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Infertility final
- 1. SubfertilitySubfertility Ahmed BadawyAhmed Badawy MSc, MD, FRCOG, PhDMSc, MD, FRCOG, PhD Professor of OB/GYNProfessor of OB/GYN
- 2. Requirements forRequirements for ConceptionConception • Male roleMale role Production of healthy spermsProduction of healthy sperms Deposition of sperms in the vaginaDeposition of sperms in the vagina • Female roleFemale role Healthy eggsHealthy eggs Patent healthy tubesPatent healthy tubes Healthy uterine cavityHealthy uterine cavity Healthy cervix and vaginaHealthy cervix and vagina
- 3. SubfertilitySubfertility The inability to conceive following unprotectedThe inability to conceive following unprotected sexual intercoursesexual intercourse for one yearfor one year – 15% of reproductive couples15% of reproductive couples – Men and women equally affectedMen and women equally affected
- 4. SubfertilitySubfertility • Reproductive age for womenReproductive age for women – Generally 15-44 years of ageGenerally 15-44 years of age – Fertility is approximatelyFertility is approximately halvedhalved between 37between 37__ 45y45y – 20%20% of women have their first child after age 30of women have their first child after age 30 – 1/31/3 of couples over 35 have fertility problemsof couples over 35 have fertility problems With the proper treatment 85% of infertileWith the proper treatment 85% of infertile couples can expect to have a childcouples can expect to have a child
- 5. Conception rates for fertile couplesConception rates for fertile couples 0 10 20 30 40 50 60 70 80 90 100 0 6 12 18 24 Months of Treatment (cycles) PercentofCouplesConceiving
- 6. SubfertilitySubfertility The inability to conceive following unprotectedThe inability to conceive following unprotected sexual intercoursesexual intercourse 22 yearsyears ((age <30age <30),), 1 year1 year ((age<35age<35) or) or 6 months6 months ((age>35age>35))
- 7. SubfertilitySubfertility • PrimaryPrimary a couple that has never conceiveda couple that has never conceived • SecondarySecondary infertility that occurs after previousinfertility that occurs after previous pregnancy regardless of outcomepregnancy regardless of outcome
- 8. Causes of subfertilityCauses of subfertility • Female factorFemale factor (30%)(30%) • OvarianOvarian • Tubal & peritonealTubal & peritoneal • UterineUterine • CervicalCervical • Vulval & vaginalVulval & vaginal • Male factorMale factor (30%)(30%) • Combined factor (30%)Combined factor (30%) • UnexplainedUnexplained (10%-20%)(10%-20%)
- 9. Basic evaluation of the subfertileBasic evaluation of the subfertile couplecouple • History and Physical examHistory and Physical exam • Semen analysisSemen analysis • Determination of ovulationDetermination of ovulation Day 21-23 serum progesteroneDay 21-23 serum progesterone • HysterosalpingogramHysterosalpingogram • Postcoital testPostcoital test • +/- laparoscopy+/- laparoscopy
- 10. Male factorMale factor subfertilitysubfertility • Defective inseminationDefective insemination • Abnormal spermatogenesisAbnormal spermatogenesis
- 11. Defective inseminationDefective insemination……………… • ImpotenceImpotence • Premature ejaculationPremature ejaculation • Retrograde ejaculationRetrograde ejaculation • Severe hypospadiusSevere hypospadius • Marked obesityMarked obesity
- 12. Semen Analysis (SASemen Analysis (SA)) • How…..How….. – Abstain from coitus 2 to 3 daysAbstain from coitus 2 to 3 days – Collect all the ejaculateCollect all the ejaculate – Analyze within 1 hour maximallyAnalyze within 1 hour maximally • Normal semen analysis excludesNormal semen analysis excludes 90% of male factor90% of male factor
