female infertility causes management

1. Female infertility
PRESENTED BY: DR MARYAM

2. DEFINITION
Inability of a couple to conceive after regular
unprotected coitus for one year.

3. Types of infertility
Primary
Couples who have had no previous conception
Secondary
Woman had previously conceived irrespective of
its results

4. epidemiology
 Affect 9% of couples.
 70% suffer from primary infertility and 30% from secondary infertility
 70 million couples suffer from infertility in worldwide

5. What increases the risks?
 Age>37
 Stress
 Poor diet
 Smoking
 Alchol
 STDs
 Overweight
 Underweight
 Caffeine intake
 Too much excercise

6. Causes of infertility in UK
prevalence%
causes primary Secondary
Unexplained 25 20
Ovulatory disorders 25 15
Tubal disease 20 40
Male factor 30 20
Uterine or peritoneal
disease
10 5

7. Etiology of female infertility
 vaginal causes
 Cervical factors
 Uterine causes
 Tubal causes
 Ovarian factors
 Peritoneal causes
 Chronic illness (throid dysfuction)

8. Vaginal causes
 Vaginismus
Hyperesthesia which leads to spasm of vaginal
sphincter and the levator ani muscles during coitus
attempt .
 Obstructive causes at the vaginal introtius
1. Rigid or imperforate hymen
2. Narrow introitus due to congenital hypoplasia
,lichen sclerosus (autoimmune)

9. Imperforate hymen Lichen sclerosus

10. Vaginal causes
3. Traumatic stenosis due to obstetric injury
followed by scarring
e.g tightly stitched perineal tear
4. large tender bartholin cyst

11. consequences
 All these vaginal causes make coitus difficult and cause
dyspareunia

12. Cervical factors
Cervix has active role in conception
 The position and patency of the cervical canal
facilitate entry of sperm
 Cervical mucous is alkaline and suited for the
semen

13. Uterine factors
 Malformed uterus
 Fibroid uterus
 Endometrial tuberculosis which cause asherman syndrome

14. Malformed uterus

15. Fibroid uterus

16. Asherman syndrome

17. Asherman on hsg with
right tubal blockage

18. Tubal causes
 Tubal damage due t0
PID
Iatrogenically in pelvic surgery
tuberculosis

19. Ovulation disorder
 Infrequent ovulation (Oligo ovulation)
 Absent ovulation (anovulation)
 Arise due to defect in the hypothalamus,the pitutary or the
ovary
 Oocyte aging

20. WHO classification of anovulation
 Classified into 3 categories
 Group1- hypothalamic pitutary failure 10%.
 Group2-hypothalamic-pitutary-ovarian axis dysfunction 85%.
 Group3- ovarian failure 4-5%.

21. Hypothalamic pitutary failure
 Cause hypogonadotrophic hypogondasimal state
 Number of disorders of anterior pitutary gland which cause
destruction of pitutary gland e.g
tumor( benign non functioning adenoma,
pitutary inflammatorytt reaction in tuberculosis,
Sheehan syndrome.
 Hypothalamic dysfunction due to excessive
exercise,psychological stress,anorexia nervosa.
 Low FSH, normal prolactin,low estrogen

22. Hypothalamic pitutary dysfunction
 Normogonadotrophic anovulation
 85% cases
 Normal FSH And ESTROGEN.
However FSH secretion during the follicular phase of cycle can
be subnormal
 This group includes women with PCOS

23. Ovarian failure
 Around 4-5% of women with ovulation disorder have group3 disoerder
 Hypergonadotrophic hypoestrogenic anovulation
 High gonadotrophins, low estrogen
Primary causes premature ovarian failure (absence of ovarian follicles)
And ovarian resistance

24. Oocyte aging
 The decrease in fecundability with aging is likely due to
decline in both the quantity and quality of the oocyte.

25. Endometriosis
 Presence of endometrial tissue outside the lining of the uterine cavity.
 In the severe stages of endometriosis there is anatomical distortion with
peri adnexal adhesions and distruction of ovarian tissue.

26. Unexplained infertility
 Failure of routine test to detect any obvious cause of infertility
 15-30%

27. Management of infertility
 History
 Examination
 Investigation
 Treatment

28. History
 Infertility: duration of infertility, length and type of
contraceptive use,fertility in previous relationship.
 Sexual: coital frequency and timing,knowledge of fertility
period, dyspareunia,PCB.
 Gynaecological: age of menarche, menstrual hx,
dysmenorrhea, menorrhagia,IMB.
 Obs: parity, miscarriages, ectopic pregnancies, time to initiate
previous pregnancies.

29. History
 Medical: Tuberculosis, diabetes mellitus,thyroid disease.
 Surgical: previous abdominal and pelvic surgery.
 Drugs: dopamine antagonist,past cytotoxic treatment,
radiotherapy.
 Occupational: work patterns including separation from
partner.

30. Examination
 General; height, weight,BMI,fat and hair distribution,
presence of acne, glactorrhea.
 Thyriod examination
 Abdominal; check for abdominal masses or
tenderness.
 Pelvis; assess state of hymen,normality of clitoris,
assess vagina for infection, cervical polyps,assess
accessibility of cervix for insemination, record uterine
size,position, mobility,tenderness.

