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Infertility
Mrs Sapna Bhavin Patel
Tutor, MTIN, CHARUSAT,
Changa
Definition
• Infertility is defined as a failure to conceive
within one or more years of regular unprotected
coitus
• Primary infertility denotes those patients who
has never conceived
• Secondary infertility indicates previous
pregnancy but failure to conceive subsequently
Incident
• 80% of couple achieve conception if they so
desire, within one year of having regular
intercourse with adequate frequency (4-5 times
a week)
• Another 10 % will achieve the objective by the
end of second year
• As such, 10% remain infertile by the end of
second year
Causes of male infertility
Pre testicular Testicular Post testicular
Endocrine
•Gonadotrophin
deficiency
•Thyroid dysfunction
•hyperprolactinaemia
Immotile cilia
Cryptorchidism
Infection
Toxins: drugs, radiation
varicocele
Obstruction of efferent
duct
Congenital:
•Absence of vas deferens
•Young’s syndrome
Psychosexual
•Erectile dysfunction
•Impotence
Immunological
Stertoli-cell-only
syndrome
Acquire infection
•Tuberculosis
•Gonorrhoea
Drugs
•Antihypertensive
•Antipsychotic
Primary testicular failure Surgical:
vasectomy
Genetics
•47 XXY
•Y chromosome deletion
Others:
Ejaculatory failure
Retrograde ejaculation
Bladder neck surgery
Causes of female infertility
Ovarian factors: (30-40%)
• Anovulation or oligo ovulation
• Decreased ovarian reserve
• Luteal phase defect
• Luteinised unruptured follicle
Tubal and peritoneal factors: (25-30%)
• Obstruction of tube due to
• Pelvic infections
• Previous tubal surgery or sterilisation
• Salpingitis isthmica nodosa
• Tubal endometritis
• Polyp or mucous debris within the tubal lumen
Continue….
Peritoneal factors:
• Peritubal adhesion and minimum endometriosis
• Deep dyspareunia
Uterine factor:
• The possible factors that hinder the nidation are:
• Hypoplasia
• Inadequate secretory endometrium
• Fibroid uterus
• Endometritis
• Congenital mal formation of uterus
Vaginal factors:
• Atresia vagina
• Transverse vaginal septum
• Septate vagina
• Vaginitis or purulent discharge
Continue….
Cervical factors:
• Anatomical defects that prevent entry of the sperm
like elongation of cervix, second degree uterine
prolapse, and acute retroverted uterus
• The fault lies in the composition of the cervical
mucus , so much that the spermatozoa fails to
penetrate the mucus.
• The mucus may be scanty following amputation,
deep cauterisation of the cervix
• The abnormal constituents include excessive,
viscous or purulent discharge as in chronic cervicitis
Combined factors
• Presence of factors both in male and female
partners causing infertility
• Advance age of wife beyond 35
• Infrequent intercourse, lack of knowledge of
coitus technique and timing of coitus to utilize
the fertile period
• Apareunia and dyspareunia
• Anxiety and apprehension
• Use of lubricant during intercourse
• Immunological factors
Investigation for infertility: Male
• History collection
• Examination
• Investigation:
▫ Routine investigation
▫ Seminal fluid analysis: the semen is collected in a clean wide
mouthed dry glass jar. It should be send to laboratory as early as
possible. The coitus should be avoided for 2-3 days prior to the
test
• In selected cases, biochemical test of creatine, phosphokinase
and reactive oxygen species are done as sperm function test
• In depth evaluation: serum FHS, LH, testosterone, prolactin,
and TSH; Fructose contain in seminal fluid; Testicular biopsy;
Transrectal ultrasound; vasogram; Karyotype analysis
Investigation: Female
• History:
▫ A general medical history
▫ The surgical history
▫ Menstrual history
▫ Previous obstetric history
▫ Contraceptive practice
▫ Sexual problem
• Examination:
▫ General examination
▫ Systemic examination
▫ Gynecological examination
▫ Speculum examination
Continue….
• Diagnosis of ovulation:
1. Indirect:
Menstrual history
Sonography
Evaluation of peripheral or endorgan changes
▫ BBT
▫ Cervical mucus study
▫ Vaginal cytology
▫ Endometrial biopsy
▫ Hormone estimation
 Serum progesterone
 Serum LH
 Serum oestradiol
 Urine LH
2. Direct: Laparoscopy
3. Conclusive: Pregnancy
Treatment
• Couple instructions:
▫ Assurance
▫ Body weight
▫ Smoking and alcohol
▫ Coital problem
Treatment for male infertility
• To improve spermatogenesis the following measures
should be useful
General care:
• Improvement of general health, reduction of weight
in obese, avoidance of alcohol and heavy smoking
• Avoidance of tight and warm undergarments or
occupation that may elevate testicular temperature
• Use of vitamin E,C,D, B12 and folic acid and
antioxidant to improve spermatogenesis
• Medication that interfere spermatogenesis should be
avoided
Continue….
