3. Female Infertility
Infertility
◦ 1 year of unprotected intercourse without conception.
Subfertility
◦ not sterile but exhibit decreased reproductive efficiency
3
4. Female Infertility
Primary infertility- no previous pregnancies
Secondary infertility-a prior pregnancy,
although not necessarily a live birth
4
5. Female Infertility
Fecundability __probability that a cycle will result in
pregnancy (estimated at 20% to 25%)
Fecundity is the probability that a cycle will result in a
live birth.
On the basis of this estimate, about 90% of couples
should conceive after 12 months of unprotected
intercourse
5
8. Female Infertility
Age
Stress
Poor diet
Smoking
Alcohol
STDs
Overweight
Underweight
Caffeine intake
Too much exercise
8
9. Female Infertility
Majority of spontaneous conception ____ within 6
months
Conception rate depends upon the age
9
Age Conception rate
≤ 25 years 73%
26-30years 74%
31-35years 62%
> 35years 27% & lower
Age Conception rate
<25 yrs 73%
26 to 30 74%
31 to 35 62%
>35 27%
10. Female Infertility
Likelihood of success declines by
◦5% for each additional year of the female
◦15-25% for each added year of infertility
10
Fertility rate Age
Peaks 20-24yrs
↓ 4-8% 25-29yrs
15-19% 30-34yrs
26-46% 35-39yrs
95% 40-45yrs
Fertility rate % Age
20-24
4-8 25-29
15-19 30-34
26-46 35-39
95 40-45
11. Female Infertility
During fetal life, germ cell proliferation
6-7 million oogonia by 16-20wks
Oocyte
1-2 million at birth
about 3,00,000 by onset of puberty
400-500 oocytes ovulate(35-40 yrs) 11
enters 1st meiotic division
mitosis
12. Female Infertility
At the time of menopause, 1000 follicles remains
Rate of follicular depletion relatively constant, during
reproductive years
Accelerates over 10-15 years
12
13. Female Infertility
Progressive follicular depletion
High abnormalities in aging oocyte
High prevalence of spontaneous miscarriage
High prevalence of benign uterine pathology
13
14. Female Infertility
naturally starts to
decline after late 20's.
After 35 decreases
rapidly.
with time, the supply
diminishes, the EGG.
The remaining eggs
also age along with the
rest of the body.
14
15. Female Infertility
Aimed at identifying individuals at risk for a
disease, (DOR).
Should have high specificity,
Aim to decrease false-positive results,
Avoiding aggressive treatment or inappropriate
recommendations in women with a normal
ovarian reserve.
15
16. Female Infertility
Treating women with unrecognized DOR is
undesirable
To minimize the risk for a falsepositive result.
Justified in,
1. Age over 35.
2. Unexplained infertility.
3. Family history of early menopause.
4. Previous ovarian surgery (ovarian cystectomy or drilling,
unilateral oophorectomy), chemotherapy, or radiation.
5. Smoking.
6. Demonstrated poor response to exogenous gonadotropin
stimulation.
16
18. Female Infertility
Rising FSH levels are one of the earliest
signs of reproductive aging
The basal FSH concentration : Simplest
and still most widely applied measure
Vary significantly across the cycle,
Best obtained during the early follicular
phase (cycle day 2-4).
18
19. Female Infertility
Assays (using IRP 78/549), FSH levels greater
than 10 IU/L (10-20 IU/L) have high specificity
(80-100%;)
Predicts poor response to stimulation
Sensitivity generally low (10-30 %;) and
decreases with the threshold value
Although most women who are tested (including those with DOR)
will have a normal result, the test is still useful because those with
abnormal results are very likely to have DOR.
19
20. Female Infertility
By itself has little value as an ovarian
reserve test,
Provide additional information for
interpretation of the basal FSH level
Basal FSH is normal
20
23. Female Infertility
Provocative and more sensitive test
Probes the endocrine dynamics of the cycle under both
basal and stimulated conditions,
Before (cycle day 3 FSH and estradiol) and after (cycle day
10 FSH) treatment with clomiphene citrate (100 mg/d,
cycle days 5-9)
A frankly elevated cycle day 10 FSH concentration can
identify women with DOR who might otherwise go
unrecognized if evaluated with basal cycle day 3 FSH and
estradiol levels alone.
23
24. Day 3 FSH and
estradiol
Clomiphene citrate
(100 mg/d, cycle
days 5-9)
Day 10 FSH
CCCT
Overall, stimulated FSH levels have higher
sensitivity but lower specificity than the basal FSH
25. Female Infertility
In studies evaluating CCCT results, stimulated
concentrations of FSH, estradiol, and inhibin B
have varied widely, limiting the value of the test.
