Presentation on Infertility in Gyne

1. MODERATED BY - DR PREETI SINGH
PRESENTED BY – DR SAUMYA GUPTA
INFERTILITY
WORK UP OF AN INFERTILE COUPLE

2. DEFINITION
INFERTILITY is defined as 1 year of regular unprotected intercourse
without conception.
The term INFERTILITY is now replaced by term SUB- FERTILITY to
describe women or couples who may not be sterile but exhibit
decreased reproductive efficiency.
o If a female patient <35 years : Start investigations after 1 year.
o If age of patient >= 35 years : Begin investigations after 6 months.
o If age of patient >= 45 years : Begin investigations after 3 months.

3. •Approximately 85 – 90% of healthy young
couples conceive within 1 year, mostly
within 6 months.
•Infertility therefore affects approximately
10-15% of couples & represents an
important part of clinical practice.

4. PRIMARY / SECONDARY INFERTILITY
•Primary : Couple without a prior pregnancy
•Secondary : Couple with previous pregnancy
including miscarriage/ ectopic pregnancy.

5. •FECUNDABILITY : Probability to
achieve pregnancy in one cycle.
•FECUNDITY : Probability that a cycle
will result in live birth.

6. ETIOLOGY
Female factor : 40-55%
•Ovulatory dysfunction
•Abnormalities of female reproductive tract
•Peritoneal factors
•Reproductive aging
•Genital infections
•Endocrine causes
•Miscellaneous
Male factor : 20-40%
•Abnormal semen quality
•Abnormalities of male reproductive tract
Idiopathic : 10%

7. Female Infertility
Causes :
•Most common are ovarian causes.
•2nd
most common Tubal factor infertility.
•Uterine causes
•Cervical causes
•Unexplained causes.

8. WHO classification of ovarian causes

9. Tests for Ovulation
1. Serum Progesterone –
Mid luteal phase progesterone level >= 3 ng/ml suggests ovulation has occurred.
Non invasive
Reliable
Best test
2. Urinary LH kits –
Similar to urine pregnancy kits.
Indicate urinary LH surge.
In urine when LH surge happens, ovulation occurs after 24 hrs.
In serum when LH surge happens, then ovulation happens after 32-36 hrs.

10. 3. Follicular monitoring –
Done with help of Trans vaginal scan starting from day 10 of cycle.
Patient must come daily or alternatively to measure the size of follicle.
The size of follicle increases 2mm/day.
Once it reaches the size of 18-20 mm, the size of follicle decreases & fluid in pod.

11. 4. Cervical mucous study – Thick, scanty, viscous & ferning absent.
5. Vaginal epithelium study – Intermediate cell predominance.

12. 6. Endometrial biopsy :
•Invasive
•To r/o genital tb
•Done in pre menstrual phase (2-4 d before cycle)
•Sample divided into 2 parts :
•1. HPE : kept in formaldehyde
•2. AFB : kept in saline

13. 7. Basal body temperature – (immediately after waking up)
If ovulation has occurred, there will be a mid cycle rise increase in BBT (0.5 degree F)

14. Management of ANOVULATION
1st
line drugs –
LETROZOLE CLOMIPHENE
CITRATE
MOA AROMATASE INHIBITIOR SERM
t1/2 48 hrs Week
Dose 2.5-7.5 mg 50-150 mg
Rate of ovulation +++ +
Singleton pregnancy rate +++ +
Live birth rate +++ +
Twin pregnancy rate Same Same

15. Either Letrozole or CC should be used for 3-6 cycles.
If fails – Next line of Mx or adjuvant therapy.
Adjuvant therapy –
Prednisolone 5 mg : if androgen (DHEA) are high.
Metformin – if insulin resistance is present.

16. HMG
Do controlled ovarian stimulation
DOC – HMG Starting dose – 75 IU/day
Multiple follicles start growing. Each follicle – 200 pg of E2
STEP UP PROTOCOL
Follicular monitoring + E2 levels
When >=3 follicles >=17 mm in diameter
Ovulation tigger – Inj HCG
After 36 hours : Ovulation occurs.
Ideal E2 levels : Peak – 500 – 1500 pg/ml

17. Laparoscopic ovarian drilling
•Principle
•Rule of 4 :
Only 4 punctures are to be done in each ovary
For 4 seconds
Using 40 watts of energy
Upto 4 mm depth

18. Tests for Ovarian reserve
Indications –
•Age >=35 years
•Chronic smoker
•Case of unexplained infertility
•H/O premature menopause in family
•Previous history of surgery/ radiotherapy/ chemotherapy.

