Raising issue

1. BhagyaShree Pareek
Roll No. – 17
Reg.No.-14M3020

2.  Basal body temperature-
 BBT falls at the time of ovulation by ½*c
 During progestational half of the cycle ,the
temperature is raised above the preovulatory
level by ½ - 1*F. if patient conceives , the
temperature does not fall as it normally would
with the onset of menstruation.
 This is due to thermogenic effect of
progesteron. Which is secreted by functioning
corpus lucteum after ovulation.
 Recordings of BBT will therefore indicate
weather cycle is ovulatory or not and also
denote the time of ovulation.

3.  Method -
 Patient is instructed to measure the oral
temperature just after waking up in the
morning before taking any hot or cold drinks
,& to record temperatures on a graph.
 Use –
 Reveal corpus luteal phase insufficiency.
 Defective folliculogenesis .
 Now become obsolete because of –
 Tedious daily recording.
 Not very accurate.
 Retrospective diagnosis and not useful
therapeutically.
 Better modalities available now (USG).

5.  Endometrial biopsy-
 Curetting small pieces of endometrium from
the uterus with a small endometrial biopsy
curette, preferably 1/2 days before the onset of
menstruation.
 Material is fixed in formalin saline and sent for
histological examination.
 Secretory changes prove that cycle has been
ovulatory .
 Endometrium is subjected to culture , PCR,
staining .to rule out genital TB.( in 5-10%indian
women complaining sterility)(now a days
Only reason to do the test )
 It can also diagnose corpus LPD.

7.  Fern test-
 A specimen of cervical mucus obtained using a
platinum loop or pipette is spread on a clean
glass slide and allowed to dry.
 Low –power microscopy Fern formation
(Oestrogenic phase)
disappear after ovulation.
Due to presence of NaCl in the mucus
(secreted under estrogen effect)

9.  Physical charcter of cervical mucus-
1. At ovulation- thin , profuse , clear discharge ,
great elasticity & will withstand stretching upto
10 cm.
SPINNBARKEIT/THREAD TEST (for
oestrogen activity)
2. Secreatory phase- tenacious , viscosity increase
, loses the property of spinnbarkeit , fracture
under tension.
TACK
This change in cervical mucus is an evidence of
ovulation.

11.  Insler scoring system –
 Based on-
 Amount,
 Spinnbarkeit ,
ferning ,
viscosity ,
 cellularity of cervical mucus .
Maximum score – 15
<10 – unfavorable.

12. Ultrasound -
 Standard.
 Non invasive , accurate and safe.
 It is used to monitor –
 Maturation of graffian follicle
Normal follicle grows at the rate of 1-2mm daily
to reach 20mm or > when follicular rupture and
ovulation occur.
 Detect imminent ovulation in IVF, IUI & in timing
intercourse.
 This require daily ultrasonic visualization of
ovaries from10th -16th day of menstrual cycle.
 Endometrial thickness (normal-8-10mm)
measurement for diagnosing pelvic pathology.
 If thickness is less , it indicates CLPD (corpus
luteal phase deficiency).

14.  Other USG findings relevant to infertility
are-
 Tubo-ovarian mass
 Uterine fibroid
 PCOD
 Endometrial volume and its blood
supply into the basal layer
 3 layered endometrial echogenicity
 Endometrial junction upward peristalsis .
 Other – Doppler USG, 3D USG.

15. Harmonal study-
1.Plasma progesterone-
 Rise after ovulation and reaches
peak of 15ng/ml at mid –luteal
phase (22-23day) and declines as
corpus leuteum degenerates.
 <5ng/ml - CLPD

16.  Aetiology-
 Hypopitutarism with low FSH ,LH
 Poor follicular development
 Hyperprolactinemia
 Clomiphene citrate (CC) ovulation induction
 Retrieval of egg in IVF. (CLPD is seen in
postmenarchal and premeopause period)
 Poor response of endometrium to endogenous
progesterone.