2006 systematic review of the predictive value of
the CCCT over a range of day 10 FSH
concentrations (10-22 IU/L) test had
◦ 47-98%; specificity and 35-93%; sensitivity for
predicting poor response to stimulation, and
◦ 67-100%; specificity and 13-66%; sensitivity for
predicting treatment failure.
25
26. Female Infertility
Secreted
◦ primarily during the follicular phase
◦ by the granulosa cells of smaller antral follicles, and
◦ might therefore be expected to have some value as an
ovarian reserve test.
However, serum inhibin B concentrations
increase in response to exogenous GnRH or
FSH stimulation and vary widely across and
between menstrual cycles.
Inhibin B is generally not regarded as a
reliable measure of ovarian reserve.
26
27. Female Infertility
low threshold values (40-45
pg/mL) have only
◦ 64-90%; specificity and
◦ 40-80%; sensitivity for predicting poor
response
27
28. Female Infertility
Produced by
◦ granulosa cells of preantal and small antral follicles,
◦ beginning when primordial follicles start development and ending
when they reach a diameter of 2-6 mm.
Small antral follicles: larger numbers of granulosa
cells and a more developed microvasculature:
likely source
Levels are gonadotropin-independent and
exhibit little variation within and between cycles
28
29. Female Infertility
In the general IVF population, low AMH threshold
values (0.2-0.7 ng/mL)
◦ 40-97%; sensitivity,
◦ 78-92%; specificity,
◦ 22-88%; PPV and
◦ 97-100%; NPV for predicting poor response to stimulation (<3
follicles, or <2-4 oocytes),
◦ but have proven neither sensitive nor specific for predicting
pregnancy
Very promising screening test for DOR,
More useful in a general IVF population or in
women at high risk for DOR than in women at low
risk for DOR
29
30. Female Infertility
20-150 growing follicles in the ovaries at any
time, although only a few are large enough
to be imaged (≥2 mm) by TVS
Follicles of that size have reached a stage of
development where they are responsive to
FSH, which stimulates and supports more
advanced stages of development.
30
31. Female Infertility
The antral follicle count (AFC; total number of antral
follicles measuring 2-10 mm in both ovaries) thus provides
an indirect but useful measure of ovarian reserve
31
Histology- proportional
Number of
small antral
follicles
2-10 mm
The number
of primordial
follicles
remaining.
32. Female Infertility
In the general IVF population, including
women at low and high risk for DOR, an
AFC threshold value of three to four follicles
has
◦ High specificity (73-100%;)
◦ For predicting poor response to ovarian stimulation and
failure to conceive (64-100%;)
A low AFC has high specificity for predicting
poor response to ovarian stimulation and
treatment failure, making it a useful test,
but low sensitivity limits its overall clinical
utility.
32
33. Female Infertility
Decreases with follicular depletion.
High inter-cycle and inter-observer
variability,
ovarian pathology such as endometriomas
and polycystic ovary syndrome, results have
limited generalizability.
Ovarian volume (length × width × depth ×
0.52) generally correlates with the number
of oocytes retrieved, but poorly with
pregnancy.
33
34. Female Infertility
A low ovarian volume (< 3mL)
◦ High specificity (80-90%;) and
◦ Widely ranging sensitivity (11-80%;)
◦ For predicting poor response to ovarian stimulation.
◦ The PPV for poor response can be as low as
17%; among women at low risk for DOR, and
as high as 53%; in women at high risk.
Overall, ovarian volume has very limited
clinical utility as an ovarian reserve test.
34
35. Female Infertility
35
Male factor 25-40%
Female factor 40-55%
Both male & female 10%
Unexplained infertility 10%
Sales, Male
problems, 35,
35%
Sales, Tubal
and pelvic
pathology, 35,
35%
Sales,
Ovulatory
disfunction, 15,
15%
Unexplained,10
Sales, Unusual
problems, 5,
5%
37. Female Infertility
The human reproductive process is complex, but
for purposes of evaluation, it can be dissected
into its most important and basic components.
Sperm must be deposited at or near the cervix at or near
the time of ovulation, ascend into the fallopian tubes, and
have the capacity to fertilize the oocyte (male factor).
Ovulation of a mature oocyte must occur, ideally on a
regular and predictable basis (ovarian factor).
37
38. Female Infertility
The cervix must capture, filter, nurture, and release sperm
into the uterus and fallopian tubes (cervical factor).
