L.A., a 29-year-old female, presented with a 7-year history of infertility despite frequent unprotected intercourse following her last successful delivery 7 years ago. Physical examination and tests revealed partial uterine synechiae (Asherman's syndrome). She underwent dilatation and curettage with insertion of an IUCD. Her partner's semen analysis was pending due to a delayed COVID-19 test result. Infertility workup and treatments were discussed.

1. INFERTILITY
Presenters: Rolex Maklago, Leruki Naftaly
Lecturer: Dr. Omoto
Date: 13th April 2021

2. History (taken on 1st April 2021)
Biodata
• Name: L.A
• Age: 29yrs
• Sex: F
• Residence: Seme
• Occupation: Business lady
• DOA : 16th March 2021
• Referral from a local clinic
• Para 2+2 (1 living child; last delivery in 2014)
• LNMP: 5th March 2021

3. Chief Complaint
• Inability to conceive - 7 years
History of Presenting Illness
• Patient was well until 2014, after delivery of her
last born, when she developed the above complaint
despite frequent unprotected coitus.
• She reports using combined oral contraceptives for
a week following this delivery, and has had not
been on any other contraception thereafter. She
stopped the COCPs due to headache, fatigue,
dizziness, nausea and vomiting as side effects
• She experiences regular menstrual cycles lasting 30
days. Menstrual bleeding lasts 4 days; she uses 2
pads per day. She also reports occasional clots

4. • Menstrual flow is often preceded by abdominal
pains which are dull in nature and non-radiating.
For these pains she uses no analgesic
• She had tried using herbal medications due to the
presenting problem prior to this presentation,
which was unsuccessful
• She has no history of dyspareunia or post-coital
bleeding
• No history of cervical cancer screening, no history
of dysuria.
• No history of smoking or alcohol intake
• No history of treatment for STDs, PID

5. • She had retained placenta for about 4 days in 2011
after losing her second pregnancy. She presented
with headache, fever and vaginal discharge. The
retained placenta was removed manually in theater
• Husband reports having no child outside their
marriage. He has no history of smoking or alcohol
intake. He reports no erectile problems and has no
history of use of anticonvulsant and
antihypertensive medications

6. Past Gynecological History
• Menarche at age of 14 years
• Regular menstrual cycles
• Experiences premenstrual abdominal pains
• No history of STI, UTI
• No history of cervical cancer screening or breast
cancer screening
• Has not been on any family planning treatment
since 2014
• Manual placental removal in 2011

7. Past Obstetric History
• 1st pregnancy in 2010 via emergency CS due to __ , and
the outcome was live male infant with birth weight of
5.0 kg (11.0 lbs.). Child died shortly due to respiratory
problems
• 2nd pregnancy in 2011. Child died about 6 months
intrauterine. No established cause for the miscarriage.
Had retained placenta that was removed manually after
4 days
• 3rd pregnancy in 2013. Lost pregnancy after about 5
months. She presented with vaginal bleeding
• 4th pregnancy in 2014 via emergency CS. The outcome
of pregnancy was a live female infant born at term
weighing 4.8 kg (10.6 lbs.). No complications reported

8. Past Medical and Surgical History
• This is her 5th admission
• She underwent blood transfusion once in 2013
when she presented with per vaginal bleeding – 1
pint given
• Has had two surgical operations in the past –
Caesarean Sections
• Not diabetic, Not hypertensive, No known thyroid
disease, No convulsive disorder, No retroviral
disease
• Not on any long-term medications
• No known allergy to food or drugs

9. • Family and Social History
• Has been married for 9 years. Lives with her
husband, one child and her niece.
• She is a business lady; husband is a bodaboda rider
• No history of alcohol intake, tobacco smoking or
use of recreational drugs
• Under a health coverage program – NHIF
• No history of congenital anomalies, multiple
gestation or chronic illnesses in the family

10. • Review of Systems
• Resp – no cough, no difficulty in breathing, no
shortness of breath
• CVS – no chest pain, no palpitations
• CNS – no headaches, no blurry vision, no loss of
consciousness
• GIT – no vomiting, no diarrhea, no constipation, no
abdominal discomfort
• Urinary – No change in frequency, color, volume
• Skin – No rash, no pruritus

11. Summary
• L.A., 29 y/oFemale, para 2+2 who presented with 7
years history of inability to conceive despite
frequent unprotected intercourse following a
successful delivery 7 years ago.