• In hypogonadotrophic hypogonadism, the disorder of
spermatogenesis can be treated with
▫ hCG 500 IU intramuscularly once or twice a week is given
to stimulate endogenous testosterone production
▫ hMG is added to hCG when there is no sperm in the
ejaculate with hCG alone
▫ Dopamine agonist is given in hyperprolactinamia to restore
normal prolactin and testosterone level
• Clomiphene citrate 25-50 mg orally daily for 25 days
with rest for 5 days for 3 cycles is given. It increase
serum level of FSH, LH and testosterone
• Genital tract infections need antibiotic like doxycycline
or erythromycine for 4-6 weeks depending on response
Continue…..
• In retrograde ejacuation- phenylephrine is used to
improve the tone of internal urethral spincter
• In teratospermia, asthenospermia no treatment is
available. Donor insemination is the option
• In genetic abnormalities, artificial insemination with
donor sperm is the option
Surgical:
• Vasoepididymostomy or vasovasostomy
• Hydrocele is corrected by surgery
• Orchidopexy in undecended testes should be done
between 2-3 years of age
Continue…
Impotency:
• Psychosexual treatment
• For erectile dysfunction, sildenafil 25-100 mg or
tadalafil 10-20 mg is currently advised. A single
dose orally one hour before sexual activities
should be given
Treatment for female infertility
Ovulatory
Tubal
Cervical
Associate disorders like
endometriosis, infection
Uterovaginal
canal
Unexplained
infertility
Immunological
ART
Ovulatory dysfunction
:
• It may be present in otherwise normal menstrual
cycle or may be associated with oligomenorrhoea or
amenorehoea
:
• General:
▫ Psychotherapy
▫ Reduction of weight in obesity
Anovulation LPD LUF
Continue…
• Drugs:
Stimulation of ovulation:
• Clomiphene citrate
• Letrozole
• hMG (humegon, pergonal)
• FSH
▫ Purified urinary FSH
▫ Highly purified urinary FSH
▫ Recombinant FSH
• hCG (Profasi, Pregnyl)
▫ Recombinant hCG
• GnRH
• GnRH analogue
Continue…..
Correction of biochemical abnormality:
• Hyper insulinaemia- Metformin
• Androgen excess- Dexamethasone
• Prolactin raised- Bromocriptine
Substitution therapy:
• Hypothyroidism- Thyroxin
• Diabetes mellitus- Antidiabetic drug
• BBT recording
Continue…..
• Natural progesterone at vaginal suppositories 100mg
thrice daily starting from the day of ovulation is effective
• Should continued until mens begins
• In unresponsive cases, clomiphene citrate may be tried.
It increases FSH
• IM injection of hCG 5000-10000 IU
• Administration of ovulation inducing drugs in follicular
phase followed by ovulatory hCG
• Bromocriptine therpy
Continue…..
• Surgery:
• Laproscopic overian drilling or laser vaporisation:
done by multiple puncture of the cysts in polycystic
ovarian syndrome by diathermy or laser
• Wedge resection: Bilateral wedge resection of the
ovaries is done in PCOS cases where clomiphane
citrate fails to induce ovulation
• Surgery for pituitary prolactinomas
• Surgical removal of virilising or other functioning
ovarian or adrenal tumour
Tubal or peritoneal factor
It can be treated by surgery
Name Description
Adhesiolysis (salpingo –
ovaroolusis)
Separation or division of adhesions
Fimbrioplasty Separation of the fimbrial adhesions to open up the
abdominal ostium
Salpingostomy That creates a new opening in a completely occluded tube.
It is called terminal or cuff at the abdominal ostium. The
eversion of the neo ostium is maintained by few stiches of
6-0 Vicryl
Tubotubal anastomosis When the segment of the diseased tube or following
tubectomy operation is resected and end to end
enastomosis is done
Tubocornual anastomosis When there is cornual block, the remaining healthy tube is
anastomosed to the patent interstitial part of the tube
Adjunctive procedure to improve the result of tubal surgery include prophylactic
antibiotics, use of adhesion prevention devise and post operative hydrotubation
Endometriosis, cervical factors
• Treated with drugs or surgery or both
• Cervical factors:
• The cervical mucus quality can be improved by
conjugated oestrogen 1.25 mg orally daily starting
on day 8 for 5 days
• In proved cases of Cl. Trachomatis or M. hominis,
doxycycline 100 mg twice daily for 14 days is to be
given to both the partners.
