More information about menopausal age

1. Infertility

2. Outline
• Session objectives
• Terminologies
• Causes
• Evaluation of infertile couple
• Treatment options

3. Session objective
• Define infertility
• Describe the magnitude of the problem
• Describe causes of infertility
• Explain approach to infertile couple
• Describe treatment options

4. Overview
Infertility: Failure to conceive for one year despite unprotected regular
intercourse
• Fecundabilty:
• Fecundity:
• Sterility:
• Subfertility:
• Could be primary or secondary
• Affects 10-15 % of couples

5. Definition…
Sterility an intrinsic inability to achieve pregnancy. VS
Infertility implies a decrease in the ability to conceive
and is synonymous with subfertility.
Primary infertility applies to those who have never
conceived.
Secondary infertility designates those who have
conceived at some time in the past.
5

6. Definition….
Fecundity is the probability of achieving a live birth in 1 menstrual
cycle.
Fecundability is expressed as the likelihood of conception per
month of exposure.
6

7. Causes of infertility
• Male factor: 25-40 %
• Female factor: 40-55%
• Both: 10%
• Unexplained:10%
• Relative sub fertility in one partner is counterbalanced by high fertility
of the other

8. Causes…
• Male factor infertility:
1. Defective spermatogenesis
2. Obstruction of efferent duct system
3. Failure to deposit sperm high in the vagina
4. Errors in seminal fluid

9. Male causes…
1. Defective spermatogenesis
• Congenital: undescended testis
• Thermal factor
• Infection
• Genetic-kleinefelter syndrome
• Endocrine- Only Sertoli cell syndrome
• Iatrogenic: radiation, cytotoxic drugs

10. Male causes…
2. Obstruction of the ducts
• Infection
• Trauma
3. Failure to deposit high in the vagina:
• Erectile dysfunction
• Ejaculatory defect
• Hypospadias

11. Male causes…
4. Defects in seminal fluid:
• Unusually high or low volume of fluid
• Low fructose level
• High prostaglandin concentration
• Undue viscosity

12. Female causes
1. Ovulatory dysfunction: 30-40 %
2. Tubal or peritoneal factor: 30-40%
3. Endomteriosis: 1-10%
4. Unexplained: 10-15%
5. Miscellanous: 10%

13. Evaluation of infertility
Objectives:
• Discover etiologic factor
• Rectify the abnormality to improve fertility
• Reassure the couples
When to investigate:
• After one year
• After 6 months in women older than 35 years & after 40 years in men

14. Evaluation…
General principles:
• Sharp decline in fertility following first year
• Minor abnormalities can be corrected promptly
• Psychosomatic factors contributing for infertility increases with time
• Involve both partners at first
• Detailed general & reproductive history to be extracted in the
presence of both
• Clinical examination to be take separately

15. Evaluation of male factor infertility
History:
• Age, prove fertility if any
• Duration of marriage
• History of previous marriage
• Medical history related to diabetes, STDs
• Surgery: herniorraphy
• Occupation: radiation, heat
• Sexual history
• Social habits: smoking, alcohol ingestion

16. Evaluation of male…
Physical examination:
• Full physical examination pertaining to general health
• Examination of reproductive system: inspection & palpation of
genitalia
1. Size & consistency of testis
2. Urethral meatus
3. Presence of varicocele

17. Investigations
• Routine investigations: U/A, RBS
• Seminal fluid analysis: Normal values
1. Volume: 2ml or more
2. PH: 7.2-7.8
3. Concentration: >20 million/ml
4. Motility: > 50% progressive
5. Morphology: > 30%
6. Leucocytes: <1 million

18. Terminologies in seminal fluid analysis
• Aspermia: failure of formation or emission of semen
• Oligospermia: < 20 million/ml
• Polyzoospermia:>350 million/ml
• Azoospermia: no spermatozoa
• Asthenozoospermia: abnormal motility
• Teratozoospermia: abnormal morphology
• Necrozoospermia: dead or motionless

19. Female evaluation
History:
• Age, duration of marriage
• History of previous marriage of proven fertility
• General medical history: Tuberculosis, STD, PID or DM
• Contraceptive history
• Sexual problems

20. Female evaluation…
Physical examination:
• General examination:
1. Obesity or weight loss
2. Hair distribution
3. Secondary sexual characteristics
4. Physical features for endocrinopathy

21. Physical examination…
Gynecologic examination:
• Adequacy of hymenal opening
• Evidences of cervical infection
• Undue elongation of cervix
• Uterine size, mobility & position
• Adenexal mass, nodules at cul de sac
Speculum examination:
• Abnormal cervical discharge
• Cervical smear

