The Management (mainly the treatment aspect) of Female Infertility is described in brief here (as much as the limit of 55 slides permitted me to discuss!). References from: Berek and Novak's Gynecology 15th editon Speroff's Clinical Gynecologic Endocrinology and Infertility 8th edition And of course, Slideshare itself!

1. -M.Sathish Kumar
Unit I

2. Age of both the partners Duration of infertility
Prior treatment Failure Cause of Infertility
Factors affecting
the Management
of Infertility

3. INFERTILITY
Embarrassment,
Depression.
The couple try hard
to conceive, put
pressure on
themselves.
Failure to conceive
further accentuates
the embarrassment.
Increased Stress,
Frustration,
Quality of Life
affected.

4.  The male and female partner are evaluated together.
 Proper and accurate information is provided to the couple
about
-the act and timing of coitus,
-nature of therapy and
-the cost of therapy.
-Treatment options available.
 It is important to mention to the couple that the probability
of unexplained infertility is around 10%.

5.  More importantly, the
couple are motivated not
to change consultants
regularly and be compliant
to therapy. A positive
attitude is needed.
 Counselling can help in
identifying functional
causes of infertility, like
PrimaryVaginismus.

6. • In cases of PCOS, Lifestyle Modification, such as following a
proper diet plan and reducing weight can go a long way in
treatment of infertility.
• Weight loss helps in increasing the levels of sex hormone
binding globulin, reduces insulin and testosterone levels ( and
hence beneficial in mild hirsutism).

7. Causes of Female Infertility
Ovarian
Causes
Tubal
Causes
Uterine
Causes
Cervical
Causes
Vaginal and
Peritoneal
Causes
Unexplained
Infertility

9. Ovulatory
Disorders
Hypogonadotropic
Hypogonadal
Anovulation
↓ GnRH,↓FSH and
↓Serum estradiol
Hypothalamic
amenorrhea due to
causes like Kallmann
syndrome, Anorexia
Nervosa etc.
GnRH
Eugonadotropic
Euestrogenic
Anovulation
Normal serum
Estradiol, FSH and
LH.
PCOS
Ovulation
Induction Drugs
Hypergonadotropic
anovulation
↑FSH
Premature
Ovarian
Failure
Artificial
Reproductive
Techniques
Hyperprolactinemic
Anovulation
↑Prolactin
↓
↓GnRH
↓
↓FSH
Bromocriptine

10. Drugs which induce Ovulation:
1) ClomipheneCitrate
2) Gonadotrophins
-Human menopausalGonadotrophin.
-Human chorionicGonadotrophin.
-Recombinant FSH.
3)Aromatase inhibitors
-Letrozole
-Anastrozole
Drugs which facilitate Induction:
Insulin Sensitizers
-Metformin
- Pioglitazone.

11. Clomiphene citrate (CC).
Clomiphene is supposed to be a SERM, but
in almost all circumstances it acts purely as
an antagonist or an anti estrogen.
It is the traditional drug of choice for ovulation
induction in anovulatory women with normal
thyroid, normal serum prolactin, normal
endogenous estrogen production – WHO Class 2.

12. Binds with estrogen receptors present in the
body (importantly, the hypothalamus) and blocks
them.
Loss of negative feedback to Hypothalamus
leads to an increase in the GnRH production.
Increased GnRH production causes an increase in
FSH and LH release from the Anterior Pituitary.
FSH and LH act on the ovary and stimulate
ovulation.
Clomiphene Citrate

13. Negative
Feedback
Inhibited

14.  Clomiphene is effective in the treatment of short
luteal phase.
 It is also useful empirically in association with IUI.
 It is of no use in hypogonadotropic hypogonadism.
A shortened luteal phase could be due to a defect in FSH –
as Corpus Luteum is derived from the Graafian Follicle,
The growth of which depends on FSH.

15. • BBT – Basal Body temperature
• OPK – Ovulation Prediction Kits (Measure urinary LH).
The dose is usually started at
the 2nd day of the cycle.

16. Mismatch between the rates of
ovulation and rates of pregnancy.
WHY?
 Endocervix :
Due to anti estrogenic action, the
cervical mucus becomes thinner and become
less favourable for sperm survival.
 Endometrium :
Again due to anti estrogenic action,
the endometrial growth is impaired. It may
affect ovum implantation.
Due to anti estrogenic action on
the genital tract. .

17. Side effects:
 Transient hot flushes-
vasomotor symptoms that occur
as a result of the drug mimicking
an estrogen deficient state.
 Other side effects –
headache, nausea,Visual
disturbances like scotoma.
Risks of ClomipheneCitrate induced
ovulation:
Multiple pregnancy .
Ovarian Hyperstimulation
Syndrome.

