ABOUBAKR ELNASHAR

1. MANAGEMENT OF INFERTILITY
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2. CONTENTS
 INTRODUCTION
1. MALE FACTOR
2. ENDOMETRIOSIS ASSOCIATED INFERTILITY
3. OVARIAN FACTOR
4. TUBAL FACTOR
5. UTERINE FACTOR
6. UNEXPLAINED INFERTILITY
ABOUBAKR ELNASHAR

3. INTRODUCTION
When to refer a couple for investigations?
After 40 y
Immediate evaluation in women.
35-40 Y
After 6 months of unprotected intercourse without
conception
<35 y
After one year
ABOUBAKR ELNASHAR

4. European Society of Human Reproduction &
Embryology (ESHRE) (2000)
Infertility testing should be classified into 3 groups
depending on correlation with pregnancy rates
I. Tests that have an established association with
pregnancy:
1. Conventional semen analysis
2. Tubal patency tests,
3. Tests of ovulation
ABOUBAKR ELNASHAR

5. II. Tests that are not consistently associated with
pregnancy:
Post-coital test,
Antisperm antibody tests
Zona-free hamster egg penetration test
III. Tests that have no association with pregnancy:
Endometrial biopsy
Premenstrual endometrial biopsy
Varicocele assessment
Chlamydia testing
ABOUBAKR ELNASHAR

6. 1. MALE INFERTILITY
Prof. Aboubakr Elnashar
Benha University, Egypt
elnashar53@hotmail.com
ABOUBAKR ELNASHAR

7. I. STANDARD SEMEN
ANALYSIS
IV. GENETIC TESTS
1. Karyotyping
2. Y chromosome microdeletions
3. Cystic fibrosis conductance
regulator (CFTR) gene
mutation
II. SPECIALIZED
SEMEN ANALYSIS
1. Sperm
autoantibodies
2. Semen Fructose
3. Semen culture
4. Sperm function
tests
CASA
S DF
S ROS
III. ENDOCRINE TESTS
1. T
2. LH and FSH
3. Prolactin
INVESTIGATIONS
ABOUBAKR ELNASHAR

8. I. STANDARD SEMEN ANALYSIS
A. Macroscopic
1. Delayed liquefaction
2. Increased viscosity
3. Semen volume
4. pH
B. Microscopy
1. Agglutination
2. Concentration
3. Motility
4. Morphology
5. Round cells
6. Leukocytes
ABOUBAKR ELNASHAR

9. Semen analysis: WHO, 2010
:
:
Lower reference limitParameter
1.5 mlVolume
7.2pH
15 million/mlConcentration
39 million/ejaculateTotal sperm number
40% or
PR: 32%
Total motility: (PR+NP)
58% live spermatozoaVitality
4% (strict criteria).Normal forms
Motility: progressive: rapid (a)+ slow (b)
A and b Not used in WHO 2010
Non progressive (c) ABOUBAKR ELNASHAR

10. Prediction of fertility
The likelihood of infertility
increased with decreases in any of the 3
parameters:
M
NM
C
Normal morphology
had the greatest discriminatory power.
ABOUBAKR ELNASHAR

11. II. SPECIALIZED SEMEN ANALYSIS
Not routinely performed
used to determine the cause of male infertility
1. Sperm autoantibodies
2. Semen biochemistry (semen fructose)
3. Semen culture
4. Sperm cervical mucus interaction tests
5. Sperm function tests
Computer aided sperm analysis (CASA)
Sperm chromatin/DNA assays
Sperm reactive oxygen species generation
ABOUBAKR ELNASHAR

12. 1. Sperm autoantibodies
4 to 8%of subfertile men.
Agglutination:
Stick of motile spermatozoa to each other.
≥10%:
suggestive but not conclusive of immunological
infertility.
should be confirmed by
Mixed antiglobulin reaction (MAR)
Immunobead test
both of which detect sperm surface antibodies.
ABOUBAKR ELNASHAR

13. 2. Semen biochemistry
Rarely useful in clinical practice.
Fructose
marker of seminal vesicle function.
Low or non-detectable:
congenital absence of the vas deferens and
seminal vesicles or
ejaculatory duct obstruction
ABOUBAKR ELNASHAR