The uterus must be receptive to embryo implantation and
capable of supporting subsequent normal growth and
development (uterine factor).
The fallopian tubes must capture ovulated ova and
effectively transport sperm and embryos (tubal factor).
38
39. Female Infertility
ANOVULATION AND OLIGOOVULATION
Hypothalamic anovulation
◦ Psychological factors
◦ Low BMI and obesity
-disrupts hypothalamic pituitary ovarian axis
- Anorexia nervosa, vigorous athletic training and
malnutrition
- Female athlete triad: Secondary amenorrhea
eating disorder, osteopenia/osteoporosis
39
40. Female Infertility
weight gain ideal treatment
- ↑ caloric intake and weight gain resumption of
menses in 90%, sponaneous conception in 73%
- mean weight gain by 3.6kg sufficient for resumption of
ovulation
Congenital hypothalamic failure( Kallmann
syndrome)
Psychotropic drugs
Tranquilizers
40
41. Female Infertility
Pituitary
◦ Sheehan’s syndrome
- Postpartum pituitary necrosis due to
postpartum haemorrhage f/b
panhypopituitarisim→ ↓FSH/LH
41
42. Female Infertility
◦ Tumor: Prolactinomas
- ↑ Prolactin level inhibitory effect on pulsatile
GnRH release→ hypogonadotropic effect
-↓granulosa cell number and FSH binding
-↓granulosa cell estradiol production
-causes inadequate luteinization and reduced
secretion of progesterone
42
43. Female Infertility
◦ Hypothalamic-pituitary axis dysfunction
Anovulation due to hypogonadotropic-hypogonadism
- Presence of ↓ serum LH, FSH and estradiol
- Causes :
Craniopharyngioma
Pituitary adenomas
Arteriovenous malformation
Central space occupying lesion
- Systemic diseases: chronic liver disease,
chronic renal failure
43
44. Female Infertility
Thyroid
◦ Prevalence of abnormal TSH in infertility
population
6.3% Anovulatory infertility
4.8% Unexplained infertility
2.6% Tubal infertility
1.55% Male infertility
◦ In one study 23% women with
hypothyroidism had irregular menses, likely
anovulation
◦ Both hypothyroidism and hyperthyroidism
44
45. Female Infertility
Adrenal: Congenital adrenal hyperplasia
Ovarian causes
◦ Polycystic ovarian syndrome
- Most common cause of anovulation and
oligovulation in infertility
- ↑LH pulse frequency, ↓FSH
- No folliculogenesis Formation of atretic follicles
- No ovulation cyst formation
45
46. Female Infertility
◦ Premature ovarian failure
- Presence of persistently elevated gonadotropins
- Associated with estrogen therapy Activate receptor
formation on the follicles
- ↑gonadotropins stimulates follicular growth and
development
- Reported with autoimmune disorder
- Demonstration of ovarian autoantibodies
46
47. Female Infertility
◦ Luteinized unruptured follicle syndrome
- Ovum trapped inside the follicle gets luteinized
- No ovulation beyond 36hours of LH surge
- Pelvic endometriosis, hyperprolactinomas
47
48. Female Infertility
LUTEAL PHASE DEFECT
- During follicular endometrium exhibit proliferative
- During luteal secretory transformation
- Inadequate corpus luteum progesterone regarded as cause
of infertility and early pregnancy loss
- ↓progesterone level with luteal phase deficiency
Delayed endometrial maturation
48
49. Female Infertility
Shift in the implantation window
Long delays may threaten embryo viability
Prevent implantation
Causes
◦ Disturbances in pituitary gonadotropin secretion pattern
- ↓GnRH pulse ↓FSH level Ass. With poor luteal function
- Rapid GnRH pulse frequency and ↓LH frequency during mid
cycle surge and reduced LH bioactivity
49
52. Female Infertility
30-40% of cases of infertility
Tubal blockage, peritubal adhesion, fimbrial end blockage
Causes :-
◦ Infection - Post abortal, puerperal nfection
- STI ( gonococcal , clamydial)
- PID
- Tubercular salphingitis
◦ Endometriosis
◦ Peritubal adhesions : Previous surgeries
52
53. Female Infertility
INFECTION
- Polymicrobial in nature, involving both the tubes
- Organisms:
- STI: Gonococcus, Chlamydia, Mycoplasma
- Pyogenic: Streptococcus, E.coli,Staphylococcus, Gp B
streptococcus, Bacteroide fragilis, actinomycoses
- Tubercular: M. tuberculosis
53
54. Female Infertility
Mode of spread:
Ascending infection
- Gonococcal infection may affect the tubes during initial