22. Investigations…
1. Ovarian factors: Ovulation
Indirect:
• Menstrual history
• Evaluation of peripheral or end organ changes like
BBT, cervical mucus, vaginal cytology
• Endometrial biopsy
• Sonography
• Hormonal estimation: progestrone, LH
• 2. Direct: laparoscopic visualization of recent
corpus luteum or detection of ovum from
aspirated peritoneal fluid

23. Uterine factor
• Ultrasound
• HSG
• Hysteroscopy
• Laparoscopy

24. Cervical factor
• Post-coital test (Sims-Huhner test): assess quality of cervical mucus &
ability of sperm to survive in it
• Sperm cervical mucus contact test (SCMCT): invitro cross over test,
indicted when three postcoital tests are negative.

25. Endocrinopathy
• Serum TSH, prolactin, FSH, LH, DHEAS
• Testestrone, progestrone
• Postprandial glucose

26. Immunological factors
• Mixed agglutination reaction (MAR)
• Immunobed tests

27. Unexplained
• No obvious cause for infertility following all standard investigations
i.e. semen analysis, ovulation detection, tubal &peritoneal factors,
endocrinopathy & post-coital test
• With expectant management, 60 % conceive in three years

28. Treatment
Couple instructions:
• Assurance: when faults found in both, treat both at a time,
• Optimal body weight
• Avoid excessive alcohol ingestion & smoking
• Coital problems need to be carefully evaluated by intelligent
interrogation

29. Treatment of male infertility
• Improve general health
• Avoid smoking, alcohol ingestion, tight underwear
• hMG & hcG: gonadotropin deficiency or failed CC cases
• Testestrone
• GnRH therapy
• ART assisted reproductive technology

30. Treatment of female infertility
1. Ovulatory dysfunction:
Drugs used for ovulation induction
• Clomiphene citrate
• hMG
• FSH
• hcG
• GnRH

31. Ovulation…
• Dexamethasone: reduction of level of androgen
• Bromocriptine: reduction of prolactin
• Substitution therapy for hypothyroidism
• Surgery: wedge resection, ovarian diathermy, surgery for
prolactinomas

32. Tubal & peritoneal factors
• Tuboplasty:
1. Adhesiolysis
2. Fimbrioplasty
3. Sapingostomy
4. Tubal anastmosis
5. Tubo-cornual anastmosis
• Poor prognosis following tuboplasty:dense adhesions, loss
of fimbriae

33. Assisted Reproductive Technologies (ART)
• Encompasses all the procedures that assist the process of
reproduction by retrieving oocytes from ovary or sperm from testis
or epididymis
• Includes:
1. IUI
2. IVF
3. GIFT
4. ZIFT
5. ICSI

34. Management of
menopause

35. Discuss this question
• Do you think that management of menopause is necessary or not?
• Did climacteric and menopause is similar or different?
• Which one is general term indicates the other?

36. Climacteric
The phase in the aging process of women marking the transition
from the reproductive stage of life to the non-reproductive stage
Menopause
The final menstrual period and occurs during the climacteric. The
average age of menopause is 51.

37. causes
• The menopause occurs when the store of oocytes is
exhausted.
• FSH levels rise (FSH >30 IU/L) but the ovary fails to
respond adequately.
• Once estradiol production falls below a critical
threshold, endometrial stimulation does not occur
and bleeding ceases.
• FSH and luteinizing hormone (LH) levels then remain
permanently elevated.

38. Menopause
• Premature menopause
• Surgical menopause
• Natural menopause
• Late menopause
Target organs of estrogen
• Bone Eyes
• Teeth Breast
• Colon Urogenital
• Vasomotor Heart

39. Menopausal symptoms
 Vasomotor symptoms: hot flushes, night sweats
and palpitation
 Urogenital atrophy: vaginal dryness,
dyspareunia, vulva pruritus, urinary frequency,
urgency, and recurrent cystitis, genital prolapse
 Psychological symptoms: irritability,
nervousness, depression, insomnia and anxiety

40. Osteoporosis
• Oestrogen deficiency
• Peak bone mass at 30-35 years old
• Bone loss at a rate of 0.5-1% per year afterward
• Bone loss at a rate of 2-3% per year for 10 years after
menopause
• Osteoporosis is associated with fracture ( femoral neck,
vertebral body and distal radius)

41. Risk factors of osteoporosis
 Family history
 Ethnicity
 Early menopause
 Hypoestrogenism (excessive exercise, anorexia)
 Cigarette smoking
 Caffeine
 High alcohol intake
 nutritional

42. Cardiovascular disease
 Rapid increase in mortality and morbidity from
cardiovascular disease after menopause
 Epidemiological evidence suggests that HRT
is associated with 50% reduction in
cardiovascular risk in menopausal women
 There is no prospective randomised data to
show that HRT is effective in the primary
prevention of cardiovascular disease.