14. 3. Semen culture
Indicated:
semen samples contain inflammatory cells
Precautions
during sample collection to prevent skin
contamination.
Results:
usually not diagnostic.
The yield of semen culture
may be improved by performing a prostatic massage
before sample collection.
ABOUBAKR ELNASHAR

15. 5. Sperm function tests
Routine:
Impractical and costly
Selective
when the standard semen analysis is normal or
near normal
ABOUBAKR ELNASHAR

16. Computer-aided sperm analysis: CASA
Assess:
1. Concentration
2. Morphology.
3. Motility:
Quantitative measurement
(curvilinear, straight line, average path)
Amplitude of lateral displacement
other derived functions.
ABOUBAKR ELNASHAR

17. Useful in:
Male unexplained infertility
predicting in vivo and in vitro fertilizing capacity,
toxicology studies.
Accuracy depend upon:
technology
analytic conditions
technical training of the operators.
ABOUBAKR ELNASHAR

18. ABOUBAKR ELNASHAR

19. Normal= 10
Fragmented= 4
DFI= 4X100/10+4
=28.5%
normal
normal
normal
normal
normal
normal
normal
normal
normal
fragmented
fragmented
fragmented
fragmented
normal
≥30: male infertility
15-30: RM.
≤15: Excellent to Good fertility potential
ABOUBAKR ELNASHAR

20. There is insufficient evidence to recommend the routine
use of SDF testing in evaluation and treatment of
infertile couple {level C}
?????????
For diagnostic test
1. Results must be reproducible
2. Applicable to a given patient
3. Change management of patient
ABOUBAKR ELNASHAR

21. III. ENDOCRINE TESTS
1. Serum testosterone (T)
2. Serum LH and FSH
3. Prolactin
ABOUBAKR ELNASHAR

22. 1. Serum testosterone (T)
Morning T
In men with borderline values:
Repeat
FT
ABOUBAKR ELNASHAR

23. 2. Serum LH and FSH
Indication:
T is low
Interpretation:
high FSH and LH:
primary hypogonadism
low or normal:
secondary hypogonadism.
low LH + low sperm counts +well-androgenized:
exogenous anabolic or
androgenic steroid abuse.
ABOUBAKR ELNASHAR

24. 3. Prolactin
Indication:
 low T
normal to low LH
4. Inhibin
low serum inhibin concentrations may be an even
more sensitive test of primary testicular dysfunction
than high serum FSH concentrations, provided the
assay is specific for inhibin B
ABOUBAKR ELNASHAR

25. IV. GENETIC TESTS
1. Karyotyping
2. Y chromosome microdeletions
3. Cystic fibrosis conductance regulator (CFTR)
gene mutation
ABOUBAKR ELNASHAR

26. ABOUBAKR ELNASHAR

27. Abnormal semen
ICSI
TT of varicocele if palpable
Hormonal tt if low FSH &Testost.
Treatment of infection ?
Mild:≥2 NM, ≥5M, ≥10%TM
Severe or
Azoospermia
3 trial IUI
ABOUBAKR ELNASHAR
TREATMENT

28. Varicocele:
(AUA&ASRM, 2004 & AFU, 2006)
Imaging examinations:
not indicated to characterize the varicocele.
TT when all of the following conditions are
present:
1. Varicocele: Palpable
2. Semen: Abnormal (at least one abnormality)
3. Couple's infertility: Documented
4. Female infertility problem: Curable
ABOUBAKR ELNASHAR

29. 2. ENDOMETRIOSIS
ASSOCIATED
INFERTILITY
Prof. ABOUBAKR ELNASHAR
Benha university, Egypt
ABOUBAKR ELNASHAR

30. INVESTIGATIONS
1. Laparoscopy
with biopsy and histology:
gold standard for diagnosis
Negative diagnostic laparoscopy:
highly accurate for excluding endometriosis
Positive laparoscopy without taking biopsies
less informative
of limited value
(Wykes et al., 2004).
To obtain tissue for histology in women undergoing
surgery for
endometrioma and/or
deep infiltrating disease
{exclude rare instances of malignancy}
{GPP}
ABOUBAKR ELNASHAR