18.  Diagnosis-
 BBT
 Mid-luteal progesterone estimation
 Endometrial biopsy.
 Treatment-
 Oral micronized progesterone 100mg bid
 300mg vaginal pessary twice daily
 Administration of hCG 5000-10000 IU /Week
 Proluton inj. 500mg /week
 Dydrogesterone –oral

19. 2. LH-
 LH surge from anterior pitutary occur
~24hr. Prior to ovulation.
 Radioimmunoassay of morning sample of
urine and blood give the LH result in 3 hr.
 Use-
 To predict ovulation
 Approximate time of ovulation can be
gauged and coitus around this time increase
chances of conception.
( it has therapeutic application in IVF &
artificial insemination).
 LH –kits are now available.

20. 3.FSH-
 Normal level in preovulatory
phase is 1-8mlIU/ml.
 Raised level – ovarian failure (
>25IU/ml on day 3)
 Low level- pituitary dysfunction
and anovulation.

21.  Aetiology-
 During embryogenesis- Poor migration
of premature eggs from the yolk sac .
 Early and increased apoptosis of eggs.
 Radiotherapy.
 Hysterectomy ( deprives blood supply to
ovaries)
 Ovarian hyperstimulation.

23.  Diagnosis-
 Day 3 serum FSH should be 10-15 IU/L or
more .
 LH <10IU/L
 Day3 serum E2 ( estradiol) should be 60-80
pg/ml or less.
 Anti-Mullerian harmone is low (normal0.2-
0.7ng/ml).
 Inhibin B is low <40 pg/ml.
 Antral follicuular count <4-5mm.on day 2-5
(normal 2-9 mm. in both ovaries )
 Ultrasound ovaries volume low
 Progesterone on 21st/22nd day >15ng/ml.

24. A.Clomiphene citrate –
 It induce ovulation with a dose of 50mg/day
starting from 2 to day 6 of cycle for 5 days .
 If response is not satisfactory dose is increased
to 100mg/day from 2-6 day.
 Ovulation is monitored by serial USG
monitoring of the follicular size and occurrence
of ovulation.
 If required dosage can be increased at infertility
set-up, where monitoring facilities are easily
available. (USG, hormone estimation etc.)

25.  If CC therapy fails following 6-8cycles
FSH and hCG therapy recommended .
Risk- Multiple Ovulation and multiple
pregnancies (~10%)
 In hypothalamic disorder –GnRH is
given.
 Side Effect-
 Suppress the peripheral oestrogen action
on cervical mucus and endometrium.

26. B.Letrozole-
 More efficient to improve fertility rate.
 Dosage- 2.5mg daily for 5 day (2-6 day) or 20
mg single dose on 3rd day.
 Contraindicated – severe hepatic dysfunction.
 Side effect- drowsiness (no driving).
 It is banned by the Gov. Of India. For use in
infertility.(2011)
 Because it is found to be teratogenic .( can
cause – bone malformation, cardiac stenosis ,
cancers)
 In CC failure-
 Clomephine 50 mg with 20mg.tamoxifen .

28. Management –
Medical –
first line of treatment –
1.Combination of CC+ hMG-
CC 50-100mg/day from 2-6 day of cycle for 5
days.
+
Inj. hMG 75 units IM added on day 3,5,7 and
more if required.
 If fail-
2. Combination of hMG +hCG is given.

29. 1. Perform baslime oestradiol assay and USG.
2. Give hMG, 2ampule (75IU each) /day for 3
days.
3. Repeat oestradiol.If it is doubled, monitor
hMG dosage, if not, Increase hMG dosage by
50%for3 days.
4. Repeat step 3 until oestradiol doubles.
5. USG every 2-3 days until the dominat follicle
is > or =to 14mm.Thereafter, daily
monitoring till size 20mm is reached.
6. IM inj. hCG5000IU.
7. Inj. hCG3000IU 7 days later.
8. Await onset of menses or perform UPT.