12. Physical Examination
General Examination
• Patient was in a good general condition; lying supine in
bed and not in any observable distress, urinary catheter
in-situ
• Not jaundiced; mild conjunctival, lingual and palmar
pallor; not cyanosed; no edema; not dehydrated; has
no lymphadenopathy
• Warm extremities; radial pulse is present, normal rate
(84), regular, of adequate volume and symmetrical.
Vital Signs: BP 113/83 mmHg, PR 84 bpm, Resp rate 19,
Temp 36.6°C

13. P/A
• Inspection – abdomen is relatively flat, symmetrical
and moves with respiration; the umbilicus is
inverted; striae gravidarum visible. An infra-
umbilical midline abdominal scar visualized.
• Light Palpation – abdomen is warm to touch, non-
tender. No obvious mass noted
• Deep palpation – No organomegaly, no abdominal
masses; Uterus non-palpable
Resp
• Bilateral symmetric chest wall expansion, trachea is
centrally located, no tenderness, normal vesicular
breath sounds

14. CVS
• Normo-dynamic precordium, S1 and S2 present, no
clicks or rubs, no heart murmurs
CNS
• Oriented, GCS 15/15, Cranial nerves are intact,
normal sensory and motor activities, normal
coordination
IMPRESSION
Secondary infertility in a para 2+2

15. Plan
• Admit to Ward 4 on 16th March
• HSG (done)
• FHG, UECs, COVID-19
• Obtain Consent
• Prepare for Dilatation and Curettage & IUCD
Insertion – scheduled for 18th March
• Semen analysis for partner (if possible)

16. Results of tests
• Full Hemogram
• Hb 14.6 g/dl
• WBC 6.91 x 103/µL
• Platelets 301.1 x 103/µL
• COVID-19 Test – Delayed
• UECs
• Creatinine 61 µmol/L (N), Cl- – N, K+ - N, BUN – N
• HSG
• Partial Uterine Synechiae (Ashermann’s Syndrome)
• Semen Analysis of partner (if possible)
(Procedure suspended on 18th March until test results availed).
Patient developed diff breathing and chest pain, and was
instructed to isolate at home and return after 10 days. To have a
have a repeat COVID test done on return if results are negative

17. Intraoperatively – D&C and IUCD
Performed in 1st April
• Ceftriaxone IV 2g stat; NS 3L; IV Dexamethasone 4mg
and IV Oxytocin 20 IU
• Procedure performed under spinal anesthesia (heavy
bupivacaine)
• Cervix exposed by Auvard speculum and uterine sound
placed
• Serial dilation performed
• Sharp curettage until frothy bright blood seen followed
by blunt curettage
• Levonogestrel IUCD inserted and left in situ

18. Postoperatively
Monitor patient quarter hourly
Removal of catheter on resumption of ambulation
NPO for 6hrs, and resume feeding once anesthesia
wears off
Encourage ambulation
Drugs
• Paracetamol IV 1g TDS 2/7
• Diclofenac IM 75mg BD 2/7
• Amoxicillin PO 500mg TDS 5/7
• Flagyl PO 400mg TDS 5/7

19. Infertility
Discussion

20. Definition of Terms
• Infertility/ Subfertility - Inability of a couple to conceive
within 1 year. It implies a decrease in the ability to
conceive
• Sterility – an intrinsic inability to achieve pregnancy.
• Primary infertility – no previous conception
• Secondary infertility –conception has occurred before
• Fecundity – ability of achieving a live birth in 1
menstrual cycle
• Fecundability – ability to achieve conception in 1
menstrual cycle

21. World Health Organization Definition
• Infertility is “a disease of the reproductive system
characterized by the failure to achieve a clinical
pregnancy after 12 months or more of regular
unprotected sexual intercourse (and there is no other
reason, such as breastfeeding or postpartum
amenorrhoea).
• Primary infertility is infertility in a couple who have
never had a child.
• Secondary infertility is failure to conceive following a
previous pregnancy.
• Infertility may be caused by a male or female factor, but
often there is no obvious underlying cause.

22. Epidemiology
• Global prevalence of infertility – 7 to 28%
• In Kenya, prevalence of infertility – 11.9% (highest
in Western and Coastal regions).
• Normal fertile couples having frequent intercourse
have a fecundability of 20 to 25%
• 90% of couples with unprotected intercourse will
conceive within 1 year.
• Sterility affects 1-2% of couples

23. Etiology
• 40% male factors
• 40% female factors
• 20% both male and female factors
• In 20% of infertile couples, the cause can not be
established( unexplained infertility)

24. Consequences of Infertility
• Anxiety to conceive, increasing sexual dysfunction.
• Marital discord.
• Clinical depression.
• Denial of motherhood as a rite of passage
• Loss of one’s anticipated and imagined life
• Feeling a loss of control over one’s life
• Doubting one’s womanhood
• Changed and sometimes lost friendships
• Emotional stress and marital difficulties are greater in
couples where the infertility lies with the man.