exposure or from Bartholin’s gland and cervix
- Pyogenic infection follow: Delivery, induced abortion,
minor procedure like D & C, hysterosalphingography,
IUCD, infected polyp
- Recently, chlamydia is regarded as common cause,
ascends up from the cervix
Direct spread : appendicitis, diverticulitis, pelvic peritonitis
54
55. Female Infertility
Pathogenesis
◦ Pyogenic: Infection from uterine cavity & cervix
Pelvic cellulitis Perisalphingitis
Lumen directly infected Endosalphingitis
Produces cornual blockage
◦ Gonococcal: directly ascends to tube through
continuity and contiguity
Endosalphingitis
55
56. Female Infertility
Pathology
◦ Pyogenic: Outer coat is involved, adhesion are
more and dense
◦ Gonococcal : - Mainly endosalphingitis, adhesions
are less and filmsy
- Fimbriae gets phymotic, edematous and
indrawn by cicatricle contraction closure of
abdominal ostium defective ovum pick up
- Loss of cilia infertility
56
57. Female Infertility
Site of obstruction
◦ Proximal :
- Prevents sperm to reach distal portion …..hinders
fertilization
- Causes: tubal spasm, temporary mucous
plugging,salpingitis isthmica nodosa(23-60%)
- Risk of perforation with cannulation ranges from
3%- 11%
◦ Distal:
- Prevents ovum capture
- Exhibits a spectrum: mild( tubal obstruction),
moderate( fimbrial phimosis) to severe (
complete obstruction)
- Causes: Pelvic infection, Endometriosis, prior
abdominal and pelvic surgery
57
58. Female Infertility
Genital tuberculosis ( Tubercular salphingitis)
- Accounts for 5-10% cases of infertility
- Infertility , the most common symptom(70-80%)
- Secondary to primary infection elsewhere : Lungs (50%),
lymph nodes, urinary tract, bones and joints
- Fallopian tubes : Invariably the primary site
◦ Mode of spread:
- Hematogenous (90%)
- Lymphatic - Peritoneum, bowel, mesenteric
nodes
- Ascending – Contact with males with
urogenital TB
58
59. Female Infertility
Pathology
- Commonest site:Fallopian tube, endometrium
- Both tubes involve simultaneously
- Initially involve submucosal layer
- Spread medially to muscles: Fibrosis
- Spread inward to mucosa
- Fimbriae everted ostium is patent
- Tubercle burst into lumen pyosalphinx
- Spread outside perisalphingitis
- Formation of diverticula Salphingitis
isthmica nodosa
59
60. Female Infertility
- 20-40% of infertile women
- Mechanism of infertility:
- Distorted adenexal anatomy
- Blockage of tubo-ovarian motility due to adhesion
- Interference with oocyte development or early
embryogenesis
- Reduced endometrial receptibility
60
62. Female Infertility
Causes:
◦ Pelvic inflammatory disease
◦ Endometriosis
◦ Previous surgeries
Distorted anatomy and pelvic adhesion : main
mechanism of infertility
62
63. Female Infertility
- Ascending infection and inflammation of the upper
genital tract
- Polymicrobial:
- STI: N. Gonorrhea 30%
Chlamydia trachomatis 30%
Mycoplasma 10%
- Aerobic: E. coli, group B streptococcus,
staphylococcus
- Anaerobic: Bacteroids, Peptococcus,
peptostreptococcus
63
64. Female Infertility
Pathology
Initiated in endosalphinx Destruction of
epithelial cells, cilia and microvilli
All three layers gets involved Edematous and
hyperemic
Exfoliated cells and exudates pour into lumen and
agglutinate mucosal fold & plugs
Abdominal ostium closed by indrawing of fimbriae
Uterine end closed by congestion
64
65. Female Infertility
Closure of both ostia
Formation of pyosalphix, hydrosalphix
Filmsy adhesions of tube and surrounding
structures
Pouring of exudates though the abdominal ostia
Pelvis peritonitis, pelvic abscess, tubo-ovarian
abscess
65
66. Female Infertility
Risk of infertility
◦ Single episode of PID is significant and increases
rapidly with subsequent episodes
66
Episode of PID % of infertility
1st 10-12%
2nd 23-35%
3rd 54-75%
Episodes of PID % of infertility
1st 10 – 12
2nd 23- 35
3rd 54- 75
67. Female Infertility
Mechanism: Defective nidation and implantation
Causes:
CONGENITAL : - Absence of uterus
Uterine hypoplasia
CONGENITAL MALFORMATION:- Uterine
didelphus(25%), Unicornuate(38%), Septate(25-47%)
- Pregnancy outcome depends upon site of blastocyst
implantation
67
68. Female Infertility
In utero EXPOSURE TO DIETHYLSTIBESTEROL