31. 3.GnRH is used in alternative to hMG
 Administered in a pulsatile fashion
preferably subcutaneously.
 Advantage-
 Risk of hyperstimulation is greatly
reduced.
 Less monitoring required. When medical
line of treatment fail
 Laparoscopic ovarian drilling with
monopolar cautery / laser.

32. 3.Prednisolone-
 Used in women with Anovulation and
increased androstenedione .
 5mg. Prednisolone at night +2.5mg every
morning.
 Poor response to induction of ovulation is
indicated by –
 <5follicles on day 5
 Estradiol level <300pg/ml.
 In such cases, testosterone patches or DHEA
given. 25mg t.i.d for 6 months.

33.  It-
 improve the number of follicles
 Improves ovulation
 Increase IGF 1
 Decrease pregnancy loss
 Reduce age related aneuploidy.

34.  Peritubal adhesion
 Endometriosis
 Diagnosed by laparoscopy
 Treated by laparoscopic surgeries.
 Endometriosis
 Treated medically surgically and by
combination of two
 Luteinized unruputured follicular syndrome
 Diagnosed by USG
 Treated by micronized progesterone or hCG.

36.  ART comprises a group of procedures that
have in common the handling of oocytes and
sperms outside of the body. The gamets or
embryos are replaced into the uterine cavity to
establish pregnancy.
 Definition –
 Any fertility treatment in which the gametes
are manipulated.
 It involves surgical removal of eggs known as
egg retrieval.
 First successful IVF baby was Louis Brown in
1978.

37.  Indications-
 Abnormal fallopian tube
 Endometriosis
 Idiopathic
 Male subfertility
 Immunologic infertility
 Failure of ovulation.

38.  Investigations prior to ART-
 Thyroid function test
 Random blood sugar test
 Serum FSH on day 3 of cycle
 Serum oestradiol on day 3
 Test for ovarian reserve
 Serological evidence of chlamydial
infection
 Zona – free hamster oocyte penetrating
test
 Enhanced sperm penetration test
 Tesing antisperm antibodies

39.  Assesment of uterine cavity –
HSG/hysteroscopy/transvaginal
sonography.
 Complete seminogram
 Diagnostic laproscopy.
 Male-seman examination
 USG-Ovulation, uterine pathology,
endometrial thickness.

40.  Poor prognosis -
 Pt. is diabetic
 Serum FSH on day 3 is >25mIU/mL.
 Serum oestradiol on day 3 is >75pg/mL
 Maternal age is >40 yr.
 Women over 35 year age who is smoker
or presence of only one ovary and
unexplained fertility.
 Presence of Hydrosalpinx ,endometriosis
etc.

41.  Oocyte collection-
 Antibiotics and
progesterone given
2 days prior to
oocyte collection to
prevent infection
and better
implantation.

43. 1.IVF-
 Procedure-

44.  In developing
countries,
Low cost
IVF-
 Intra vaginal
culture (IVC)
or intra
vaginal culture
of oocyte
(INVO)
fertilized is
being
developed.

46.  IVF Complications-
 Short term-
 Failure
 Oocyte retrival can cause bleeding
trauma, infection, pain , pelvic abscess.
 Ectopic and hetertropic pregnancy (0.4%)
 Multiple pregnancies and its
complication
 Abortion
 IUGR
 Hyperstimulation syndrome
 Expensive

47.  Long term-
 Premature ovarian failure
 Ovarian cancer
 Breast cancer

48. 2.GIFT-
 Gamete intra fallopian transfer.
2 Ova +
50,000
sperms
into each
fallopian
tube.

49. 3.ZIFT-
 Zygote Intrafallopian Transfer.

50. 4.ICSI-
 Intracytoplasmic sperm Injection.

51. 5.Other techniques –
 Zonal drilling and injecting the sperm
 Subzonal injection
 Ovum donation
 Ovarian transplantation
 Surrogacy and posthumous reproduction
 Stem cell culture agar (future goal)
 Adoption
 Surrogacy required in –
 Absent uterus, diseased uterus
 Repeated pregnancy loss
 Hereditary disease
 Failed IVF.