- 13. Normal Values for SA (WHO 1999Normal Values for SA (WHO 1999)) • Volume……………….Volume………………. • Sperm Conc…………Sperm Conc………… • Motility……………….Motility………………. • Viscosity…………….Viscosity……………. • Morphology…………Morphology………… • pH………………………pH……………………… • WBC …………………..WBC ………………….. 2.0 ml or more 20 million/ml or more20 million/ml or more 50%50% forward progression 25%25% rapid progression Liquification in 30-60 min 30% or more normal forms30% or more normal forms 7.2-7.8 Fewer than 1 million/ml
- 14. Normal Values for SA (WHO 2010Normal Values for SA (WHO 2010)) • Volume……………….Volume………………. • Sperm Conc…………Sperm Conc………… • Motility……………….Motility………………. • Viscosity…………….Viscosity……………. • Morphology…………Morphology………… • pH………………………pH……………………… • WBC …………………..WBC ………………….. 1.5 ml or more 15 million/ml or more (15 million/ml or more (39 m39 m totaltotal)) 32%32% forward progression 40%40% total motility Liquefaction in 30-60 min 4% or more normal forms4% or more normal forms 7.2-7.8 Fewer than 1 million/ml
- 15. Abnormal spermatogenesisAbnormal spermatogenesis • AspermiaAspermia • AzospermiaAzospermia • OligospermiaOligospermia • AsthenospermiaAsthenospermia • TeratospermiaTeratospermia • NecrospermiaNecrospermia • PyospermiaPyospermia • HematospermiaHematospermia
- 16. Female factorFemale factor subfertilitysubfertility • Ovulatory defects (20-25%)Ovulatory defects (20-25%) • Anatomic defects of genital tractAnatomic defects of genital tract • Tubal & peritonealTubal & peritoneal (15-25%)(15-25%) • UterineUterine (2-3%)(2-3%) • CervicalCervical (1-2%)(1-2%) • Vulval & vaginalVulval & vaginal (2-3%)(2-3%)
- 19. Diagnosis of ovulationDiagnosis of ovulation SymptomsSymptoms Regular cyclic menstruationRegular cyclic menstruation Ovulation pain “Ovulation pain “Mittle-Schmertz painMittle-Schmertz pain"" Ovulation bleedingOvulation bleeding Ovulation cascadeOvulation cascade Premenstrual mastalgiaPremenstrual mastalgia Premenstrual tension syndromePremenstrual tension syndrome Elevated body temperature in second half of cycleElevated body temperature in second half of cycle Primary dysmenorrhoeaPrimary dysmenorrhoea
- 20. Diagnosis of ovulationDiagnosis of ovulation SignsSigns Biphasic body temperature chartBiphasic body temperature chart Changes in cervical mucousChanges in cervical mucous Changes in cervical smearChanges in cervical smear
- 21. Diagnosis of ovulationDiagnosis of ovulation SignsSigns 1.1.Biphasic basal body temperature chartBiphasic basal body temperature chart Due to thermogenic effect progesterone
- 22. Diagnosis of ovulationDiagnosis of ovulation SignsSigns 2. Changes in characters of cervical mucous2. Changes in characters of cervical mucous It shows +ve Spinnbarkiet and ferning & after ovulation become -ve
- 23. Diagnosis of ovulationDiagnosis of ovulation SignsSigns 3. Change in character of vaginal smearChange in character of vaginal smear
- 24. Diagnosis of ovulationDiagnosis of ovulation InvestigationsInvestigations Laboratory hormonal assayLaboratory hormonal assay Ultrasound folliculometryUltrasound folliculometry LaparoscopyLaparoscopy Premenstrual endometrial biopsyPremenstrual endometrial biopsy
- 25. Diagnosis of ovulationDiagnosis of ovulation InvestigationsInvestigations Progesterone level in day 21 is 10-15 ng/dl L.H level in plasma and urine
- 26. Diagnosis of ovulationDiagnosis of ovulation Investigations U.S for follicular growth and maturation "normally 18 - 22mm“ then CL
- 27. Diagnosis of ovulationDiagnosis of ovulation Investigations laparoscopy for direct visualization of the stigma of ovulation
- 28. Diagnosis of ovulationDiagnosis of ovulation Investigations Premenstrual endometrial biopsy to see secretory endometrium
- 30. Causes of anovulationCauses of anovulation Physiologic causesPhysiologic causes • Before puberty • Peripubertal • During pregnancy • During lactation • After menopause