20. 1. Basal FSH & Estradiol – Done on day 3 of cycle.
2. Serum AMH (Best test) –
Small antral/ pre antral follicles produce AMH from granulosa cells.
Levels do not fluctuate in menstrual cycle.
2-10 IU Normal reserve
>=10 Poor reserve
>=40 Premature ovarian failure/ Menopause
1-3 ng Normal
<0.5 Poor reserve : POI
>3 PCOS

21. 3. Antral follicle count –
Total number of antral follicles measuring 2-9 mm in both ovaries
Done on D-3 with TVS.
If the combined score is <10 – Poor reserve.
4. Serum Inhibin B levels - <45 pg on day 3 : poor reserve
5. Clomiphene citrate challenge test :
D3 – S. FSH
D5 – D9 – 100 mg CC
D10 – S. FSH (Rising value on d10 – poor ovarian reserve)

22. Tubal factor infertility
Causes –
Prior PID
Genital Tuberculosis
Chlamydia
Gonorrhea
Salpingitis following septic abortion
Salpingitis following puerperal sepsis
Salpingitis ishthmica nodosa
Mucus debris in fallopian tube causing blockage
Benign polyp in fallopian tube

23. Tubal Patency tests
IOC- Hysterosalpingography – done in post menstrual phase (D7 – D10)
C/I – Pregnancy, Genital TB, active PID

24. Gold standard – Laparoscopic Chromopertubation
Spillage & outside of the tube can be visualised.

25. HyCoSy

26. Uterine factor infertility
Causes –
Sub mucosal fibroid
Endometrial polyp
Asherman syndrome
Chronic endometritis due to chlamydia
DES exposure
Septate uterus
Investigations –
Routine usg
Hsg
Hysteroscopy – Gold standard

27. Cervical factor infertility
Presence of anti – sperm antibodies, cervical stenosis, infections
Test – Post coital test/ Sims Huhner test –
Done on day 12-14 of cycle
After intercourse, within 2 hours, the female should reach the lab & cervical smear is prepared
If sperm shows rotatory motion instead of progressive motility, the presence of anti-sperm
antibody is suspected
Management- IUI

28. MALE INFERTILITY

29. SEMEN ANALYSIS
Semen analysis is the first & basic investigation to be
done for an infertile couple
Best method to obtain sample – Masturbation
Minimum abstinence of 2 days, Maximum of 7 days
The sample should reach the laboratory within 1 hour
Analysis is done on liquified sample
Liquefaction time : 20-30 min

30. WHOparametersofsemenanalysis
WHO 2010 WHO 2022
Semen volume (mL) 1.5 (1.4–1.7) 1.4 (1.3–1.5)
Concentration 15 16
Total motility (%) 40 (38–42) 42 (40–43)
Progressive motility (%) 32 (31–34) 30 (29–31)
Total sperm
number (106
per
ejaculate)
39 (33–46) 39 (35–40)
pH 7.2 7.2
Vitality (%) 58 (55–63) 54 (50–56)
Normal forms (%) 4 (3–4) 4 (3.9–4)
WHO 2010 (5th Edition) and WHO 2022 (6th Edition) lower fifth percentile (with 95% confidence interval) of semen parameters
from men in couples starting a pregnancy within one year of unprotected sexual intercourse leading to a natural conception.

31. Investigations:
Semen analysis
FSH(>12 mIU/ml) LH(>12 mIU/ml) Testosterone(<300 ng/dl) Prolactin TSH HbA1c
Karyotyping
TESA/ TESE/ PESA/ MESA
For testis & epididymis : Scrotal usg
For seminal vesicle, ejaculatory duct & prostate gland : Transrectal usg
Recently MRI has became a preferred modality for imaging of male sex glands & ducts.
 Urine examination
Supra-vital stain (eosin/ trypan blue) & hypotonic osmotic sperm swelling test

32. ApproachtoObstructiveAzoospermia
VOLUME IS NORMAL
(PH IS ALKALINE)
Seminal vesicle is giving its
contribution to semen
Obstruction is either in epididymis/
vas deferens
Scrotal usg
LOW VOLUME SEMEN
(PH IS ACIDIC)
Seminal vesicle has not given its secretion.
Obstruction in Ejaculatory duct
Trans rectal usg
(r/o EDO/ retrograde ejaculation)

33. Management of Male Infertility
Testicular/ Non obstructive azoospermia – TESA + ICSI
Based on sperm concentration - <15 but >10 million/ml – IUI
5-10 million/ml – IVF
<5 million/ml – ICSI
Unexplained infertility – CC + IUI (X 3 cycles) If it fails – IVF
Erectile dysfunction – Sildenafil
Premature ejaculation – SSRI
Ejaculatory dysfunction (Hypospadias) – IUI
Retrograde ejaculation - IUI

34. THANK YOU!