18.  It describes women who do not ovulate in response to clomiphene
and not those who fail to conceive despite ovulation.
 CC with Glucocorticoids:
Either prednisone (5mg daily) or dexamethasone (0.5 to 2 mg daily)
is used ,usually in the follicular phase. Glucocorticoids suppress
elevated androgen concentrations (DHEAS).
 CC with hCG - “Trigger shot”
Useful only in women who ovulate but where an LH surge does
not occur to trigger ovulation.

19.  CC with metformin- can be used Polycystic Ovarian Disease.
Metformin reduces insulin resistance.
 CC with hMG (human Menopausal Gonadotropin) - can also
be used to induce ovulation in case of resistance to
Clomiphene alone.
Not this HMG !!!!

20.  Used in women who do not ovulate with Clomiphene.
 hMG (human Menopausal Gonadotropin) – contains both
FSH and LH.
 Recombinant FSH – only FSH activity.
Dose – 50-75mIU/ml of FSH, given IM on day 5 of cycle.
Step up the dose based on follicular size measured in
transvaginal ultrasound.
hCG 5000 IU is administered IM to trigger ovulation.

21.  Perform baseline USG of ovary.
 Administer hMG ,75-150 IU/day
for 3-5 days.
 Measure estradiol. If the level of
estradiol has doubled, continue
the same HMG dosage .If not,
increase hMG by 50% for 3 days.
 Repeat step 3 until estradiol
doubles.
 Perform ovarian scan every 2-3
days until dominant follicle is 14
mm.
 The aim of the therapy is to
develop a single preovulatory
follicle.

22.  Androgens Estrogen.
Aromatase
Aromatase
inhibitors
Aromatase inhibitors include
Letrozole and Anastrozole.
Advantages:
1)No anti estrogenic effects on
the cervix and endometrium.
2) Monofollicular
development.
Letrozole is banned for use in
infertility due to teratogenic
effects.

23.  Ovarian Hyperstimulation syndrome
 MultifetalGestation.
Characterised by –
Ovarian enlargement
Ascites,
Abdominal distension
Oliguria
Management :
Conservative
Give Fluids/albumin.

24. Rule of ‘4’
4 punctures,
4 millimeters,
4 seconds,
40 watt current.

25.  GnRH can be given in a pulsatile fashion (like
the way GnRH is naturally secreted),
subcutaneously. An advantage of GnRH is
that the risk of hyperstimulation is greatly
reduced compared to hMG.
 However, GnRH is very expensive.

26.  In IVF, GnRH is not given in a pulsatile fashion
(in the long protocol it is given for 2 -3
weeks). It acts by desensitizing the GnRH
receptors present in the pituitary gland, to
prevent premature LH surge and thus,
premature ovulation.

27.  Used for short periods.
 Act by blocking the GnRH receptors in the pituitary gland.
 Prevents premature LH surge and thus premature
endogenous ovulation in patients undergoing exogenous
stimulation with FSH in preparation for IVF.
 Administered by IM or SC.
 Preparations :
 Cetrorelix
 Ganirelix

28.  Luteinized Unruptured Follicular Syndrome ,
micronized progesterone or hCG can be given.
 Hyperprolactinemia : Bromocriptine (Dopamine
agonist) is given , at a dose of 1.25mg at bedtime
daily for 7 days.
 Hypothyroidism: Treatment with L-Thyroxine can
help resume normal menstrual patterns and
enhance fertility in those diagnosed with
Hypothyroidism.

29.  . Tubal Occlusion
Proximal Tubal
Occlusion
1)Selective salpingography
2)Radiologically guided tubal
cannulation
3)Hysteroscopic cannulation
4)Microsurgery
-Resection and anastomosis
-Tubocornual anastomosis
DistalTubal
Occlusion
1) Fimbrioplasty
2) Neosalpingostomy
3) Salpingectomy and
InVitro Fertilisation
(IVF).

30.  For Uterine Fibroids, initial medical therapy with GnRH to shrink
the tumor size followed by Myomectomy is effective.
 For Endometrial polyps – Polypectomy is done.
 For Ashermann’s syndrome,
 Hysteroscopic Adhesiolysis is done.
 To prevent readhesions, Intra uterine
Contraceptive Device can be inserted and
Oral Contraceptive Pills can be given for 3
Cycles.
 For Uterine hypoplasia, it is best to opt
for surrogacy.