- 32. Causes of anovulationCauses of anovulation According to WHO classificationAccording to WHO classification • Hypogonadotrophic hypogonadismHypogonadotrophic hypogonadism (WHO I)(WHO I) • Hypergonadotrophic hypogonadismHypergonadotrophic hypogonadism (WHOII)(WHOII) • Eugonadotrophic hypogonadismEugonadotrophic hypogonadism (WHOIII)(WHOIII) • HyperprolactinemiaHyperprolactinemia (WHO IV)(WHO IV)
- 33. Causes of anovulationCauses of anovulation Pathologic causesPathologic causes Hypogonadotrophic (WHO I)Hypogonadotrophic (WHO I) • Hypothalamic causesHypothalamic causes • Dysfunction (Anorexia N, Stress, severe exercise)Dysfunction (Anorexia N, Stress, severe exercise) • Congenital (Kallaman’s syndrome)Congenital (Kallaman’s syndrome) • Organic lesions (Trauma, inflammation, tumours)Organic lesions (Trauma, inflammation, tumours) • Pituitary causesPituitary causes • Congenital syndromesCongenital syndromes • Sheehan’s syndromeSheehan’s syndrome • Trauma (surgery, irradiation)Trauma (surgery, irradiation) • InflammationInflammation • Tumours (craniopharyngioma)Tumours (craniopharyngioma)
- 34. How to treatHow to treat?? Induction of ovulation with either GnRH (in hypothalamic problems) or gonadtropins (in pituitary problems) GnRH therapy GnRH should be given in a pulsatile manner
- 35. How to treatHow to treat?? Induction of ovulation with either GnRH (in hypothalamic problems) or gonadtropins (in pituitary problems) Gonadotrphin therapy • Combined FSH (75IU) and LH (75 IU) • FSH alone • LH alone (or hCG )
- 36. How to treatHow to treat?? Long-actingLong-acting recombinantrecombinant gonadotropinsgonadotropins Recombinant Gn Highly purified HMG Purified HMG Urinary HMG Gonadotrphin therapy
- 37. How to treatHow to treat?? Gonadotrophin therapy • Multiple pregnancies are high • Ovarian hyperstimulation syndrome (OHSS) Severe type might be fatal
- 38. Causes of anovulationCauses of anovulation According to WHO classificationAccording to WHO classification • Hypogonadotrophic hypogonadismHypogonadotrophic hypogonadism (WHO I)(WHO I) • Hypergonadotrophic hypogonadismHypergonadotrophic hypogonadism (WHOII)(WHOII) • Eugonadotrophic hypogonadismEugonadotrophic hypogonadism (WHOIII)(WHOIII) • HyperprolactinemiaHyperprolactinemia (WHO IV)(WHO IV)
- 39. Causes of anovulationCauses of anovulation Pathologic causesPathologic causes Hypergonadotrophic (WHO II) • Streak gonades e.g Turner’s syndrome • Resistant ovary syndrome • Premature ovarian failure • SpontaneousSpontaneous • Trauma i.e surgeryTrauma i.e surgery • Chronic inflammationChronic inflammation • IrradiationIrradiation • ChemotherapyChemotherapy
- 40. Primary ovarian failurePrimary ovarian failure • NONO current treatment • Oocyte donation • Stem cell therapy?? How to treatHow to treat??
- 41. Causes of anovulationCauses of anovulation According to WHO classificationAccording to WHO classification • Hypogonadotrophic hypogonadismHypogonadotrophic hypogonadism (WHO I)(WHO I) • Hypergonadotrophic hypogonadismHypergonadotrophic hypogonadism (WHOII)(WHOII) • Eugonadotrophic hypogonadismEugonadotrophic hypogonadism (WHOIII)(WHOIII) • HyperprolactinemiaHyperprolactinemia (WHO IV)(WHO IV)
- 42. Causes of anovulationCauses of anovulation Pathologic causesPathologic causes Eugonadotrophic (WHO III) • Ovarian dysfunction 80% is polycystic ovary syndrome (PCOS)
- 43. Polycystic ovary syndrome (PCOS)Polycystic ovary syndrome (PCOS) Chronic anovuationChronic anovuation • OligomenorrhoeaOligomenorrhoea • AmenorroeaAmenorroea • Irregular uterine bleedingIrregular uterine bleeding • InfertilityInfertility
- 44. Polycystic ovary syndrome (PCOS)Polycystic ovary syndrome (PCOS) hyperandrogenemiahyperandrogenemia • HirsutismHirsutism • AcneAcne • Virilization is rareVirilization is rare • LaboratoryLaboratory – High testosterone (free & total)High testosterone (free & total) – high androstendionehigh androstendione – Low SHBGLow SHBG
- 45. Polycystic ovary syndrome (PCOS)Polycystic ovary syndrome (PCOS) ObesityObesity • Insulin resistance • Hyperlipidemia • Hypertension X syndrome
