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Infertility by Dr qaisar

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Infertility by Dr qaisar

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Infertility by Dr qaisar

  1. 1.  Infertility  Inability of a couple to conceive after one year of regular and unprotected intercourse (6 months for women over 35?)  Fertility  Ability to conceive
  2. 2. 1. Primary infertility: the couple have never achieved conception before 2. Secondary infertility: the couple who fails to achieve conception after having conceived once or more
  3. 3.  80% of couples will conceive within 1 year of unprotected intercourse  ~86% will conceive within 2 years  ~14-20% of US couples are infertile by definition (~3 million couples)  Origin:  Female factor ~40%  Male factor ~30%  Combined ~30%
  4. 4.  Sperm disorders 30.6%  Anovulation/oligoovulation 30%  Tubal disease 16%  Unexplained 13.4%  Cervical factors 5.2%  Peritoneal factors 4.8%
  5. 5.  PID  Endometriosis  Ovarian aging  Spermatic varicocoele  Toxins  Previous abdominal surgery (adhesions)  Cervical/uterine abnormalities  Cervical/uterine surgery  Fibroids
  6. 6.  Female  Ovary  Tube  Corpus  Cervix  Peritoneum  Male  Sperm count and function  Ejaculate characteristics, immunology  Anatomic anomalies
  7. 7.  Both couples should be present  Age  Previous pregnancies by each partner  Length of time without pregnancy  Sexual history  Frequency and timing of intercourse  Use of lubricants  Anorgasmia, dyspareunia  Contraceptive history
  8. 8.  History of pelvic infection  Radiation, toxic exposures (include drugs)  Mumps  Testicular surgery/injury  Excessive heat exposure (spermicidal)
  9. 9.  Previous female pelvic surgery  PID  Appendicitis  IUD use  Ectopic pregnancy history  Endometriosis
  10. 10.  Irregular menses, amenorrhea, detailed menstrual history  Stress  Weight changes  Cervical and uterine surgery
  11. 11.  Patient not sexually-active  Patient not in long-term relationships  Couple does not meet the definition of an infertile couple
  12. 12.  Size of testicles  Testicular descent  Varicocoele  Outflow abnormalities (hypospadias, etc)
  13. 13.  Pelvic masses  Uterosacral nodularity  Abdominopelvic tenderness  Uterine enlargement  Thyroid exam  Uterine mobility  Cervical abnormalities
  14. 14. Failure of ovulationFailure of ovulation Tubal factorsTubal factors Cervical factorsCervical factors Uterine factorsUterine factors Hormonal disordersHormonal disorders MiscellaneousMiscellaneous
  15. 15.  Gonadotropin deficiencyGonadotropin deficiency  Polycystic ovarian diseasePolycystic ovarian disease  Ovarian failure:Ovarian failure: I.I. Congenital (turner syndrome)Congenital (turner syndrome)  HyperprolactenemiaHyperprolactenemia  Weight changesWeight changes  Drugs (tri-cyclic anti depressant, phenothiazine,Drugs (tri-cyclic anti depressant, phenothiazine, methyldopa, reserpine)methyldopa, reserpine)
  16. 16. Fallopian tubes may be blocked in the followingFallopian tubes may be blocked in the following conditioncondition ; PIDPID EndometriosisEndometriosis Tubal surgery ( ectopic pregnancy, sterilization)Tubal surgery ( ectopic pregnancy, sterilization) Ruptured AppendixRuptured Appendix Ulcerative ColitisUlcerative Colitis Crohn’s DiseaseCrohn’s Disease
  17. 17. The cervical mucus may interfere with sperm ascent inThe cervical mucus may interfere with sperm ascent in the presence of ;the presence of ; Reduced amount of thin cervical mucusReduced amount of thin cervical mucus Anti-sperm-antibodiesAnti-sperm-antibodies
  18. 18. A fertilize ovum may fail to Implant in the presence ofA fertilize ovum may fail to Implant in the presence of i) Multiple fibroids ii) Intra-uterine adhesions (Asherman syndrome)
  19. 19.  Absence of menstruationAbsence of menstruation  Early depletion of ovarian follicles before age 35Early depletion of ovarian follicles before age 35  Fertilization problemFertilization problem  Oocyte membrane proteinOocyte membrane protein  The developing embryo may be mistaken for foreign body byThe developing embryo may be mistaken for foreign body by deranged immune systemderanged immune system  Developmental problemsDevelopmental problems  1.Hard egg1.Hard egg  2.Teratogens2.Teratogens
  20. 20.  OthersOthers .. Medications (alcohol,thalidomide etc…..)Medications (alcohol,thalidomide etc…..) .. Thyroid problems (mainly hypothyroid)Thyroid problems (mainly hypothyroid) .. Sickle cell diseaseSickle cell disease .. HIV/AIDSHIV/AIDS .. Kidney diseaseKidney disease .. DiabetesDiabetes
  21. 21.  Serum FSH, PRL levels(mainly FSH)  Semen analysis  Testicular biopsy  Sperm penetration assay (SPA)
  22. 22.  Collected after 480 of abstinence  Evaluated within one hour of ejaculation  If abnormal parameters, repeat twice, 2 weeks apart
  23. 23. Quality Normal Value Volume >1 cc Concentration >2 x 106 /cc Initial Forward Motility >50% Normal Morphology >60%
  24. 24.  Dynamic test of fertilization capacity of sperm  False positives and negatives exist
  25. 25. According to cause Ovulation inductionOvulation induction  clomiphene (clomiphene (drug of choice in normaldrug of choice in normal gonadotropin and prolactin levelgonadotropin and prolactin level))  tamoxifentamoxifen  cylcofenil(cylcofenil(anti oestrogenic and also makeanti oestrogenic and also make cervical mucus thin and copiouscervical mucus thin and copious))  bromocriptin(bromocriptin(drug of choice indrug of choice in hyperprolactinaemiahyperprolactinaemia))  gonadotropins(gonadotropins(human menopausal gonadotropin,GnRHhuman menopausal gonadotropin,GnRH))
  26. 26.  General advice  Reduce alcohol consumption  Reduce smoking  Should avoid testiculotoxic drugs etc.....  Hypogonadotrophism  GnRH  hCG results poor  Varicocoele  Patient with varicocoele may be fertile or infertile but the surgical procedures may not be affective  Retrograde ejaculation  Ephedrine, imipramine
  27. 27. Idiopathic oligospermia  No effective treatment  ?IVF  donor insemination Antisperm antibodies  Treated with prednisolone
  28. 28. ((counselingrequiredcounselingrequired)) A. Intra-uterine inseminationA. Intra-uterine insemination indications:indications: i) unexplained infertilityi) unexplained infertility ii) cervical factorsii) cervical factors iii) poorsemen reportiii) poorsemen report iv) impotenceiv) impotence
  29. 29. B. In-vitro fertilizationB. In-vitro fertilization indicationsindications i) tubal diseasetubal disease ii)un-explained infertilityii)un-explained infertility iii)endometriosisiii)endometriosis iv)male factorsiv)male factors v)failed intra-uterine inseminationv)failed intra-uterine insemination vi)cervical hostilityvi)cervical hostility ______________________________________________________________________________________________________________________

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