- ↑ risk for congenital malformation and obstetric
complication
- 70% exposed had uterine malformation
- Most common malformation: T shaped uterus
- Infertility associated with constriction of upper segment
of reproductive tract
68
69. Female Infertility
UTERINE LEIOMYOMA
- Various factors affect pregnancy: size, location, number
and presence of associated symptoms
Possible mechanism:
- Altered uterine contractility: Disrupt normal sperm
migration, embryo transport
- Cornual occlusion by myoma, compression of interstitial
segment of the tube
69
70. Female Infertility
Adversely affect vascular and molecular profiles of
implantation
Poor regional blood flow
focal endometrial attenuation or ulceration
- A meta-analysis showed:
Pregnancy rate increased to 57-67% after abdominal
myomectomy for infertiltiy
70
71. Female Infertility
ENDOMETRIAL POLYP
- Incidence of asymptomatic endometrial polyp in
infertility ranges: 10-32%
- Overall prevalence after hysteroscopy : 3-5%
- Higher in patients with other symptoms and with
endometriosis
- Rare in young women
71
72. Female Infertility
- Menstrual symptoms( hypomenorrhoea, amenorrhoea,
dysmenorrhoea) and infertility
Pathophysiology:-
- Scant or poorly vascularised and dysfuncitonal
endometrium resulting from
- Intraop or postoperative complication
- Intrauterine infection
72
73. Female Infertility
Intraop and postop complication
- 90% in curattage of pregnancy termination
- 22% in postpartum curettage..↑ risk of
endometritis
- Evacuation of missed abortion, H. mole or after
cesarean section
- Abdominal or hysteroscopic myomectomy,
septoplasty, uterine surgery
Intrauterine infection
- Genital tuberculosis( tubercular endometritis)
- Schistosomiasis
73
74. Female Infertility
CHRONIC ENDOMETRITIS
- Uncommon cause, true prevalence not known
- Mucopurulent cervicitis associated with
Chlamydia trachomatis, Mycoplasma genitalis
- Significant cause of chronic endometritis with tubal
factor infertility
- Chlamydia produces silent tubal infection
- Mycoplasma & Ureaplasma recovered from cervix
mucous of infertile couple
47% of couple who conceived
53% of couple who remained infertile
74
75. Female Infertility
ANATOMIC
- Congenital elongation of cervix
- Cervical stenosis( pinhole Cx os)
PHYSIOLOGICAL
- Fault in compositon of cervical mucous
- Antisperm antibodies
75
76. Female Infertility
Fault in cervical mucous
- Becomes abundant, clear, watery and easily
penetrable by the sperm
- Scant and poorly estrogenised cervical mucous
- Cervicitis
- Previous injury to cervical glands
- Treatment with antiestrogen( Clomiphene
citrate)
76
77. Female Infertility
Anti sperm antibodies
Either autoimmune or allogenic response
Mostly immunoglobulins, Can be free/ agglutinating
- IgA: Cervical mucous, seminal plasma
- IgG: Cervical mucous, semen
- IgM: serum( larger difficult traversing the genital tract)
Causes:
- Coital trauma, genital tract infection
- Testicular trauma: Torsion
- Occlusion of vas deference : Inguinal herniorrhaphy, cystic
fibrosis, Vasectomy reversal
77
80. Female Infertility
- Is the diagnosis of exclusion, after systematic evaluation fails
to identify the cause
- All standard elements of the infertility evaluation yield
normal results
- Incidence 10%, as high as 30%
- Avg. fecundity rate in untreated women 2-4%
- Role of diagnostic laparoscopy
- 29% of women conceived after 36 weeks of t/t ē
laparoscopy compared to 17%
80
81. Female Infertility
BODY WEIGHT
- Overweight BMI >27, Obese BMI >30
- Underweight BMI < 17
- Disorders of hypothalamic GnRH, Pituitary
gonadotroin release
- Mean wt loss of 10.2kg/m2,spontaneous ovulation
and pregnancy occurred in 90% and 30% resp
81
82. Female Infertility
-13% of female infertility relate to smoking
- Higher prevalence of infertility, lower fecundability,
longer time of conception
- Mechanism:
- Accelerated follicular depletion
- Loss of ciliary function
- Menstrual cycle abnormalities
- Gamete or embryo mutagenesis
82
83. Female Infertility
- Marijuana inhibits secretion GnRH
- Interferes with ovulatory function
- Cocaine impairs spermatogenesis, ↑risk of tubal
disease
ALCOHOL