- 46. Polycystic ovary syndrome (PCOS)Polycystic ovary syndrome (PCOS) Gross pictureGross picture
- 47. Polycystic ovary syndrome (PCOS)Polycystic ovary syndrome (PCOS) Ultrasound pictureUltrasound picture ● Presence of 12 or more small follicles in each ovary ● Increased ovarian volume (>10 ml) ● hyperdense stroma ● Thick tunica albugenia
- 48. Polycystic ovary syndrome (PCOS)Polycystic ovary syndrome (PCOS) TreatmentTreatment • Lifestyle modificationLifestyle modification • Menstrual cycle regulationMenstrual cycle regulation • Ovulation inductionOvulation induction • Anti-androgensAnti-androgens • Insulin lowering agentsInsulin lowering agents
- 49. Causes of anovulationCauses of anovulation According to WHO classificationAccording to WHO classification • Hypogonadotrophic hypogonadismHypogonadotrophic hypogonadism (WHO I)(WHO I) • Hypergonadotrophic hypogonadismHypergonadotrophic hypogonadism (WHOII)(WHOII) • Eugonadotrophic hypogonadismEugonadotrophic hypogonadism (WHOIII)(WHOIII) • HyperprolactinemiaHyperprolactinemia (WHO IV)(WHO IV)
- 50. Causes of anovulationCauses of anovulation Pathologic causesPathologic causes Hyperprolactinemia (WHO IV)Hyperprolactinemia (WHO IV)
- 51. Causes of anovulationCauses of anovulation HyperprolactinemiaHyperprolactinemia Physiologic causesPhysiologic causes PregnancyPregnancy LactationLactation Sexual excitementSexual excitement StressStress
- 52. Causes of anovulationCauses of anovulation HyperprolactinemiaHyperprolactinemia Pathologic causesPathologic causes Pituitary adenomas (micro/macro)Pituitary adenomas (micro/macro) Primary hypothyroidismPrimary hypothyroidism Drugs (reserpine, psychotic drugs, ocs, H2 blockers..)Drugs (reserpine, psychotic drugs, ocs, H2 blockers..) Chronic renal failureChronic renal failure Chest wall injuries, surgeries or HZIChest wall injuries, surgeries or HZI
- 53. Causes of anovulationCauses of anovulation HyperprolactinemiaHyperprolactinemia GalactorrhoeaGalactorrhoea Oligo/amenorrhoeaOligo/amenorrhoea Abnormal uterine bleedingAbnormal uterine bleeding InfertilityInfertility PMSPMS Sexual dysfunctionSexual dysfunction
- 54. Causes of anovulationCauses of anovulation HyperprolactinemiaHyperprolactinemia DiagnosisDiagnosis Serum prolactin >20ng/mlSerum prolactin >20ng/ml MRI pituitary (to exclude adenomas >100ng/ml)MRI pituitary (to exclude adenomas >100ng/ml) Serum TSHSerum TSH Review therapeutic historyReview therapeutic history
- 55. Causes of anovulationCauses of anovulation HyperprolactinemiaHyperprolactinemia TreatmentTreatment • Surgical treatment for macroadenomasSurgical treatment for macroadenomas • Antiprolactinemic drugs (dopamine agonist)Antiprolactinemic drugs (dopamine agonist) BromocriptineBromocriptine LesurideLesuride QuinagolideQuinagolide CabergolineCabergoline
- 57. Female factorFemale factor subfertilitysubfertility • Ovulatory defects (20-25%)Ovulatory defects (20-25%) • Anatomic defects of genital tractAnatomic defects of genital tract • Tubal & peritonealTubal & peritoneal (15-25%)(15-25%) • UterineUterine (2-3%)(2-3%) • CervicalCervical (1-2%)(1-2%) • Vulval & vaginalVulval & vaginal (2-3%)(2-3%)
- 58. Causes of tubal pathologyCauses of tubal pathology 1.1. CongenitalCongenital 2.2. EndometriosisEndometriosis 3.3. TraumaticTraumatic Previous ectopic Tubal sterilization peritubal surgery 4.4. SalpingitisSalpingitis Stds (Chlamydia, G)Stds (Chlamydia, G) TBTB 5.5. NeoplasticNeoplastic Tubal malignancyTubal malignancy Broad ligament fibroidsBroad ligament fibroids
- 59. Diagnosis of tubal pathologyDiagnosis of tubal pathology 1.1. HistoryHistory 2.2. ExaminationExamination 3.3. investigationsinvestigations HysterosalpingographyHysterosalpingography SonohysterographySonohysterography LaparoscopyLaparoscopy HysteroscopyHysteroscopy
- 60. Diagnosis of tubal pathologyDiagnosis of tubal pathology HysterosalpingographyHysterosalpingography