31. Histopathologic confirmation
necessary for the diagnosis of endometriosis
ectopic endometrial stroma and glands
(Berker, Seval, 2015)
ABOUBAKR ELNASHAR

32. 2. TVS:
To diagnose or to exclude
ovarian endometrioma
(Moore et al., 2002).{A}
 rectal endometriosis
(Hudelist et al., 2011).{A}
ABOUBAKR ELNASHAR

33. Diagnosis of endometrioma
•Ground glass echogenicity
•1-4 compartments
•No papillary structures
•Detectable blood flow
(Van Holsbeke et al., 2010).{GPP}
ABOUBAKR ELNASHAR

34. Endometrioma. Sagittal TVS
an ovarian mass with multiple fine internal echoes (arrows) and
several hyperechoic mural foci (arrowheads).
ABOUBAKR ELNASHAR

35. Ovarian endometrioma (A, B).
The structure is hypoechoic and exhibits low amplitude
uniformly distributed echotexture in the cavities of the
cysts.ABOUBAKR ELNASHAR

36. 3D ultrasound
To diagnose rectovaginal endometriosis is not
well established
(Pascual et al., 2010).{D}
MRI
To diagnose peritoneal endometriosis is not well
established
(Stratton et al., 2003) {D}
ABOUBAKR ELNASHAR

37. ABOUBAKR ELNASHAR
TREATMENT

38. 3. OVARIAN
FACTOR
INFERTILITY
Prof. Aboubakr Elnashar
Benha university Hospital,
Egypt
ABOUBAKR ELNASHAR

39. INVESTIGATIONS
 Routine
1. Ultrasound folliculometry
Costly
Time consuming
To be reserved for induction ovulation or COS
(NICE, 2013; Practice Committee of the ASRM, 2015;
UpToDat,2016)
ABOUBAKR ELNASHAR

40.  Diagnosis of Spontaneous Ovulation
1. Mature F. (contain mature oocyte) = 17 – 25 mm (Inner
dimensions)
2. Reduction in mature follicle size (40%) Or
Disappearance (60%)
3. Intra peritoneal fluid
-Normal: 1-3 ml
-With ovulation: 4- 5 ml
4. CL: 4-8 days after ovulation
 Irregular thick wall .
 Hypoechoic
 May contain internal echos (hge.)
 15 mm
ABOUBAKR ELNASHAR

41. 2. Mid luteal serum progesterone
in regular and irregular cycles
Mid-luteal
 7 days before the next expected period
day 21 and day 28 in 28-day and 35-day cycles,
respectively.
In irregular prolonged cycles
depending upon the timing of menstrual periods,
conducted later in the cycle (for example day 28 of a
35-day cycle) and repeated weekly thereafter until the
next menstrual cycle starts
Advantages:
Reliable
Safe
Inexpensive
ABOUBAKR ELNASHAR

42. 3. LH surge in urine
Commercially available urinary LH detection kits can
detect the LH surge and can be used to time
intercourse with ovulation induction
 Inexpensive,
 Pinpoint the day of ovulation
 Reduced the uncertainty in interpretation of
progesterone levels by better-identifying the time of
peak progestrone secretion at which to obtain serum
ABOUBAKR ELNASHAR

43. May be done
1. Basal FSH and LH
 Only in
irregular prolonged cycles
2. Prolactin
Only in
ovulatory disorder
galactorrhoea or
pituitary tumour
3. TSH:
only if
symptoms of thyroid disease
ABOUBAKR ELNASHAR

44. 4. Ovarian reserve testing
 Woman’s age:
An initial predictor of overall chance of success
through natural conception or with IVF
 Predictors of ovarian response to Gnt stimulation
High responseLow response
16 or more4 or lessTotal AFC
3.5 or more
25
0.8 or less
5.5
AMH
ng/ml
pmol/l
Conversion ratio:7
4 or less8.9 or moreFSH IU/L
ABOUBAKR ELNASHAR