31.  Cervicitis
 treat the cause
 Poor cervical Mucus Production
 IUI(Intra Uterine Insemination)-effective for treatment of
unexplained infertility.
• Management of immunity against sperm:
Use of condom or a diaphragm as a barrier method
for 3 months.
Use of Immuno suppressants like dexamethasone,
cyclosporine and methotrexate.

32.  VAGINISMUS :
 First essential treatment is win the confidence
of the couple
 Counselling
 Fenton operation(for rigid hymen)
 DYSPAREUNIA :
 Use lubricant such as K.Y.Jelly.
 Lignocaine ointment for pain.
 Treat the local cause.

33. Management of
endometriosis
Symptomatic
cases
GnRH
analogues
Letrozole
RU-486
Destruction
by cautery
Excision of
cyst
adhesiolysis
Incision of
chocolate cyst
Asymptomatic
minimal
endometriosis
Observe 6-
8 months
investigate
infertility

34.  Peritoneal disorders like peritubal adhesions are
diagnosed laparoscopically and adhesiolysis is done.
 For unexplained infertility, low dose aspirin 75mg can
be tried out.Assisted ReproductiveTechniques are usually
required to achieve pregnancy.

35. TYPES OF ARTIFICIAL
INSEMINATION
 Intra Uterine
Insemination (IUI )
 Intracervical
 Pericervical & Vaginal
 Direct Intra Peritoneal
Insemination (DIPI)

36. STEP2
COH is done
with Clomiphene
Citrate and
follicle size is
monitored till it
reaches around
20mm.
hCG is injected to
trigger ovulation.
STEP1
STEP3
IUI is done by
introducing the
prepared
semen via an
intrauterine
catheter, 36
hours after hCG
injection.
Semen from
male partner
is collected,
washed and
stored.

37.  All fertility treatment procedures that involve
handling of oocytes and sperms outside the
body.
 TYPES:
 Invitro fertilization(IVF)
 Gamete intrafallopian transfer(GIFT)
 Zygote intrafallopian transfer(ZIFT)
 Intracytoplasmic sperm injection(ICSI)

38.  1978 -The First succesful
birth using IVF by Patrick
Steptoe and Robert
Edwards. Louise Brown was
the baby.
Louise Brown is
the lady in the
picture and not
the baby !

39.  Blocked/damaged fallopian tubes
 Endometriosis
 Male infertility
 Idiopathic infertility
 Immunological infertility
 Ovarian failure and diminished reserve
 Pelvic malignancy

40.  Process by which an
egg is fertilised outside
the body and placed
back into the body for
further development.

41. Controlled Ovarian Hyperstimulation with
Gonadotrophins.
Prevention of premature LH surge.
Ultrasound guided oocyte aspiration after
maturation.
Processing of Sperm.
Laboratory Fertilisation and InVitro Embryo
Culture.
Endometrial Preparation for Implantation for
the Embryo using Progesterone.
Transfer of embryos into the uterus.

43.  Ovarian hyperstimulation syndrome
 Multiple pregnancy
 Ectopic pregnancy
 Miscarriage
 Prematurity
 LBW babies
 Birth defects

44.  Results are better with
- age <35 years
- previous live birth
- previous success IVF
 poor results with
- diminished ovarian reserve
- uterine factors and smoking.

45.  Ovarian reserve
 Male factor
 Infectious disease
chlamydial ,HIV,HBV,HCV,
 Evaluation of uterus
HSG,Hysteroscopy,Sonohysterography.

46.  Intracytoplasmic
sperm injection (ICSI)
is an in vitro fertilization
procedure in which a
single sperm is injected
directly into an egg.
 Used mainly for male
infertility, it may also be
used where eggs cannot
easily be penetrated by
sperm, and occasionally
as a method of in vitro
fertilization.

47.  Male factor
 Oligospermia <5%
 Asthenospermia <5%
 Teratospermia <4%
 PGD
 Poor IVF/failed IVF

48.  In gamete intrafallopian
transfer (GIFT), eggs are
removed from the
woman, and placed in
one of the fallopian
tubes, along with the
sperm.
 This allows fertilization
to take place inside the
woman's body.
Therefore, this variation
is actually an in vivo
fertilization.

50.  Surrogacy is defined as carrying of pregnancy
for intended parents.
Undertaken in following conditions
- absent/diseased uterus.
- repeated pregnancy loss.
- hereditary disease.
- failed IVF.

51.  It refers to legal process of becoming a non-
biological parent,(the child that is not one's
biological child).
 Many prefer to have their own genetic babies
and resort to adoption when all other
measures fail.

52. Both had children through IVF (surrogate mothers).