- 61. Diagnosis of tubal pathologyDiagnosis of tubal pathology SonosalpingographySonosalpingography
- 62. Diagnosis of tubal pathologyDiagnosis of tubal pathology HysteroscopyHysteroscopy
- 63. Diagnosis of tubal pathologyDiagnosis of tubal pathology LaparoscopyLaparoscopy
- 64. Treatment of tubal factorTreatment of tubal factor subfertilitysubfertility Tubal reconstructiveTubal reconstructive surgerysurgery 1.1. laparoscopylaparoscopy 2.2. MicrosurgeryMicrosurgery salpingolysis &salpingolysis & adhesiolysisadhesiolysis fimrioplastyfimrioplasty salpingostomysalpingostomy tubal reimplantationtubal reimplantation tubal reanastomosistubal reanastomosis
- 65. Treatment of tubal factorTreatment of tubal factor subfertilitysubfertility Assisted reproductive technology (ART)Assisted reproductive technology (ART)
- 66. Assisted ReproductiveAssisted Reproductive Technologies (ART)Technologies (ART) Treatments or procedures that include the handling of human eggs and sperm or embryos for the purpose of establishing a pregnancy
- 67. WHAT IS ARTWHAT IS ART?? • IUIIUI intrauterine inseminationintrauterine insemination • IVFIVF in vitro fertilizationin vitro fertilization • GITGIT gamete intrafallopian transferegamete intrafallopian transfere • ZIFTZIFT zygote intrafallopian transferezygote intrafallopian transfere • ZDZD zona drillingzona drilling • PZDPZD partial zona dissectionpartial zona dissection • SUZISUZI subzonal sperm injectionsubzonal sperm injection • ICSIICSI intracytoplasmic sperm injectionintracytoplasmic sperm injection Assisted ReproductiveAssisted Reproductive Technologies (ART)Technologies (ART)
- 68. • Male factor infertilityMale factor infertility • Cervical factor infertilityCervical factor infertility • Unexplained infertilityUnexplained infertility Intrauterine insemination (IUI)Intrauterine insemination (IUI) • Impotence • Retrograde ejaculation • HIV males
- 69. Sperm preparationSperm preparation • Swim up techniqueSwim up technique • Percoll gradientPercoll gradient • Sperm washingSperm washing Intrauterine insemination (IUI)Intrauterine insemination (IUI)
- 70. Intrauterine insemination (IUIIntrauterine insemination (IUI(( •Intravaginal insemination •Intracervical insemination •Intrauterine insemination •Intratubal insemination
- 71. IVF-ETIVF-ET • Tubal factor subfertilityTubal factor subfertility • OligospermiaOligospermia • Unexplained subfertilityUnexplained subfertility In vitro Fertilization (IVF)In vitro Fertilization (IVF)
- 72. Assisted reproductive technology (ART)Assisted reproductive technology (ART)
- 73. ICSIICSI • Failure of fertilization in IVFFailure of fertilization in IVF • Severe male factorSevere male factor – Oligo/azoOligo/azo – AsthenoAstheno – teratoterato Intracytoplasmic spermIntracytoplasmic sperm injectioninjection
- 74. Steps of IVF/ICSISteps of IVF/ICSI • Pituitary downregulationPituitary downregulation • Ovarian stimulationOvarian stimulation • Ovum retrievalOvum retrieval • Sperm collectionSperm collection • Fertilization & cleavageFertilization & cleavage • Embryo transferEmbryo transfer • Luteal phase supportLuteal phase support
- 75. Pituitary down regulationPituitary down regulation • Gonadotrophins releasing hormones agonists • Gonadotrophins releasing hormones antagonists
- 76. Ovarian stimulationOvarian stimulation Gonadotrphin therapy • Combined FSH (75IU) and LH (75 IU) • FSH alone • LH alone (or hCG )
- 77. Steps of IVF/ICSISteps of IVF/ICSI
- 78. Inverted microscopy withInverted microscopy with micromanipulatormicromanipulator Steps of IVF/ICSISteps of IVF/ICSI
- 79. MicroinjectionMicroinjection Steps of IVF/ICSISteps of IVF/ICSI
- 80. Gamete andGamete and embryo incubationembryo incubation (3-5 days(3-5 days((
- 81. Fertilization &Fertilization & CleavageCleavage Steps ofSteps of IVF/ICSIIVF/ICSI
