Pri. and secondary infertility

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Pri. and secondary infertility

  1. 1. Nandaram SeerviSMS MEDICAL COLLEGE JAIPURMANAGEMENT PROTOCOL FOR PRIMARYAND SECONDARY INFERTILITYObjectives• Define primary and secondary infertility• Describe the causes of infertility• Diagnosis and management of infertilityRequirements for Conception• Production of healthy egg and sperm
  2. 2. • Unblocked tubes that allow sperm to reach the egg• The sperms ability to penetrate and fertilize the egg• Implantation of the embryo into the uterus• Finally a healthy pregnancyDefinition of InfertilityThe inability to conceive following unprotected sexualintercourse• 1 year (age < 35) or 6 months (age >35)• Affects 15% of reproductive couples• Men and women equally affectedType of Infertility• Primary infertility
  3. 3. – a couple that has never conceived• Secondary infertility– infertility that occurs after previous pregnancyregardless of outcome(abortion/actopic preg)Causes for infertility• Anovulation (10-20%)• Anatomic defects of the female genital tract (30%)• Abnormal spermatogenesis (40%)• Unexplained (10%-20%)Evaluation of the Infertile couple• History and Physical exam• Semen analysis
  4. 4. • Thyroid and prolactin evaluation• Determination of ovulation– Basal body temperature record– Serum progesterone– Ovarian reserve testing• HysterosalpingogramAbnormalities of SpermatogenesisMale Factor• 40% of the cause for infertility• Sperm is constantly produced by the germinalepithelium of the testicle– Sperm generation time 73 days
  5. 5. – Sperm production is thermoregulated• 1° F less than body temperature• Both men and women can produce anti-spermantibodies which interfere with the penetration of thecervical mucusSemen Analysis (SA)• Obtained by masturbation• Provides immediate information– Quantity– Quality– Density of the sperm
  6. 6. • Abstain from coitus 2 to 3 days• Collect all the ejaculate• Analyze within 1 hour• A normal semen analysis excludes male factor 90% ofthe timeNormal Values for Semen Analysis(WHO-2010normal & lower reference limit )– Volume - 2.0 ml or more (1.5ml )– pH - 7.2-7.8– Viscosity - Liquefaction in 30-60 min– Sperm Conc. - 20 million/ml or more (15mililion/ml )
  7. 7. – Total sperm count- >40 million/ejacu (39 million/ejacul )– Viability - >75% living ( 58% )– Motility - >50% forward progression (32% progressivemotility )– Morphology – >14 % normal forms ( 4% )– WBC - < 1 million/ml– Round cells < 5 million/mlCauses for male infertility• 42% varicocele– repair if there is a low count or decreased motility• 22% idiopathic• 14% obstruction
  8. 8. • 20% other (genetic abnormalities)Evaluation of OvulationMenstruation• Ovulation occurs 13-14 times per year• Menstrual cycles on average are 28 days with ovulationaround day 14• Luteal phase– dominated by the secretion of progesterone– released by the corpus luteum• Progesterone causes– Thickening of the endocervical mucus
  9. 9. – Increases the basal body temperature (0.6° F)• Involution of the corpus luteum causes a fall inprogesterone and the onset of mensesOvulation• A history of regular menstruation suggests regularovulation
  10. 10. • The majority of ovulatory women experience– fullness of the breasts– decreased vaginal secretions– abdominal bloating• Absence of PMS symptoms may suggest anovulationDiagnostic studies to confirm OvulationBasal Body Temperature• Basal body temperature– Inexpensive– Accurate• Endometrial biopsy
  11. 11. – Expensive– Static information• Serum progesterone– After ovulation rises– Can be measured• Urinary ovulation-detection kits– Measures changes in urinary LH– Predicts ovulation but does not confirm it
  12. 12. Serum Progesterone• Progesterone starts rising with the LH surge– drawn between day 21-24– Mid-luteal phase– >10 ng/ml suggests ovulation
  13. 13. • AnovulationSymptoms• Irregular menstrual cycles• Amenorrhea• Hirsuitism• Acne• Galactorrhea• Increased vaginal secretions
  14. 14. Evaluation*• Follicle stimulating hormone• Lutenizing hormone• Thyroid stimulating hormone• Prolactin• Androstenedione• Total testosterone• DHEAS
  15. 15. Anatomic Disorders of the Female Genital TractSperm transport, Fertilization, & Implantation• The female genital tract is not just a conduit– facilitates sperm transport– cervical mucus traps the coagulated ejaculate– the fallopian tube picks up the egg• Fertilization must occur in the proximal portion of thetube– the fertilized oocyte cleaves and forms a zygote– enters the endometrial cavity at 3 to 5 days• Implants into the secretory endometrium for growth anddevelopment
  16. 16. Acquired Disorders• Acute salpingitis– Alters the functional integrity of the fallopian tube• N. gonorrhea and C. trachomatis• Intrauterine scarring– Can be caused by curettage• Endometriosis, scarring from surgery, tumors of theuterus and ovary– Fibroids, endometriomasTraumaCongenital Anatomic Abnormalities
  17. 17. Hysterosalpingogram•An X-ray that evaluates the internal female genital tract– architecture and integrity of the system•Performed between the 7thand 11thday of the cycle•Diagnostic accuracy of 70%•