• Cervical factors when cannot be treated, is overcome
by ART procedures like IUI, IVF, GIFT.
Immunological factors
• In the presence of antisperm antibodies in the
cervical mucus, dexamethasone 0.5 mg at bed
time in the follicular phase may be given
• In antisperm antibody positive pateint COH and
IUI or IVF or ICSI is recommended
Uterovaginal surgery
• Myomectomy
• Metroplasty
• Adhesiolysis with insertion of IUCD in uterine
synchiae
• Enlargement of the vaginal introitus or removal of
vaginal septum
• Apart from cauterisation, amputation of the cervix
may have to be done for congenital elongation of the
cervix
• Gilliam’s type of operation to correct third degree
retroversion in unexplained infertility
Unexplained infertility
• It is for the couples who have undergone
complete basic infertility work up and in whom
no abnormality has been detected and still
remain infertile
• The recommended treatment are induction of
ovulation, IUI, superovulation combined with
IUI and ART
• The fault detected in both the partners should be
treated simultaneously and not one after the
other
Assisted Reproductive Technology(ART)
• ART comprise all the procedures that involve manipulation of
gamates and embryos outside the body for the treatment of
infertility
• Different methods of ART
▫ IVF-ET- In vitro fertilization and embryo transfer
▫ GIFT- Gamate intra fallopian transfer
▫ ZIFT- Zygote intra fallopian transfer
▫ POST- Peritoneal oocyte and sperm transfer
▫ SUZI- Subzonal insemination
▫ ICSI- Intracytoplasmic sperm ijection
• Methods of sperm recovery
▫ TESE- Testicular sperm extraction
▫ MESA- Microsurgical epididymal sperm aspiration
▫ PESA- Percutaneous epididymal sperm aspiration
Prognosis
• The pregnancy rate within 2 years after the start
of investigation, ranges between 30-40%
• The rate will increase up to 50-60% if AID cases
are included
• Adoption is the alternative for many couples
References
• Dutta D.C. Textbook of gynaecology. 5th edition.
Kolkata: New central book agency;2008
Infertility

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Infertility

  • 1. Infertility Mrs Sapna Bhavin Patel Tutor, MTIN, CHARUSAT, Changa
  • 2. Definition • Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus • Primary infertility denotes those patients who has never conceived • Secondary infertility indicates previous pregnancy but failure to conceive subsequently
  • 3. Incident • 80% of couple achieve conception if they so desire, within one year of having regular intercourse with adequate frequency (4-5 times a week) • Another 10 % will achieve the objective by the end of second year • As such, 10% remain infertile by the end of second year
  • 4. Causes of male infertility Pre testicular Testicular Post testicular Endocrine •Gonadotrophin deficiency •Thyroid dysfunction •hyperprolactinaemia Immotile cilia Cryptorchidism Infection Toxins: drugs, radiation varicocele Obstruction of efferent duct Congenital: •Absence of vas deferens •Young’s syndrome Psychosexual •Erectile dysfunction •Impotence Immunological Stertoli-cell-only syndrome Acquire infection •Tuberculosis •Gonorrhoea Drugs •Antihypertensive •Antipsychotic Primary testicular failure Surgical: vasectomy Genetics •47 XXY •Y chromosome deletion Others: Ejaculatory failure Retrograde ejaculation Bladder neck surgery
  • 5. Causes of female infertility Ovarian factors: (30-40%) • Anovulation or oligo ovulation • Decreased ovarian reserve • Luteal phase defect • Luteinised unruptured follicle Tubal and peritoneal factors: (25-30%) • Obstruction of tube due to • Pelvic infections • Previous tubal surgery or sterilisation • Salpingitis isthmica nodosa • Tubal endometritis • Polyp or mucous debris within the tubal lumen
  • 6. Continue…. Peritoneal factors: • Peritubal adhesion and minimum endometriosis • Deep dyspareunia Uterine factor: • The possible factors that hinder the nidation are: • Hypoplasia • Inadequate secretory endometrium • Fibroid uterus • Endometritis • Congenital mal formation of uterus Vaginal factors: • Atresia vagina • Transverse vaginal septum • Septate vagina • Vaginitis or purulent discharge
  • 7. Continue…. Cervical factors: • Anatomical defects that prevent entry of the sperm like elongation of cervix, second degree uterine prolapse, and acute retroverted uterus • The fault lies in the composition of the cervical mucus , so much that the spermatozoa fails to penetrate the mucus. • The mucus may be scanty following amputation, deep cauterisation of the cervix • The abnormal constituents include excessive, viscous or purulent discharge as in chronic cervicitis
