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SEMINAR ON FEMALE INFERTILITY.ppx.pptx
- 1. FEMALE INFERTILITY BY DR FARHEEN SIDDIQUI MODERATOR : DR VAIBHAV KANTI
- 2. LEARNING OBJECTIVES DEFINATION TYPES OF INFERTILTY CAUSES OF FEMALE INFERTILITY HISTORY AND PHYSICAL EXAMINATION INVESTIGATIONS APPROACH OVULATORY FACTORS TUBAL FACTORS UTERINE FACTORS OTHER FACTORS CAUSING INFERTILITY COUNSELLING REFRENCES
- 3. DEFINITIONS Infertility is defined as 1 year of regular unprotected intercourse without conception. The term subfertility is used interchangeably to describe women or couples who may not be sterile but exhibit decreased reproductive efficiency. Fecundability is the probability that a cycle will result in pregnancy. Fecundity is the probability that a cycle will result in a live birth.
- 4. Eg : Sheehan’s syndrome
- 5. CAUSES OF INFERTILITY : OVARIAN DYSFUNCTION 30-40% MALE FACTOR INFERTILITY 40% OTHERS UTERINE CAUSES 15% TUBO PERITONEAL DISORDERS 20-40% CERVICAL FACTOR INFERTILITY UNEXPLAINED INFERTILITY PID ENDOMETRIOSIS TUBERCULOSIS
- 7. HISTORY TAKING AGE DURATION OF MARRIAGE DURATION OF INFERTILITY PAST OBSTETRIC HISTORY MENSTRUAL HISTORY PAST MEDICAL AND SURGICAL HISTORY FAMILY HISTORY CONTRACEPTION HISTORY OCCUPATION HISTORY ADDICTION HISTORY SEXUAL OR COITAL HISTORY HISTORY OF GALACTORRHEA HISTORY OF CHANGE IN WEIGHT GAIN HISTORY OF HIRSUITISM
- 9. INVESTIGATIONS GENERAL INESTIGATIONS CBC ABO RH HIV HCV HEPATITIS B VDRL LFT KFT SPECIAL INVESTIGATIONS THYROID PROFILE DIABETIC SCREENING HORMONAL STUDY SERUM FSH SERUM ESTRADIOL SERUM LH SERUM PROLACTIN ANATOMICAL INVESTICATIONS PELVIC ULTRASOUND HSG MALE FACTOR HUSBAND SEMEN ANALYSIS
- 12. TEST OF OVULATION (DETECTION OF OVULATION) Urinary LH monitoring Mid luteal serum progesterone Endometrial biopsy Cervical mucous study Basal body temperature BBT Vaginal cytology Menstrual history
- 13. OVARIAN RESERVE TESTS OTHERS OVARIAN VOLUME ANTRAL FOLLICLE COUNT AMH ANTI MULLERIAN HORMONE INHIBIN B CLOMIPHENE CHALLENGE TEST SERUM FSH AND SERUM ESTRADIOL LEVELS
- 15. OVULATORY FACTORS INFREQUENT MENSES HOT FLUSHES HIGH FSH AND LH (POST MENOPAUSAL RANGE) APPROACH PREMATURE OVARIAN FAILURE ART DONOR EGG -IVF ADOPTION HIGH DAY 3 FSH ABNORMAL OVARIAN RESERVE TEST ADVANCED AGE DECREASED OVARIAN RESERVE DECREASE CHANCES OF SUCCESSFUL TX INCREASE RISK OF MISCARRIAGE AND ANEUPLOIDY IUI IVF SIGNS AND SYMPTOMS HYPERANDROGENISM OLIGOMENORRHEA OR ANOVULATION EXCLUDED OTHER MEDICAL CONDITIONS PCOS OVULATION INDUCTION
- 19. CLOMIPHENE CITRATE SERM SELECTIVE ESTROGEN RECEPTOR MODULATOR
- 21. Enclomiphene Zuclomiphene Cis form Trans form t1/2 short t1/2 long More potent CC 2nd most common drug used in PCOS for ovulation induction CC m/c drug for non PCOS pt for ovulation induction Not useful in WHO group I
