Subfertiliteit

1. Subfertility
Dr. R. Schats
Amsterdam UMC,
Locatie VUmc

2. What is meant by
(sub)fertility ?
 What is normal ?
 Subfertility
 What percentage of couples ?
 The human is a relatively infertile
mammal
 Every month a chance
 Successful species (?)

3. Getting pregnant in time

4. The monthly chance

5. The monthly chance
and age

6. A few aspects of
subfertility
 Child wish / Reproduction
 A condition, disease …
or just a luxury problem??

7. A few aspects of
subfertility
 Psychological versus physical
 Emotional aspects
 ‘Postponing behavior’

8. Age of European women at
birth of first child
21
22
23
24
25
26
27
28
29
30
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
Netherlands
West
and
Southern
Northern Europe Europe
Eastern
Europe

9. Age of Dutch women at birth
of first child
22
23
24
25
26
27
28
29
30
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000

10. Age of European women at
birth of first child
22,0
24,0
26,0
28,0
30,0
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
NEDERLAND Zweden Rusland Polen

11. Subfertility
 Not getting pregnant at home
 What period ??
 Initiative with patient
 Fertility investigations
 Diagnostics
 Diagnosis
 Therapy

12. Fertility investigations
 History of the couple
 Basal Body Temperature Chart (BBT)
 Semen analysis (SA)
 (Post Coital Test (PCT))
 Hysterosalpingogram (HSG)
 Laparoscopy

13. Fertility investigations
 History of the couple
 Basal Body Temperature Chart (BBT)
 Semen analysis (SA)
 (Post Coital Test (PCT))
 Hysterosalpingogram (HSG)
 Laparoscopy

14. History of the couple
 Primary / secondary
 Duration of subfertility
 Menstrual Cycle
 Infections: STD’s, appendicitis
 Coitus: frequency, ovulation timing
 Puberty
 Operations

15. Alcohol, smoking, drugs,
& being overweight
These lifestyle factors have
a bad effect on getting
pregnant

16. Alcohol
 Advice for women: 0
 Advice for men: 0-2, and no binge
drinking

17. Smoking in women
As the women smokes:
 It takes twice as long to get pregnant
 Twice as frequent a miscarriage
 The chance for pregnancy becomes
comparable with a 10 years older woman
in case of smoking 10 or more cigarettes
per day
 Earlier menopause

18. Smoking in men
As the man smokes:
 The number of progressive motile
spermatozoa can diminish
 The spermatozoa have a lower
fertilisation potential

19. Drugs
 The spermatozoa have a lower
fertilisation potential
 Disturbance of hormone levels and
therefore semen

20. Adipositas 1 BMI 21-29
 Van der Steeg 2007

21. Adipositas 2
 It takes time:
 For weight redusction
 To get pregnant
 Recovery to normal menstrual cycles at
5-10% weight reduction

22. Fertility investigations
 History of the couple
 Basal Body Temperature Chart (BBT)
 Semen analysis (SA)
 (Post Coital Test (PCT))
 Hysterosalpingogram (HSG)
 Laparoscopy

23. Hormones in the
menstrual cycle
0,1
1
10
100
1000
1 4 7 10 13 16 19 22 25 28
cyclusdag
LH,FSH,P4
0
200
400
600
800
1000
1200
oestradiol
FSH LH Progesteron Oestradiol

24. Basal Body Temperature
chart (BBT)
 Ovulatory cycle
 Follicular phase
 Luteal phase
 Progesteron
 No forecast
 Valuable information

25. Basal Body Temperature
chart (BBT)
36
36,2
36,4
36,6
36,8
37
37,2
37,4
1 3 5 7 9 11 13 15 17 19 21 23 25 27
cyclusdag
Temperatuur
temperatuur

26. Basal Body Temperature
chart (BBT)
36
36,2
36,4
36,6
36,8
37
37,2
37,4
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
cyclusdag
Temperatuur
temperatuur

27. Basal Body Temperature
chart (BBT)
36
36,2
36,4
36,6
36,8
37
37,2
37,4
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35
cyclusdag
Temperatuur
temperatuur

28. Hormones in the
menstrual cycle
0
10
20
30
40
50
60
70
1 4 7 10 13 16 19 22 25 28
cyclusdag
progesteron
Progesteron (ng/ml)

29. Fertility investigations
 History of the couple
 Basal Body Temperature Chart (BBT)
 Semen analysis (SA)
 (Post Coital Test (PCT))
 Hysterosalpingogram (HSG)
 Laparoscopy

30. Semen analysis
Great variations
Density per ml
Motility
Morphology
Chemical analysis

31. WHO criteria Semen analysis
 Volume: 2 – 5 mL
 Density: > 15 million/mL
 Motility: > 40%
 Morphology: > 40% normal
 Chemical analysis: acidic fosfatase, fructose

32. Terminology Semen analysis
 Normospermia
 Low density: oligospermia
 Low motility: astenospermia
 Low morphology score: teratospermia
 Combinations: ‘OATS’

33. Variations in semen parameters:
density over time

34. Fertility investigations
 History of the couple
 Basal Body Temperature Chart (BBT)
 Semen analysis (SA)
 Post Coital Test (PCT)
 Hysterosalpingogram (HSG)
 Laparoscopy

35. Post Coital Test (PCT)
 Survival of spermatozoa in cervical
mucus ± 10 hour following
intercourse
 Semen and mucus quality
 Midcycle: before ovulation
 What is tested ?
 Prognostic value
 No better test available

36. Fertility investigations
 History of the couple
 Basal Body Temperature Chart (BBT)
 Semen analysis (SA)
 (Post Coital Test (PCT))
 Hysterosalpingogram (HSG)
 Laparoscopy

37. Procedure HSG

38. HSG pictures

39. Fertility investigations
 History of the couple
 Basal Body Temperature Chart (BBT)
 Semen analysis (SA)
 Post Coital Test (PCT)
 Hysterosalpingogram (HSG)
 Laparoscopy

40. Procedure
laparoscopy

41. Several causes
 Female: tubal, anovulation,
cervix, uterine and…. ???
 Mannelijk: Oligo Astheno
Terato Spermia (OATS)
 Combinations
 Idiopathic

42. Treatment Options
 Just do nothing:
 Favourable prognosis: Hunault score >30%
 Surgical
 Ovulation induction
 Intra-uterine insemination
 IVF
 ICSI

43. Conclusions
 Infertility a disease !
 Physical and emotional aspects
 Investigations with pitfalls
 Treatments are stressful
 Complications
 Very rewarding