26. CAUSES OF INFERTILITY
Male factor
Endocrine factors
• Hypothalamic-pituitary
factors
• Hyperprolactinemia
• Hypopituitarism
• Thyroid disorders
• Adrenal hyperplasia
Anatomic disorders
• Absence of the vas
deferens
• Obstruction of the vas
deferens
• Abnormalities of the
ejaculatory system
Abnormal Spermatogenesis
• Chromosomal
abnormalities
• Mumps orchitis
• Cryptorchidism
• Chemical or radiation
exposure

27. Male factor cont…
Abnormal Motility
• Absent cilia – Kartagener’s syndrome
• Varicocele
• Antibody formation
Sexual dysfunction
• Retrograde ejaculation
• Erectile dysfunction
• Decreased libido

28. Female Factors

29. Ovulatory defects
• Advanced maternal age
• Hyperprolactinemia (drug,
tumor)
• Hypothalamic insufficiency
• Pituitary insufficiency
(trauma, tumor)
• Primary ovarian insufficiency
• Polycystic ovarian syndrome
Ovarian defects
• Gonadal dysgenesis
• Premature ovarian failure
• Ovarian tumour
• Ovarian resistance
Metabolic disease
• Thyroid disease
• Liver disease
• Renal disease
• Obesity
• Androgen excess – adrenal
or neoplastic
Female Factors

30. Female factors cont…
Pelvic/ Uterine factors
• Infections
• Uterine polyps
• Pelvic inflammatory
disease
• Uterine adhesions
(Asherman’s syndrome)
• Endometriosis
• Congenital malformations
• Uterine fibroids
Cervical factors
• Congenital Mullerian duct
abnormality eg Mullerian
dysgenesis
• Surgical treatment
• Infection
• Antibodies
Tubal factors
PID/ Salpingitis
Tubal ligation
Endometriosis
Pelvic adhesions

31. Diagnosis
History of both partners
History for male factors
• Congenital abnormalities
• Undescended testes
• Frequency of intercourse
• Exposure to toxins
• Previous infections,
treatment
• General health
• Previous surgery
History of female factors
• Pubertal development
• Characteristics of menstrual
cycle
• Contraceptive history
• Prior pregnancies, outcomes
• Previous surgeries
• Previous infections
• History of abnormal cervical
cancer screening, treatment
• General health

32. Evaluation of male factors
• History and physical
examination
• Post coital test – to assess
cervical hostility to sperm
(Sims-Huhner test)
• Semen analysis
Normal semen parameters
• Liquefaction – 30min
• Count – 20 million/ml or
more
• Motility – more than 50%
moving normally within 1
hr after collection
• Volume – 2ml or more
• Morphology - more than
50% normal
• pH - 7.2 to 7.8
• White blood cell count –
less than 1 million/ml

33. Patient preparation before collection
• Avoid ejaculation for 24 to 72 hours
• Abstain from OH, Caffeine for two to five days
• Avoid herbal medications e.g. Mashua
• Avoid hormone medications
• Abstain from intercourse and use of spermicides
• Discuss with patient potential effects of daily
medications
• Explain the collection process - masturbation

34. Typically, day 21 to 23 serum progesterone concentrations of
more than 10 ng/mL indicate normal ovulation and concentrations
below 10 ng/mL suggest anovulation, inadequate luteal phase
progesterone production, or inappropriate timing of sample collection
Day 3 FSH levels, estradiol
Antral Follicle count

35. Female factors
History and physical
examination.
Ovulatory factors
• Ultrasound
• Basal body temperature
• Endometrial biopsy –
secretory endometrium
indicates ovulation
• Cervical mucus
ferning/aborization
Pelvic/Uterine factors
• Pelvic examination
• Ultrasound
• Hysterosalpingogram
• Laparoscopy with dye
instillation
Cervical factors
• Abnormal cervical screening
• Previous surgery
• Post coital test

36. Treatment – Assisted reproduction
technologies
Male factor
• Intrauterine insemination
(IUI)
• Intracytoplasmic sperm
injection (ICSI)
• Surgical anastomosis for
obstructive defects
• Donor sperm
Female factor
• Ovulation induction –
clomiphene citrate,
gonadotropins
• In vitro fertilization (IVF)
• Surgery for pelvic factor –
adhesiolysis, salpingostomy,
anastomosis