- 22. REGIMEN : 50 MG OD for 5 days [day 2 to day 6 ] or [day 5 to day 9] Max dose 150 mg lushes, headache, breast tenderness, pelvic pain , nausea , visual disturban RISKS : 7-10% Multi fetal pregnancy OHSS rare No evidence of anomaly in fetus Can be used in combination with adjuvants Glucocorticoids ( 5mg prednisolone or 0.5 -2 mg of dexa) Metformin HCG inj 5000 IU
- 24. LETROZOLE
- 29. LETROZOLE : DOC in PCOS 2.5 mg OD for 5 days [ day 3 of cycle] Max dose 7.5 mg Side effects : hot flushes, headache , cramps , fatigue , dizziness Risks : multifetal gestation risk is same as CC LETROZOLE CLOMIPHENE Ovulation 88% Preg rate 27 % Live birth 27% Ovulation 75% Preg rate 21 % Live birth 19%
- 30. GONADOTROPIN
- 31. Gonadotropin therapy Highly effective Costly OHSS max risk Multifetal gestation risk Good in WHO group I patients Preparations : hMG , Menotropins 1 ml = 75 IU FSH Inj im 75 IU LH Purified varieties of FSH ; 75 IU FSH with 1LH or 0 LH 0r 0.001 LH. GIVEN sc route Brand name : urofollitropin Recombinant FSH also available
- 32. INDICATIONS : GROUP I WHO ( hypogonadotropin hypogonadism) Drug failure ( CC or letrozole failure) Unexplained infertility Contraindications: Pregnancy Primary ovarian failure Uncontrolled thyroid / adrenal dysfunction Unexplained abnormal uterine bleeding Intracranial lesions Non PCOS ovarian cyst RISKS Multifetal gestation OHSS
- 34. OHSS OVARIAN HYPERSTIMULATION SYNDROME Inc capillary permeability Inc VEGF and other cytokines Fluid shift to extravascular compartment Hypovolemia Hypercoagulation RISK FACTORS Young age Thin patient PCOS Increase ovarian reserve(high AMH High dose of gonadotropin Inj HCG high dose
- 37. PREVENTION OF OHSS IF estrogen levels >2500 pg/ml — coasting to be done and delay inj HCG If inj HCG to be given , give low dose 5000IU USING GnRH agonist Cabergoline( anti VEGF property) Progesterone(100mg) can be given instead of inj HCG
- 38. Mild to moderate type Ovarian enlargement Lower abdominal discomfort Nausea vomiting and diarrhoea Abdominal distension TREATMENT Expectant management Counselling Avoid intercourse Weight chart Urine frequency chart Hematocrit level Serum electrolyte Serum creatinine Fluids intake Electrolyte rich drinks Avoid heavy activity
- 39. SEVERE OR CRITICAL OHSS Hospitalization to be done Severe pain Rapid weight gain Tense ascitic Respiratory distress Lower blood pressure Electrolyte abnormality Na <135 meq/L K>5 meq/L Hematocrit>55% Creat >1.2 mg/dl Haemorrhage DVT TREATMENT ICU mx IVF NS is preferred Slow albumin infusion Avoid diuretics K+ if raised insulin +D 25% Ascitis——paracentesis VTE Stockings Heparin therapy continued till first trimester
- 40. TUBAL FACTORS
- 41. Tubal factor accounts for 25% to 35% of infertility. CAUSES : TUBERCULOSIS (10-15%) PID. SEPTIC ABORTION ENDOMETRIOSIS TUBAL SURGERY ECTOPIC PREGNANACY SURGERY 1 TIME PID —10-12% CHANCES OF TUBAL BLOCK 2 TIMES PID —-23-35% CHANCES 3 TIMES PID ——54-75% CHANCES