31. investigations
1. ovulation disorders
Assessment of ovulation
 Basal body temperature
falls during at the time of ovulation by about 1-2 F
Should be taken orally in early morning
 Urine LH kits
 Mid luteal serum progesterone
 Routine hormonal profile (FSH,LH,PROLACTIN,THYROID PROFILE)
 Serial pelvic ultrasound
 Tests for ovarian reserve

32. Hormonal profile interpretation
Test Result Interpretation
Progesterone <30nmol/L Anovulation
FSH >10IU/L Reduced ovarian reseve
LH >10IU/L May be PCOS
Ultrasound to confirm
Prolactin >1000IU/L May be pituitary adenoma

33. Test for ovarian reserve
 total Antral follicular count
Transvaginal usg used to determine antral follicles
 AMH levels
 Day 3 FSH

34. Investigation of tubal factors
 Hysterosalpingography (HSG)
 Hystero salpingo contrast sonography (HyCoSy)
 Laproscopic chromotubation
 Falloscopy

35. Hysterosalpingogram (normal)

36. HSG

37. Hystero salpingo contrast sonography

38. Laparoscopy and dye test
(gold standard)

39. Assessment of uterus
Uterine anatomy can be visualized by
 Transvaginal usg
 Saline hysterosonography
 Hysteroscopy
 Hysterosalpingography

40. Saline hysterosonography

41. Transvaginal ultrasound

42. Hysteroscopy

43. Hysteroscopy

44. management in primary
care
Lifestyle modifications:
 Smoking cessation
 normalization of body weight in underweight and obese
patients
 stress free life
 stop alcohol consumption

45. management in secondary
care
Depends upon the etiology…

46. hyperprolectenemic
anovulation
 Give dopamine agonist

47. MANAGEMENT OF ANOVULATORY
INFERTILITY
 TREATMENT FOR GROUP 1:
 LIFESTYLE INTERVENTIONS
 PULSATILE GnRH
 Human menopausal gonadotrophin(HMG) contains both
FSH and LH in 1:1 ratio.

48. TREATMENT FOR GROUP 2
 Weight loss
Medical management
 Should be offered metformine and ovulation induction
 Ovulation induction with clomifene citrate or with aromatase
inhibitor
 Clomifene citrate should not continued more than 6 month
Surgical treatment
 Ovarian drilling

49. Mechanism of action of clomifene
citrate
 Non steroidal compound similar to estrogen blocks estrogenic
hypothalamic receptors

50. Mechanism of action aromatase
inhibitor (Lezra)
 Inhibits aromatase in ovaries and peripheral tissue reducing estrogen
levels
 Negative feed back being active stimulate hypothalamus-pituitary axis
 GnRH release produces FSH
 FSH mediated stimulation of follicle

51. Lezra mechanism of action

52. Advantages of lezra over clomifene
 Short acting
 Improve endometrial thickness
 Monofollicular and better folliculogenesis
 Higher pregnancy rate

53. TREATMENT for group3
 with Donor oocyte …

54. Treatment for tubal diseases
 Aim is to restore normal anatomy
 Laproscopic adhesiolysis
 Fimbrioplasty
 In vitro fertilization(IVF)

55. Uterine factors
 Myomectomy
 In case of endometrial polyp : polypectomy
 Hysteroscopic adhesiolysis

56. Endometriosis and peritoneal causes
Minimal-mild endometriosis :
 ablation of endometriotic lesion and adhesiolysis
Moderate to severe disease:
 Surgical removal of endometriotic tissue by
laproscopy/laparotomy
Ovarian endometrioma
 Laparoscopic cystectomy

57. Endometriosis
“Treatment with GnRH agonst for 3-6 months before
IVF in women with endometriosis may increase the rate
of clinical pregnancy “

58. Assisted conception
1.Gamete intrafallopian transfer(GIFT)
 Extraction of the oocyte is followed by the transfer of
gametes(sperm$oocyte) into a normal fallopian tube by
laparoscopy.
2. Zygote intrafallopian transfer(ZIFT)
 Refers to the placement of the embryos into the tube via
laparoscopy after oocyte retrieval and fertilization.

59. GIFT Procedure

60. ZIFT Procedure

61. Assisted conception
3.Intracytoplasmic sperm injection(ICSI)
 A single spermatozoon is injected microscopically in to each
oocyte, and the resulting embryos are transferred
transervically into the uterus.
4.In vitro fertilization(IVF)
 Ultrasonographically guided aspiration of oocyte and
laboratory fertilization with prepared sperm,and transcervical
transfer of the resulting embryos into the uterus.

62. IVF Procedure

63. Indications of IVF in females
1.Tubal conditions
 Large hydrosalpinx
 Absence of fimbria
 Severe adhesive disease
 Repeated ectopic pregnancies
 Failed reconstructive surgical therapy.
2. Endometriosis if treatment failed
3.Unexplained infertility
4.Seeking fertility preservation after chemotherapy or irradiation of
pelvic region

64. Thank you