- 82. Fertilization & CleavageFertilization & Cleavage Steps of IVF/ICSISteps of IVF/ICSI
- 83. Embryo transferEmbryo transfer Steps of IVF/ICSISteps of IVF/ICSI
- 84. Assisted hatchingAssisted hatching • MechanicalMechanical • LaserLaser • ChemicalChemical
- 85. Laser Assisted hatchingLaser Assisted hatching
- 86. Embryo transferEmbryo transfer Steps of IVF/ICSISteps of IVF/ICSI
- 87. Pre implantationPre implantation genetic diagnosisgenetic diagnosis ))PGDPGD((
- 88. • Embryo freezing • Gamete freezing • Ovarian tissue freezing Freezing technologyFreezing technology
- 89. Complications of Ovarian hyperstimulation • OHSSOHSS • Multiple pregnancyMultiple pregnancy • POF ????POF ???? • Ovarian malignancy ????Ovarian malignancy ???? In Vitro Fetilization (IVF)In Vitro Fetilization (IVF) Intracytoplasmic sperm injection (ICSI)Intracytoplasmic sperm injection (ICSI)
- 91. Female factorFemale factor subfertilitysubfertility • Ovulatory defects (20-25%)Ovulatory defects (20-25%) • Anatomic defects of genital tractAnatomic defects of genital tract • Tubal & peritonealTubal & peritoneal (15-25%)(15-25%) • UterineUterine (2-3%)(2-3%) • CervicalCervical (1-2%)(1-2%) • Vulval & vaginalVulval & vaginal (2-3%)(2-3%)
- 92. Causes of uterine pathologyCauses of uterine pathology 1.1. CongenitalCongenital 2.2. TraumaticTraumatic Asherman’s syndrome Hysterectomy 4.4. EndometritisEndometritis TBTB 5.5. NeoplasticNeoplastic FiFibroidsbroids
- 93. Diagnosis of uterine pathologyDiagnosis of uterine pathology 1.1. HistoryHistory 2.2. ExaminationExamination 3.3. investigationsinvestigations UltrasonographyUltrasonography HysterosalpingographyHysterosalpingography SonohysterographySonohysterography HysteroscopyHysteroscopy
- 94. Diagnosis of uterine pathologyDiagnosis of uterine pathology Congenital causesCongenital causes
- 95. Diagnosis of uterine pathologyDiagnosis of uterine pathology Asherman’s syndromeAsherman’s syndrome
- 96. Diagnosis of uterine pathologyDiagnosis of uterine pathology Uterine fibroidsUterine fibroids
- 98. Female factorFemale factor subfertilitysubfertility • Ovulatory defects (20-25%)Ovulatory defects (20-25%) • Anatomic defects of genital tractAnatomic defects of genital tract • Tubal & peritonealTubal & peritoneal (15-25%)(15-25%) • UterineUterine (2-3%)(2-3%) • CervicalCervical (1-2%)(1-2%) • Vulval & vaginalVulval & vaginal (2-3%)(2-3%)
- 99. Causes of cervical pathologyCauses of cervical pathology 1.1. CongenitalCongenital 2.2. TraumaticTraumatic 3.3. CervicitisCervicitis 4.4. ImmunologicImmunologic 5.5. NeoplasticNeoplastic FiFibroidsbroids Cancer cervixCancer cervix
- 100. Diagnosis of cervical pathologyDiagnosis of cervical pathology 1.1. HistoryHistory 2.2. ExaminationExamination 3.3. investigationsinvestigations UltrasonographyUltrasonography HysterosalpingographyHysterosalpingography Postcoital testPostcoital test
- 101. Diagnosis of cervical pathologyDiagnosis of cervical pathology Post-coital testPost-coital test Vagina Cervix No coitus Hostile vagina Hostile cervix Normal No Dead Living Living No No Dead Living
- 102. Treatment of cervicalTreatment of cervical pathologypathology 1.1. AetiologicAetiologic 2.2. Intrauterine insemination (IUI)Intrauterine insemination (IUI)
- 104. Causes of subfertilityCauses of subfertility • Female factorFemale factor (30%)(30%) • OvarianOvarian • Tubal & peritonealTubal & peritoneal • UterineUterine • CervicalCervical • Vulval & vaginalVulval & vaginal • Male factorMale factor (30%)(30%) • Combined factor (30%)Combined factor (30%) • UnexplainedUnexplained (10%-20%)(10%-20%)
- 105. Treatment of unexplainedTreatment of unexplained subfertilitysubfertility 1.1. Wait and seeWait and see 1-2 years1-2 years 1.1. Superovulation & timed intercourseSuperovulation & timed intercourse 6 cycles6 cycles 2.2. Superovulation and IUISuperovulation and IUI 3-6 cycles3-6 cycles 3.3. IVF/ICSIIVF/ICSI