  • 8. Combined factors • Presence of factors both in male and female partners causing infertility • Advance age of wife beyond 35 • Infrequent intercourse, lack of knowledge of coitus technique and timing of coitus to utilize the fertile period • Apareunia and dyspareunia • Anxiety and apprehension • Use of lubricant during intercourse • Immunological factors
  • 9. Investigation for infertility: Male • History collection • Examination • Investigation: ▫ Routine investigation ▫ Seminal fluid analysis: the semen is collected in a clean wide mouthed dry glass jar. It should be send to laboratory as early as possible. The coitus should be avoided for 2-3 days prior to the test • In selected cases, biochemical test of creatine, phosphokinase and reactive oxygen species are done as sperm function test • In depth evaluation: serum FHS, LH, testosterone, prolactin, and TSH; Fructose contain in seminal fluid; Testicular biopsy; Transrectal ultrasound; vasogram; Karyotype analysis
  • 10. Investigation: Female • History: ▫ A general medical history ▫ The surgical history ▫ Menstrual history ▫ Previous obstetric history ▫ Contraceptive practice ▫ Sexual problem • Examination: ▫ General examination ▫ Systemic examination ▫ Gynecological examination ▫ Speculum examination
  • 11. Continue…. • Diagnosis of ovulation: 1. Indirect: Menstrual history Sonography Evaluation of peripheral or endorgan changes ▫ BBT ▫ Cervical mucus study ▫ Vaginal cytology ▫ Endometrial biopsy ▫ Hormone estimation  Serum progesterone  Serum LH  Serum oestradiol  Urine LH 2. Direct: Laparoscopy 3. Conclusive: Pregnancy
  • 12. Treatment • Couple instructions: ▫ Assurance ▫ Body weight ▫ Smoking and alcohol ▫ Coital problem
  • 13. Treatment for male infertility • To improve spermatogenesis the following measures should be useful General care: • Improvement of general health, reduction of weight in obese, avoidance of alcohol and heavy smoking • Avoidance of tight and warm undergarments or occupation that may elevate testicular temperature • Use of vitamin E,C,D, B12 and folic acid and antioxidant to improve spermatogenesis • Medication that interfere spermatogenesis should be avoided
  • 14. Continue…. • In hypogonadotrophic hypogonadism, the disorder of spermatogenesis can be treated with ▫ hCG 500 IU intramuscularly once or twice a week is given to stimulate endogenous testosterone production ▫ hMG is added to hCG when there is no sperm in the ejaculate with hCG alone ▫ Dopamine agonist is given in hyperprolactinamia to restore normal prolactin and testosterone level • Clomiphene citrate 25-50 mg orally daily for 25 days with rest for 5 days for 3 cycles is given. It increase serum level of FSH, LH and testosterone • Genital tract infections need antibiotic like doxycycline or erythromycine for 4-6 weeks depending on response
  • 15. Continue….. • In retrograde ejacuation- phenylephrine is used to improve the tone of internal urethral spincter • In teratospermia, asthenospermia no treatment is available. Donor insemination is the option • In genetic abnormalities, artificial insemination with donor sperm is the option Surgical: • Vasoepididymostomy or vasovasostomy • Hydrocele is corrected by surgery • Orchidopexy in undecended testes should be done between 2-3 years of age
  • 16. Continue… Impotency: • Psychosexual treatment • For erectile dysfunction, sildenafil 25-100 mg or tadalafil 10-20 mg is currently advised. A single dose orally one hour before sexual activities should be given
  • 17. Treatment for female infertility Ovulatory Tubal Cervical Associate disorders like endometriosis, infection Uterovaginal canal Unexplained infertility Immunological ART
  • 18. Ovulatory dysfunction : • It may be present in otherwise normal menstrual cycle or may be associated with oligomenorrhoea or amenorehoea : • General: ▫ Psychotherapy ▫ Reduction of weight in obesity Anovulation LPD LUF
  • 19. Continue… • Drugs: Stimulation of ovulation: • Clomiphene citrate • Letrozole • hMG (humegon, pergonal) • FSH ▫ Purified urinary FSH ▫ Highly purified urinary FSH ▫ Recombinant FSH • hCG (Profasi, Pregnyl) ▫ Recombinant hCG • GnRH • GnRH analogue