45.  Do not use
ovarian volume
ovarian blood flow
inhibin B
E2
ABOUBAKR ELNASHAR

46. Not recommended
Historically, the effects of progesterone on basal body
temperature, endometrial histology or cervical mucus
were commonly used.
1. PMEB:
histologic dating is not a valid diagnostic method
lacks both accuracy and precision
To evaluate the luteal phase: No
{no evidence that medical tt of luteal phase defect
improves pregnancy rates]
ABOUBAKR ELNASHAR

47. 2. BBT
 Stressful
 Predicted the day of ovulation in10% of cycles
 Less accurate for confirming ovulation
(Guermandi et al, 2001)
ABOUBAKR ELNASHAR

48. TREATMENT
 Types of anovulation
WHO

49. Types of ovarian stimulation
Controlled ovarian
stimulation
Super
ovulation
Induction of
ovulation
Anovulatory or ovulatoryAnovulatoryPatient
Multiple> oneOne mature
follicle
Objective
IVFIUI
Unexp infert
AnovulatoryExample
Down regulation
Stimulation
Prevent premature
LH surge
StimulationStimulationMethod
ABOUBAKR ELNASHAR

50. Amenorrhea or severe oligomenorrhea
FSH & LH: low
Prolactin: normal
I. Hypogonadotrophic hypoestrogenic
Type I
ABOUBAKR ELNASHAR

51. 1. Reverse the life style factors:
Increase wt if BMI <19
When the metabolic state is normalized reflected
by a normal BMI (>20 kg/m2), a regular menstrual
cycle will be restored in the majority of patients.
(Stafford, 2005)
Moderating exercise if high levels of exercise.
Treat stress
CC:
not effective
ABOUBAKR ELNASHAR

52. 2. Gonadotrphins with LH activity or
Pulsatile GnRH (pump)
3. luteal support
hCG or progesterone from time of ovulation induction
until sufficient hCG production by trophoblast
cells is necessary.
(Beckers et al., 2006)
ABOUBAKR ELNASHAR

53. II. Normogonadotrophic Normoestrogenic
Type II
PCOS
2 of 3 (Roterdam definition,2003):
•U/S PCO
•Hyperandrogenism (Clinical or Laboratory)
•Irregular or absent ovulation
ABOUBAKR ELNASHAR

54. Weight reduction
letrozole or CC
Obese &overweight
Normal weight &No weight loss & No ovulation
LODGnT
No ovulation after 3 cycles.
No pregnancy after 6 cycles.
No pregnancy
after 6 cycles.
No pregnancy after spontaneous,
CC, FSH ovulation
IVF
Other surgical indication
Difficult follow up
Less aggressive
No desire for
surgery
Add metformin
IGT &IR
ABOUBAKR ELNASHAR

55. III. Hypergonadotrophic hypoestrogenic
< 40 yr, 2ndry amenorrhea
Repeated FSH > 20 IU/L
Causes
1. Idiopathic.
2. Genetic.
3. Autoimmune
3. Viral/bacterial infection
4. Pelvic surgery, chemotherapy
5. Galactosemia
ABOUBAKR ELNASHAR

56. 1. Oral contraceptive suppression of gonadotrpins
followed by discontinuation
to allow a rebound in gonadotropins & ovarian
function.
2. GnRHa suppression of gonadotropins secretion
followed by high dose gonadotropin injection
3. Glucocorticoids suppression of immune system.
Non of these tts has demonstrated efficacy in RCT
ABOUBAKR ELNASHAR

57. IV. Hyperprolactinaemia
I. Idiopathic
Dopamine agonist (anxiety, pregnancy).
Stop during pregnancy
II. Microadenoma
Dopamine agonist (anxiety, pregnancy).
Stop after 2-3 yr.
Surgery (rapid growth).
III. Macroadenoma
Dopamine agonist: long term
Surgery
(No response, suprasellar extension, pregnancy).
ABOUBAKR ELNASHAR

58. 4. TUBAL FACTOR
INFERTILITY
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

59. INVESTIGATIONS
1. Hysterosalpingography
The most commonly performed screening test for tubal
patency.
Advantages:
1.Position of tubal occlusion
2. Unilateral patency can be dd from bilateral patency.
3. Degree of damage to tubal endothelium
4. Peritubal adhesion.
5. Uterine cavity
ABOUBAKR ELNASHAR