  18. 18. • The endometrial cavity– Smooth– Symmetrical• Fallopian tubes– Proximal 2/3 slender– Ampulla is dilated• Dye should spill promptly
  19. 19. Unexplained infertility• 10% of infertile couples will have a completely normalworkup• Pregnancy rates in unexplained infertility– no treatment 1.3-4.1%– clomiphene and intrauterine insemination 8.3%– gonadotropins and intrauterine insemination 17.1%Treatment of the Infertile CoupleInadequate Spermatogenesis• Eliminate alterations of thermoregulation
  20. 20. • Clomiphene citrate is occasionally used for induction ofspermatogenesis– 20% success• In vitro fertilization may facilitate fertilization• Artificial insemination with donor sperm is oftensuccessfulAnovulation• Restore ovulation– Administer ovulation inducing agents• Clomiphene citrate– Antiestrogen
  21. 21. – Combines and blocks estrogen receptors at thehypothalamus and pituitary causing a negative feedback– Increases FSH production• stimulates the ovary to make folliclesClomiphene Citrate• Given for 5 days in the early part of the cycle• Maximum dose is usually 150mg• 50mg dose - 50% ovulate• 100mg -25% more ovulate• 150mg lower numbers of ovulation• No changes in birth defects If no pregnancy in 6 monthsrefer for advanced therapies
  22. 22. • 7% risk of twins 0.3% triplets• SAB rate 15%Superovulatory Medications• If no response with clomiphane then gonadotropins- FSH(e.g. pergonal) can be administered intramuscularly– This is usually given under the guidance of someone whospecializes in infertility• This therapy is expensive and patients need to befollowed closely• Adverse effects– Hyperstimulation of the ovaries– Multiple gestation
  23. 23. – Fetal wastageAnatomic Abnormalities• Surgical treatments– Lysis of adhesions– Septoplasty– Tuboplasty– Myomectomy• Surgery may be performed– laparoscopically– hysteroscopically• If the fallopian tubes are beyond repair one mustconsider in vitro fertilization
  24. 24. Assisted Reproductive Technologies (ART)Intrauterine InseminationIndicationsUnexplainedMild male factorSuccess/Cycle---Natural 10-15%, Stimulated 15-20%Question on management protocol of pri. & sec. infertility1. Best prognosis in infertile women is seen in/most reversible form of infertility is :(a) Tubal block(b) Anovulation(c) Oligospermia(d) Endometritis
  25. 25. 2. The risk of Asherman syndrome is the highest if Dilatation and Curettage (D&C) is done for the followingcondition :(a) Medical termination of pregnancy(b) Missed abortion(c) Dysfunctional uterine bleeding(d) Post partum haemorrhage3. Fern test is due to :(a) Presence of NaCl under progesterone effect(b) Presence of NaCl under estrogenic effect(c) LH/FSH(d) Mucus secretion by Glands4. An infertile women has bilateral tubal block at cornua diagnosed on hysterosalpingography. Next step intreatment is :(a) IVF(b) Laparoscopy and hysteroscopy(c) Tuboplasty(d) Hydrotubation5. Post coital test detects all of the following except :(a) Fallopian tube block(b) Cervical factor abnormality(c) Sperm count(d) Sperm abnormality6. A 25 year old infertile male underwent semen analysis. Results show : sperm count-15 million/ml; pH-7.5; volume-2 ml; no agglutination is seen. Morphology shows 60% normal and 60% motile sperms. Mostlikely diagnosis is :(a) Normospermia(b) Oligospermia
  26. 26. (c) Azoospermia(d) Aspermia7. Which of the following is true about obstructive azoospermia :(a) FSH and LH(b) Normal FSH and Normal LH(c) LH, Normal FSH(d) FSH, Normal LH8. In azoospermia, the diagnostic test which can distinguish between testicular failure and obstruction ofVas deferens is :(a) Estimation of FSH level(b) Estimation of testosterone level(c) Karyotyping(d) FNAC of testes9. Semen analysis of a male of an infertile couple, shows absence of spermatozoa but presence of fructose.The most probable diagnosis is :(a) Prostatic infection(b) Mumps orchitis(c) Block in efferect duct system(d) All of the above10. Artificial insemination with husband’s semen is indicated in all the following situations, except :(a) Oligospermia(b) Impotency(c) Antisperm antibodies in the cervical mucous(d) Azoospermia11. Aspiration of sperms from testes is done in :(a) TESA
  27. 27. (b) MESA(c) ZIFT(d) GIFT12. Luteal phse is best diagnosed by :(a) Serum progesterone levels(b) Endometrial biopsy(c) Basal body temperature(d) Ultrasonography13. What is the optimal time during the menstrual cycle when serum progesterone should be drawn toconfirm the diagnosis of luteal phase deficiency :(a) Day 18(b) Day 21(c) Day 23(d) Day 2514. All are used in treatment of infertility, except :(a) Luteinizng hormone (LH)(b) Prolactin(c) GnRH(d) Clomiphene15. Asthenospermia means :(a) Failure of the formation of sperms(b) No spermatozoa in the semen(c) Reduction in the motility of sperms(d) Sperm count less than 20 million/ml of semen
  28. 28. Answers key1.B2.D3.B4.B5.A6.B7.B8. A9. C10. D11. A12. B13. B14. B15. C

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