43. Management of menopause
• healthy life style mgt
• Psychological support
• Hormone replacement therapy HRT

44. General Management of menopausal symptoms
 Understand menopause
 Strengthening of self-image
 Avoid spicy food, alcohol, strong tea and
coffee.
 Healthy life style
 Hormone Replacement Therapy

45. Prevention of osteoporosis
• Change lifestyle risk factors
• Exercise
• Adequate calcium / vitamin D intake
• Hormone Replacement Therapy
• Alendronate and Raloxifene a drug of choice.

46. Prevention of cardiovascular disease
• Healthy life style
• Diet
• Avoid smoking
• Control of hypertension, diabetic and hyperlipidaemia
• Hormone Replacement Therapy (Not effective for secondary
prevention. ? Primary prevention)

47. HRT
Indications
• To Relief of menopausal symptoms
• To prevent Long term complication of osteoporosis

48. Absolute contraindications
• Existing breast cancer
• Existing endometrial cancer
• Venous thrombo-embolism
• Acute liver disease

49. Routes of administration of oestrogen
• Oral
• Transdermal
• Implants
• Local vaginal preparation

50. Oral therapy
 Natural occurring oestrogens: includes premarin and
various oestradiol preparations. These oestrogens are
metabolised in the liver to the weaker metabolite
oestrogene and then converted to oestradiol in the
peripheral circulation and in the target tissue.
 Tibolone: a steroid hormone that has oestrogenic,
progestogenic and androgenic properties.
 Synthetic oestrogens: such as mestranol or ethinyl
oestrodiol are not generally prescribed for older women
for HRT.

51. Transdermal therapy
• Patches (oestrogen only or combined preparation) or oestrogen
gels
• Skin irritation may be a problem but new matrix patches and the
gels are usually well tolerated
• Route of choice for women with risk factors for venous thrombo-
embolism, liver disease or gastro-intestinal problems

52. Oestrogen implants
• Now less widely used
• Implants should be given no more than every 6 months

53. Local vaginal therapy
• Useful for local vaginal dryness and symptoms of urgency
• Contraindication to systemic HRT but require oestrogen for
local symptoms

54. HRT regimens
 Women who have had a hysterectomy only
need to take oestrogen.
 Women with an intact uterus must take
progestogen for endometrial protection to
prevent endometrial cancer or hyperplasia
 Regular surveillance of endometrium is
required for women (extreme intolerance of
progestogen) on unopposed oestrogen

55. HRT regimens
 Sequential preparation: progestogen added for
12-14 days each month. Some women will not bleed
on sequential preparations and this is not a cause for
concern provided that the progestogen is taken
correctly.
 Continuous combined HRT: give oestrogen and
progestogen daily. These preparation induces
endometrial atrophy. Intermittent bleeding and
spotting are common in the first few month of use.
More suitable for women who are at least one year
since their last spontaneous period.

56. Progestogen
• Oral
Eg. 1. C21 progesterone derivatives : dydrogesterone
or medroxyprogesterone acetate
2. C19 nor-testosterone derivatives: norethisterone
acetate or levonorgestrel
Transdermal form
• Levo-norgestrel releasing intra-uterine system

57. Side effects of HRT
 Nausea
 breast pain
 heavy or painful withdrawal period
 premenstrual syndrome type of side effects
 weight gain
Risk of HRT
 Breast and endometrial cancer
 Thrombo-embolism

58. HRT and breast cancer
 The extra risk of developing breast cancer on HRT
does not persist beyond about 5 years after stopping
treatment.
 Women taking HRT diagnosed with breast cancer are
less likely to have tumours with metastatic spread and
therefore have an improved prognosis.
 Regular mammography is indicated for women on
HRT after 50 years old.
.

59. HRT and venous thrombo-embolism
• Natural oestrogens
• Women taking HRT have a 2-4 fold increase in risk of venous
thrombo-embolism (VTE).
• Women with significant past history of VTE should have a
thrombophilia screen before commercing HRT