Medicolegal
complications

60. COMPLICATIONS
Ovarian Hyperstimulation
Syndrome (OHSS)
Multiple Pregnancy

61. WELCOME TO KUCHING

64. THANK YOU