- Heavy alcohol consumption: ↓ fertility
- Moderate alcohol consumption: ↓ fecundability
- Associated with lower pregnancy rate achieved with
ART
83
85. Female Infertility
Coital errors
◦ Dyspareunia
◦ Frequency and timing coitus
◦ Use of spermicide
Anxiety / apprehension
Family disposition, genetic and constitutional
factors
85
86. Female Infertility
Evaluation of infertility focuses on the couple
regardless of past reproductive performances
Objective:
- To identify and correct specific causes of infertility
- To provide accurate information
- To provide emotional support
- To guide for alternatives ART, use of donar gamete
and adoption
- Counseling must be the ongoing process
86
87. Female Infertility
Couple-centered management
Access to evidence-based information
(verbal and written)
Counseling from someone not directly involved in
management of the couple’s fertility problems
Contact with fertility support groups
Specialist teams
87
88. Female Infertility
- All couples who failed to conceive after a year or
more of unprotected coitus
88
89. Female Infertility
- Starts with a careful history and physical
examination as ususal
HISTORY
- Age , duration of marriage, previous marriage
- Occupation
- Duration of infertility/ previous evaluation and
treatment
- Coital frequency/time of cycle/ sexual dysfunction
- Vaginal discharge/ chronic pelvic pain
89
91. Female Infertility
PAST HISTORY
- Medical illness, previous surgeries, wound infection
- H/o thyroid disease, galactorrhoea, headache, visual
field defect, hirsutism
- H/o PID , STD
- Previous abnormal pap smear, D&C, Cx biopsy, DC
cautery, HSG
- H/o tuberculosis, contact history
- Drug history, h/o contraception
91
92. Female Infertility
FAMILY HISTORY
- Early menopause, reproductive failure
PERSONAL HISTORY
- Use of tobacco, alcohol, smoking, drug abuse
- Eating habit, exercise
PHYSICAL EXAMINATION
- Weight/ BMI/ Secondary sexual characteristic
- Signs of androgen excess
- Thyroid enlagement, nodules, tenderness
- Breast secretion, character
92
93. Female Infertility
SYSTEMIC EXAMINATION
- Renal disease, hepatic disease
- Abdominal masses, pelvic masses
- Vaginal abnormality, cervical abnormality
- Abnormal secretions and discharge
- Size of the uterus, adenexal masses, tenderness on
cx motion, nodularity in adenexae or cul-de-sac
93
94. Female Infertility
Initial advice for people concerned about delays in
conception:
•Cumulative probability of pregnancy in general
population:
– 84% in 1st year
– 92% in 2nd year
• Fertility declines with a woman’s age
94
95. Female Infertility
• Lifestyle advice:
– Sexual intercourse every 2–3 days
– ≤ 1–2 units alcohol/week for women; ≤ 3–4
units/week for men
– Smoking cessation programme for smokers
– Body mass index of 19–29
– Information about prescribed, over-the-
counter and recreational drugs
– Information about occupational hazards
95
97. Female Infertility
Any investigation for infertility couple should begin
with:
- Semen analysis
- Confirmation of ovulation
- Documentation of tubal pathology
97
98. Female Infertility
Initial assesment
TLC/ DC/ Bl group/ RBS/ Hb/ ESR
Chest x ray/sputum AFB/ RFT/ LFT/HVS c/s
Assessment of ovulation
Frequency and regularity of menses
Endometrial biopsy (+ AFB culture)
Follicular study
Progesterone level/ FSH,LH level
Urinary LH excretion
BBT, Cx mucous study
98
99. Female Infertility
Test for tubal patency
HSG/ Laparoscopy ē chromotubation
TVS & Saline hysterosalphingography
(Transvaginal hydrolaparoscopy & fertiloscopy)
(Falloposcopy)
Test for uterine abnormality
Hysteroscopy
TVS & Saline hysterosalphingography
Laparoscopy
99
100. Female Infertility
MENSTUAL HISTORY
BASAL BODY TEMPERATURE
- Body temperature under basal condition
- Procedure
- Smoking forbidden
- Principle: Thermogenic property of progesterone
- Rise in 0.4˚to 0.8 ˚ f over the base line
100
101. Female Infertility
- Recording is biphasic in nature
- Falls to lowest before ovulation & before
menses
- Objective evidence of ovulation and its
approx time
- BBT is still useful and may be the best
method for couple who are reluctant or
unable to persue more formal and costly
evaluation
101
102.