  • 20. Continue….. Correction of biochemical abnormality: • Hyper insulinaemia- Metformin • Androgen excess- Dexamethasone • Prolactin raised- Bromocriptine Substitution therapy: • Hypothyroidism- Thyroxin • Diabetes mellitus- Antidiabetic drug • BBT recording
  • 21. Continue….. • Natural progesterone at vaginal suppositories 100mg thrice daily starting from the day of ovulation is effective • Should continued until mens begins • In unresponsive cases, clomiphene citrate may be tried. It increases FSH • IM injection of hCG 5000-10000 IU • Administration of ovulation inducing drugs in follicular phase followed by ovulatory hCG • Bromocriptine therpy
  • 22. Continue….. • Surgery: • Laproscopic overian drilling or laser vaporisation: done by multiple puncture of the cysts in polycystic ovarian syndrome by diathermy or laser • Wedge resection: Bilateral wedge resection of the ovaries is done in PCOS cases where clomiphane citrate fails to induce ovulation • Surgery for pituitary prolactinomas • Surgical removal of virilising or other functioning ovarian or adrenal tumour
  • 23. Tubal or peritoneal factor It can be treated by surgery Name Description Adhesiolysis (salpingo – ovaroolusis) Separation or division of adhesions Fimbrioplasty Separation of the fimbrial adhesions to open up the abdominal ostium Salpingostomy That creates a new opening in a completely occluded tube. It is called terminal or cuff at the abdominal ostium. The eversion of the neo ostium is maintained by few stiches of 6-0 Vicryl Tubotubal anastomosis When the segment of the diseased tube or following tubectomy operation is resected and end to end enastomosis is done Tubocornual anastomosis When there is cornual block, the remaining healthy tube is anastomosed to the patent interstitial part of the tube Adjunctive procedure to improve the result of tubal surgery include prophylactic antibiotics, use of adhesion prevention devise and post operative hydrotubation
  • 24. Endometriosis, cervical factors • Treated with drugs or surgery or both • Cervical factors: • The cervical mucus quality can be improved by conjugated oestrogen 1.25 mg orally daily starting on day 8 for 5 days • In proved cases of Cl. Trachomatis or M. hominis, doxycycline 100 mg twice daily for 14 days is to be given to both the partners. • Cervical factors when cannot be treated, is overcome by ART procedures like IUI, IVF, GIFT.
  • 25. Immunological factors • In the presence of antisperm antibodies in the cervical mucus, dexamethasone 0.5 mg at bed time in the follicular phase may be given • In antisperm antibody positive pateint COH and IUI or IVF or ICSI is recommended
  • 26. Uterovaginal surgery • Myomectomy • Metroplasty • Adhesiolysis with insertion of IUCD in uterine synchiae • Enlargement of the vaginal introitus or removal of vaginal septum • Apart from cauterisation, amputation of the cervix may have to be done for congenital elongation of the cervix • Gilliam’s type of operation to correct third degree retroversion in unexplained infertility
  • 27. Unexplained infertility • It is for the couples who have undergone complete basic infertility work up and in whom no abnormality has been detected and still remain infertile • The recommended treatment are induction of ovulation, IUI, superovulation combined with IUI and ART • The fault detected in both the partners should be treated simultaneously and not one after the other
  • 28. Assisted Reproductive Technology(ART) • ART comprise all the procedures that involve manipulation of gamates and embryos outside the body for the treatment of infertility • Different methods of ART ▫ IVF-ET- In vitro fertilization and embryo transfer ▫ GIFT- Gamate intra fallopian transfer ▫ ZIFT- Zygote intra fallopian transfer ▫ POST- Peritoneal oocyte and sperm transfer ▫ SUZI- Subzonal insemination ▫ ICSI- Intracytoplasmic sperm ijection • Methods of sperm recovery ▫ TESE- Testicular sperm extraction ▫ MESA- Microsurgical epididymal sperm aspiration ▫ PESA- Percutaneous epididymal sperm aspiration
  • 29. Prognosis • The pregnancy rate within 2 years after the start of investigation, ranges between 30-40% • The rate will increase up to 50-60% if AID cases are included • Adoption is the alternative for many couples
  • 30. References • Dutta D.C. Textbook of gynaecology. 5th edition. Kolkata: New central book agency;2008