60. 6. Relatively cheap & simple.
7. HSG is in agreement with the laparoscopic
findings approximately two thirds of the time.
Sensitivity: 73
Specificity: 83%
High specificity makes it useful in ruling in tubal
obstruction
ABOUBAKR ELNASHAR

61. Disadvantages
1. The pelvis including the ovaries is exposed to
radiation:
significant problem if the patient had an early
pregnancy.
2. Abdominal pain
which peaks 5 min after starting
usually settles within 30 min.
ABOUBAKR ELNASHAR

62. 3. Intravasation
Network of streaklike opacities adjacent to the
uterine cavity
extend toward the pelvic side walls and
subsequently migrate in a cephalad direction.
Early detection:
minimizes complications
injection should be discontinued
immediately, regardless of the contrast
medium used.
ABOUBAKR ELNASHAR

63. 2. Sono hystero salpingography
An US contrast dye or saline (10-40 ml) is injected into
the uterus through the cervix by a Foley catheter
the passage of the dye is followed by TVS.
76% concordance rate with laparoscopy dye
The addition of pulsed wave or color Doppler imaging
may improve the predictive value of TV
sonosalpingography
Experience
effective alternative to HSG
(NICE, 2013)
The ideal test is HyCoSy which combines cavity check
with tubal assessment.
ABOUBAKR ELNASHAR

64. 3. Laparoscopy
Indication
1. Abnormal HSG or US
2.History or symptoms suggestive of pelvic disease.
Normal HSG or no history suggestive of tubal disease:
probability of clinically relevant tubal disease or
endometriosis is very low:
laparoscopy is not justified or cost effective
(Fatum et al, 2002).
ABOUBAKR ELNASHAR

65. Hysteroscopy
Not an initial investigation unless clinically
indicated
{effectiveness of surgical treatment of uterine
abnormalities on improving pregnancy rates has not
been established}.
(NICE, 2013)
ABOUBAKR ELNASHAR

66. 4. Transvaginal hydrolaparoscopy (THL)
±Method of choice for the clarification of mechanical
infertility factors in symptom free patients with no
suspicion of pelvic pathologies
(Nawroth et al,2001).
THL in association with minihysteroscopy:
more information
better tolerated than HSG in outpatient infertility
investigation
ABOUBAKR ELNASHAR

67. 5. Chlamydia antibody testing (CAT)
HSG is more accurate than CAT in predicting tubal
disease
(Elnashar et al,2000).
If both tests were negative
the tubal disease was identified on laparoscopy in
only 4 % of case.
ABOUBAKR ELNASHAR

68. TREATMENT
IVF
Main player for tt of tubal factor.
Indication
1. Moderate to severe tubal disease
A. Distal tubal occlusion with hydrosalpiges >1.5 cm in
diameter.
B. Distortion of the intraluminal architecture or
endotubal adhesions detected by HSG, salpingoscopy or falloscopy
2. Other factors
A. Sperm dysfunction
B. Age >36 yr
ABOUBAKR ELNASHAR

69. 1. Laparoscopic Surgery:
Fimbrioplasty
Lysis of fimbrial adhesions or the dilation of
fimbrial strictures.
Neosalpingostomy
Creation of a new opening in a fallopian tube with
a distal occlusion.
Adhesiolysis
more likely to work in the presence of patent tubes
& filmy adhesions
ABOUBAKR ELNASHAR

70. 2. Transcervical cannulation of the proximal fallopian
tube
Methods
hysteroscopy
fluoroscopy, or
sonography
Results
successful catheterization
80% to 90%
cumulative pregnancy
23% and 39% within the first 6 to 12 months.
Ectopic pregnancy
5% to 13%
ABOUBAKR ELNASHAR

71. Selective salpingography plus tubal catheterisation,
or hysteroscopic tubal cannulation
Proximal tubal disease
If pregnancy has not occurred within 12 mo of
surgery: IVF
ABOUBAKR ELNASHAR

72. 3. Microsurgical reanastomosis of the fallopian
tubes:
 for tubal ligation reversal.
performed by
Laparotomy
Laparoscopy
comparable rates of success
ABOUBAKR ELNASHAR