103. Female Infertility
PROGESTERONE CONCENTRATION
- Level remains below 1ng/ml,
- rise 1-2ng/ml on the day of LH surge,
- peaks 7-8 days after ovulation
- Mid luteal peak i.e day 21-23 of 28 days cycle
- Level of 3ng/ml documents ovulation
- Day of measurement: Day 21 of day 28, where ovulation
occur on day 14
103
104. Female Infertility
- Normal cycle 21-35 days,
- ideal 1 week before the expected date of menses
& morning hour is the best time to test
- Has been used for quality of luteal function
- There is no consensus minimum serum
progesterone concentration that defines normal
luteal function.
- A midluteal serum progesterone level greater than
10 ng/mL is a popular standard
- A midluteal serum progesterone
concentration cannot define the quality of
luteal function and has little value beyond
documenting ovulation 104
105. Female Infertility
URINARY LH EXCRETION
- Ovulation prediction kits/ LH kits , detects mid cycle LH
surge
- LH surge is a brief event lasting 48-50hours
- Ovulation occurs 12-26 hours after onset of LH surge and
almost always within 48 hrs
- Consequently,the interval of greatest fertility includes the
day the surge is detected and the following 2 days
- Using ELISA 40mIU/ml taken as threshold
105
106. Female Infertility
- Short half life, rapidly cleared via urine, exceed threshold
level during LH surge
- Done on daily basis, beginning 2-3 days before surge is
expected
- Results sensitive to volume of urine and time of day
106
107. Female Infertility
- Based on the characteristic histological change brought
about by progesterone
- Secretory endometrium implies recent ovulation
- Simple office procedure
- Performed on day 21-24
- Pretreatment with NSAID, sedation, paracervical block
- Until recently, EB to exclude luteal phase deficiency is no
longer practiced
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108. Female Infertility
FOLLICULAR STUDY
- TVS monitoring of the developing dominant follicle prior to and
immediately after ovum release
- Gives detailed information of size and number of pre-ovulatory
follicle
- Time of test: day 12 of menses till ovulation
- Follicle reaches size upto 21-23mm
( 17mm – 29mm)
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109. Female Infertility
- Ovulation documented: abrupt decrease in the size
of follicle & ↑ fluid in the posterior cul-de-sac
- Abnormal pattern of follicular development
- ↑ at abnormal pace, collapse when follicle is still
small
- Continue to grow but fail to rupture & persists
as a cyst
- T/T with NSAID can disrupt ovulatory process
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110. Female Infertility
HSG
- Out patient procedure,
less costly, therapeutic
values
- Uncomfortable and
painful
- Risk of infectious
complication & radiation
exposure
- Images uterine cavity and
reveals internal
architecture of tubal
lumen
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Laparoscopy
- More invasive, requires GA
- Anaesthesia complication
- Accidental injuries to
bowel and blood vessels
- Detailed information of
pelvic anatomy including
adhesion, endometriosis &
ovarian pathology and
their treatment
111. Female Infertility
HYSTEROSALPHINGOGRAPHY (HSG)
- Sensitivity of 85-100% in detecting tubal diseases
- Specificity of 90% in detecting PID related disease
Indication
- To establish tubal patency
- To diagnose developmental anomalies of uterus
- Can identify submucous myoma, endometrial polyp,
intrauterine adhesion
Time
- Between cycle days 6and 11
- Pretreatment: Antibiotic, NSAID
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112. Female Infertility
Procedure
- Vaginal cleansing
- An acorn (Jascho) cannula or via ballon catheter
introduced
- Contrast material is then injected
- Water soluble contrast media ( Meglumine
diatrizoate, Renografin 60)
- Oil-based (Ethiodol)
- Volume of contrast
- Initial 3-4ml: outline of uterine cavity
- Further 5-10ml: demonstrate B/L tubal patency
112
113. Female Infertility
Water soluble contrast
- Rapid absorption
- Less risk
- Better resolution tubal
architecture
- No such action
- Low
- Pregnancy rate 17%
113
Oil based contrast
- Less rapid
- More risk of lipid
embolism, lipid granuloma
formation
- Less
- Flushes out inspissated
mucus & debris
- High post procedure
pregnancy rate
- Pregnancy rate 33%
114. Female Infertility
- Image intensification fluoroscopy should be used
with minimal radiation exposure
- 3 basic films are required
- A scout
- One to detect uterine countour & tubal patency
- Post evaluation to detect area of contrast