73. IVF or ICSI:
IVF should be the initial treatment of choice
(Aboulghar et al,1996; Bukulmez et al,2000).
{No significant difference in PR. or take-home baby}.
ABOUBAKR ELNASHAR

74. Hydrosalpinges
salpingectomy, or tubal disconnection
preferably by laparoscopy, before IVF treatment
{improves the chance of a live birth}.
ABOUBAKR ELNASHAR

75. 5. UTERINE FACTOR
INFERTILITY
Prof. Aboubakr Elnashar
Benha university Hospital,
Egypt
ABOUBAKR ELNASHAR

76. INVESTIGATION
1. HSG
2. TVS
3. SIS
1. 3DUS
2. MRI
3. Hysteroscopy.
ABOUBAKR ELNASHAR

77. Tubal
patency
Ut
cavity
Developmental
defects
Endometriosis
or PAD
Ovaries
HSG + + - +/- -
TVS - +/- +/- - +
3-D TVS - + + - +
SIS - + +/- - +
MR Imaging - + + - +
Hysteroscopy - + + (with
laparoscopy)
- -
Laparoscopy + - + (with
hysteroscopy)
+ +
(Hoffman et al., 2012).
PAD=Pelvic adhesive disease
ABOUBAKR ELNASHAR

78. 1. HSG
Assess
patency of the fallopian tubes
contour of the endometrial cavity
presence of any complex communications in the
setting of a müllerian anomaly.
Disadvantages:
1. Sensitivity to detect intrauterine abnormalities
can be as low as 50%
2. lack of information about the external uterine
contour: limits its utility for evaluating a uterine
anomaly.
use of TVS or HSG to evaluate the uterine cavity
in women with suspected abnormalities may lead to
suboptimal assessment of the uterus.
ABOUBAKR ELNASHAR

79. 2. TVS
Routine diagnostic tool for assessment of the pelvis,
including the uterus and adnexa.
Timing:
Secretory phase of the menstrual cycle:
better visualization of the endometrium, and
contour of the uterine cavity.
Advantages:
Specificity and sensitivity for detecting uterine
abnormalities: high
Accuracy:
excluding endometrial hyperplasia: high
Disadvantages:
dd SM fibroids & polyps: low (A).
ABOUBAKR ELNASHAR

80. Information
Uterus Assessment: Dimension, Endometrial: thickness, appearance
Abnormalities: Anomalies, Tumors
Ovaries Assessment: Position, Mobility, Volume, AFC
Abnormalities: PCOS, Cysts, Tumors
Tube Hydrosalpinx, Patency
Pelvis Free fluid, Mass
Basal Vaginal U/S
The Pivotal US (performed D8-12)
± Saline infusion sonography (SIS)
ABOUBAKR ELNASHAR

81. 3. SIS:
experience
effective alternative to HSG
(NICE, 2013)
Effectively delineate
intracavitary space
internal and external uterine contours.
Most accurate for evaluating the size, location,
and intracavitary component of the myoma.
SIS Vs office hysteroscopy:
•Comparable
•easier
•less uncomfortable
•less expensive
ABOUBAKR ELNASHAR

82. 4. 3 DUS
highly accurate imaging of pelvic anatomy
including detailed assessment of the uterus.
ABOUBAKR ELNASHAR

83. 5. MRI
Excellent delineation of internal and external
uterine contours
gold standard ” for the diagnosis of
müllerian anomalies
can identify rudimentary uterine structures and
the presence of unctional endometrium.
can differentiate
 leiomyomas, adenomyosis and adenomyomas.
ABOUBAKR ELNASHAR

84. Hysteroscopy
As a routine procedure in the infertility work-up:
still under debate
no consensus on its efficacy and effectiveness in improving the
prognosis of infertile couples
(Sardo et al., 2016).
Not an initial investigation unless clinically
indicated
(NICE, 2013)
{its effectiveness on improving reproductive
outcome has not been established }
ABOUBAKR ELNASHAR

85. Endometrial biopsy:
1. Irregular or intermenstrual bleeding.
2. Abnormal endometrial thickening on TVS
ABOUBAKR ELNASHAR

86. TREATMENT
1. CONGENITAL (MULLERIAN) ANOMALIES
Prevalence
Fertile and infertile women
3 – 4%
Normal reproductive outcomes
3.2%
1st T RM:
5%-10%
2nd T RM:
25%
(Khati, et al., 2012; Grimbizis et al., 2016).
ABOUBAKR ELNASHAR

87. I- Uterine septum for primary infertility: (NICE 2015)
 Current evidence on efficacy is inadequate:
should only be done:
 Multidisciplinary team
 specialists in reproductive medicine
 uterine imaging
 hysteroscopic surgery.
 Clear written consent:
 uncertain efficacy
 risks
 audit or research
 special arrangements for clinical governance
ABOUBAKR ELNASHAR

88. II. Unicornuate uterus
(with obstructed uterine horn)
{at higher risk for infertility, endometriosis, premature
labor, and breech presentations}.
Excision of the obstructed rudimentary blind horn
prevent
endometriosis by eliminating reflux
development of a pregnancy (and pregnancy
complications) in the obstructed uterine horn
(Khati, et al., 2012) .
ABOUBAKR ELNASHAR

89. III. The Mayer-Rokitansky-Küster-Hauser syndrome
=congenital absence of the vagina with variable
uterine development
{müllerian agenesis}.
(Iverson et al ., 2016)
2014:
First live birth following uterus transplantation
uterine factor infertility, even when considered
absolute, is now treatable
(Brannstrom et al. 2015).
3 more births proving the outcome of uterus
transplantation in this early stage of clinical
implementation to be astonishing
(Brannstrom 2015)
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90. 2. FIBROID
Prevalence
Women of reproductive age
20- 40%
Associated with infertility:
5- 10%.
Only cause of infertility:
2- 3%
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92.  Indications of Myomectomy:
1. Distorting the cavity
Submucous:
(Gambadauro,2012).
Intramural:
2. Not distorting
1. >5 cm
2. Multiple >3 (3 cm)
(Bajekal & Li, 2000)
3. only cause of infertility
Myomectomy of IM fibroid not distorting cavity:
no study has yet confirmed improvement of
outcome
(Paulson, 2016; Khalaf ,2016)
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93. 3. ADENOMYOSIS
 Diagnosis:
1. TVS: 3 or more of the followings:
1. Globular uterus: 95% of cases.
2. Asymmetrical thickening: Anterior or posterior myometrial
wall appearing thicker than its counterpart
3. Mottled heterogeneous myometrial texture: All cases.
4. Small myometrial hypoechoic cysts, which are cystic
glands within ectopic endometrial foci: 82%.
5. “Shaggy” indistinct endometrial strips: 82%.
6. Striated projections extending from the endometrium into
the myometrium
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94. Adenomyosis. Sagittal TVS
Globular uterine enlargement
Asymmetric thickening
Heterogeneity of the myometrium (arrows)
Poor definition of the endomyometrial junction
(arrowheads). E = endometrium.
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95. Interrogation Sign

96. 2. Color or power Doppler
Adenomyosis: diffuse vascularity
Fibroid: peripheral vascularity
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97. Color Doppler imaging showing radial arteries running straight rather than the
typical circular vascularization of fibroids

98. 3. MRI
Indication:
diagnosis is inconclusive
 when further delineation would affect patient
management
when coexisting uterine myomas distort anatomy
(ACOG, 2014).
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99. ABOUBAKR ELNASHAR