loculation
- Additional when uterus obscure tubes & uterine
cavity is abnormal
114
117. Female Infertility
LAPAROSCOPY
- Gold standard
- Indication
- Abnormal HSG
- Failure to conceive of normal HSG
- Unexplained infertility
- Age > 35years
117
118. Female Infertility
Procedure
- Scheduling, antibiotics and risk of infection
- Performed under GA, deep anesthesia or local anesthesia
- Systematic and thorough inspection of pelvis
- Include uterus, anterior and posterior cul-de-sac, ovarian
surfaces and fossa and fallopian tubes
- Chromotubation: Injection of dilute dye through the cervix
( Indigo carmine dye/ methylene blue)
118
119. Female Infertility
- Operative finding : Photographed
- Can identify
- Distal tubal occlusion( fimbrial agglutination)
- Pelvic or adenexal adhesion
- Endometriosis
- Therapeutic
- Lysis of filmsy adhesion or focal lesion
- Ablation or excision of superficial
endometriosis
119
120. Female Infertility
- Sono hysterography has better sensitivity than HSG in
intrauterine lesion
- Saline sono hysterosalphingography → extension of the
procedure to asses tubal patency
Timing
- Proliferative phase : Endometrial polyp
- Secretory phase: Submucous fibroid
- Pregnancy to be ruled out
120
121. Female Infertility
Preparation
- Pelvic infection ruled out, Prophylactic antibiotic,
NSAID
- Standard Transvaginal USG carried out
- Fibroid, adenexal masses, thickened endometrium
- Introduction of saline through a catheter
Interpretation
- Detection of saline in POD indicated tubal patency
- Hysterosalphingo contrast sonography( HyCoSy)
Contrast media consisting of surfactan
121
122. Female Infertility
TRANSVAGINAL HYDOLAPAROSCOPY AND
FRETILOSCOPY
- Based on the technique COLDOSCOPY
Procedure
- Veres needle inserted through post. fornix ↓ LA
- 200ml saline introduced, endoscope introduced
- Pelvic pathology visualized
Fertiloscopy extension of hydrolaparoscoy, endoscope is
introduced through fimbrial end
- Allows visualization of tubal ostial spasm, Abn tubal
mucosal pattern, intraluminal debris
122
123. Female Infertility
3 basic methods: HSG, TVS, Saline/ contrast
sonohysterography
TRANSVAGINAL USG
- Modern transducers produce high resolution images
- Endovaginal probes yield details of
- Uterus, ovaries or adenexal pathology
- Fallopian tubes cannot be visualised
- Saline sonohysterosalphingography performed
123
124. Female Infertility
Indication
- Identification of congenital malformation
- Septate, bicornuate, unicornuate, didelphus
- Adenexal mass
- Endometrial polyp, submucous fibroid
- Intrauterine adhesion
Timing
- In all phases of the cycle
Diagnostic accuracy can be compared with
hysteroscopy
124
126. Female Infertility
Procedure
- Performed as office procedure
- Prior administration of intravaginal Misoprostol
200µg
- In infertility, best initial choice for diagnosis and
treatment of suspicious intrauterine lesion
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128. Female Infertility
POST COITAL TEST ( SIMS – HUNNER TEST)
Objective
- To assess quality of cervical mucous
- To assess presence of number or motile sperm
- To see interaction between Cx mucous and sperm
Prerequisite
- Absteinence for 48hrs, no lubricants, douching, medications
- Performed shortly before ovulation, examined within 2-12hours
of coitus
- The post coital test for diagnosis of cervical factor is no longer
recommended
128
129. Female Infertility
Cervical mucous study
- Volume : copius and thin
- Clearity : watery and clear
- PH: 6.8 - 7.4 at the time of ovulation
- Cellularity:
- Viscosity: Spinnbarkeit , length that can be stretched
10cm
- Salinity: Fern pattern, complexity of network of
crystal
- Poor quality: Improper timing, cervicitis, CIN, anti
estrogens like chlomiphene citrate
129
130. Female Infertility
Presence of no. of motile sperm
- Presence one motile sperm/hpf in most fields → normal
- Confirms effective coital technique and survival
- Motile sperm predicts normal semen quality
- Negative results
- Ineffective coital technique
- Failed ejaculation
- Poor semen quality
- Use of lubricants/spermicide
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131. Female Infertility
Interaction between cervical mucous and sperm
- Presence of >25% sperm exhibiting shaking and jerky
movement / immotile sperm→ Anti sperm antibodies
Test for antisperm antibodies
- Sperm agglutination test
- Sperm compliment dependant immobilization
- Immunobead test
- Mixed agglutination test
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