100. Treatment: (Tsui et al, 2015).
1. Routine infertility investigation plus ORT
Normal: long agonist protocol and natural
conception
Abnormal: IVF
2. Failed natural conception or IVF:
repeat IVF
3. Failed IVF:
conservative surgery
IVF after 3 m
(Tsui et al, 2015).
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101. 4. ENDOMETRIAL POLYPS
Define:
hyperplastic overgrowths of endometrial glands
and stroma that forms a projection from the
surface of the endometrium
(Stewart 2016).
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102. Treatment
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103. 5. INTRAUTERINE ADHESIONS
Prevalence
HSG:
1.5 %
History of postpartum uterine curettage
21.5 % (hysteroscopy)
(Deans, 2010).
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104. Treatment
Hysteroscopic adhesolysis.
The goal is to restore the size and shape of the uterine cavity,
as well as endometrial function and fertility
(Yu et al., 2008).
An experienced hysteroscopic surgeon.
Guidance with US:
help define the cervical canal and the junction between
the cervical internal os and the intrauterine cavity
guide dissection.
A small (5 mm) rigid hysteroscope can be used to pass
through the cervical canal and into the uterine cavity under
direct visualization to decrease the creation of a false passage
(Cedars and Yanett, 2016).
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105. 6. REFRACTORY ENDOMETRIUM
Prevalence
Low: 2.4%
(Kasius et al., 2014),
Causes
I. Surgical:
dilation and curettage
partial ablation
aggressive myomectomy
II. Radiotherapy
III. Infections
IV. Congenital Müllerian anomalies
V. Idiopathic
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106. According to the most recent evidence:
EnT≤7 mm would define a refractory
endometrium with compromised success rates
(Dix and Check, 2010; Kasius et al., 2014).
ABOUBAKR ELNASHAR

107.  Treatment
I. Hysteroscopic adhesiolysis
II. Hormonal manipulation
Estrogen:High dose 6−8 mg from cycle day 1
High doses for long periods, up to 9 ws
vaginal
HCG injection in the proliferative phase:1500 iu SC, daily
starting from day 8 of the cycle For 7 days or until EnT 7mm
Midluteal GnRHa:
Single dose: Triptorelin: 0.1 SC 6 days after ICSI.
Multiple doses: Triptorelin: daily 0.1 mg SC until day of beta-HCG or
14 days after OR
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108. III. Improving endometrial perfusion
LDA
Pentoxifylline and vitamin E. Pentoxifylline: 800 mg vit E:
1000 IU daily for 6-9 months
Sildenafil: 25 mg/6 h in vaginal supp in the proliferative phase,
stopped prior to HCG administration or ET.
L-arginin: 6 g/day
Nitroglycerin
IV. New modalities
Granulocyte colony-stimulating factor
Autologous platelet-rich plasma
Endometrial stem cells from bone marrow
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109. 6. UNEXPLAINED
INFERTILITY
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

110. DEFINITION
Inability to conceive (before 35 y)
after one year
with routine (standard, basic) investigations of
infertility showing no abnormality.
(RCOG guidelines,1998; Randolph,2000)
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111. INVESTIGATIONS
 Tests that have an established association with
pregnancy:
1. Conventional semen analysis
2. Tubal patency tests,
3. Tests of ovulation
 35-40
After 6 months
After 40 y
Immediate evaluation in women.
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112. Laparoscopy should be omitted in couples with
unexplained infertility
1.Laparoscopy may reveal
minimal or mild endometriosis or
peritubal adhesions:
Surgery or medical tt has not been proven to
improve fecundity.
2. In women with unexplained infertility
laparoscopy did not increase the PR
(Badawy et al, 2010)
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113. Hysteroscopy
Not routine in investigation of infertility
except when an intrauterine lesion is suspected.
Not an initial investigation
unless clinically indicated
{effectiveness of surgical treatment of uterine
abnormalities on improving pregnancy rates has not
been established}.
(NICE, 2013)
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114. TREATMENT
 By definition: Empiric
 {does not address a specific defect or functional impairment}
(Soules,2000 , Balen,2003; ASRM, 2006)
 Dependent on:
 Resources
 Patients’ age
 Duration of infertility.
 The standard protocol is to:
 Progress from simple to complex
 Balance the effectiveness against the cost and
side effects.
(Ray et al,2012)
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115.  Lines of treatment
I. Expectant management (EM)
II. Ovulation-inducing agents
1. CC:
2. Aromatase inhibitors (AI)
3. Gonadotropins
III. IUI
IV. ICSI
Tubal flushing or perturbation
Fallopian tube sperm perfusion
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116.  Protocol for Management
(Ray et al, 2012)
6
4
2
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117. ABOUBAKR ELNASHAR
You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3.elnashar53@hotmail.com