- 42. TUBOCORNUAL REGION Failure of contrast to enter tube Salpingitis isthmica nodosa (SIN) Endometriosis Polyps ISTHMUS Occlusion AMPULLA Intraluminal adhesions Tubal pregnancy INFUNDIBULUM Hydrosalpinx Phimosis of distal tubal ostium INTRAPERITONEAL SPREAD Adhesions
- 43. TEST OF TUBAL PATENCY Gold standard HyCoSy SONOSALPINGOGRAPHY DIAGNOSTIC LAPROSCOPY HSG (HYSTEROSALPINGOGRAPHY CHLAMYDIA ANTIBODY TESTING
- 51. LAPROSCOPY INDICATED WHEN HSG IS ABNORMAL. DIAGNOSTIC LAPROSCOPY IS DONE IN G.A. or CAN BE DONE IN SEDATION + LA . OPERATIVE LAPROSCOPY IS DONE IN G.A. IT IS GOLD STANDARD WE CAN SEE : UTERUS , ANTERIOR AND POSTERIOR POUCH , OVARIAN SURFACE , FOSSA , FALLOPIAN TUBES. CHEMOPERTUBATION CAN BE DONE WHERE METHYLENE BLUE INDIGO CARBINE IS USED
- 56. HyCoSy IN THIS , CONTRAST MEDIA IS USED FOR USG (SURFACTANT + BUBBLES) SENSITIVITY 92% SPECIFICITY 95%
- 58. Falloposcopy—A transvaginal endoscopic procedure to examine the fallopian tubes, especially the intramural and isthmic segments. Fimbrial phimosis—Agglutination of the fimbriae. Fimbrioplasty—The reconstruction of the fimbriae or tubal infundibulum. Hysterosalpingography (HSG)—An X-ray based con- trast test to assess the uterine cavity and the fallopian tubes. Hydrosalpinx—A distally occluded tube, usually sec- ondary to infection, which distends with accumulation of serous fluid. Pelvic inflammatory disease (PID)—An inflammatory disorder of the uterus, fallopian tubes, and adjacent pelvic structures usually secon Salpingoovariolysis—The division and/or excision of periadnexal adhesions with the aim of restoring normal anatomy. Salpingoscopy—An endoscopic examination of the am- pullary portion of the tubal lumen. Salpingostomy—The creation of a new stoma in a tube with a completely occluded distal end. Tubal cannulation—The passage of a flexible guide wire and narrow-gauge cannula through the proximal tubal ostia along the length o Tubotubal anastomosis—The surgical approximation of tubal segments after tubal sterilization or excision of an occluded or diseased
- 59. CLASSIFIACTION PROXIMAL BLOCK DISTAL BLOCK MILD -TUBAL FIMBRIAL AGGLUTINATION MODERATE—FIMBRAIL PHIMOSIS SEVERE—OBSTRUCTION (COMPLETE BLOCK)
- 60. TREATMENT OF TUBAL BLOCK IVF (ART) TUBAL SURGERY TUBAL CANNULATION
- 61. THINGS TO CONSIDER BEFORE PLANNING A TREATMENT AGE OF PATIENT OVARIAN RESERVE PREVIOUS FERTILITY NO OF CHILDREN PLANNED COST MALE FACTOR / OTHER FACTORS SITE AND EXTENT OF TUBAL DAMAGE
- 62. TUBAL SURGERY IS DONE IN : YOUNG PATIENTS NORMAL OVARIAN RESERVE PROVEN FERTILITY MULTIPLE CHILDREN PLAN
- 63. TUBAL SURGERIES
- 64. REVERSAL OF STERILIZATION PRE OPERATIVE HSG IS MUST SEMEN ANALYSIS NORMAL YOUNG PATIENT <35 YEARS ISTHMO-ISTHMIC ANASTOMOSIS IS DONE (BEST) SUCCESS RATE 40-80% ECTOPIC RATE 5-10%
- 65. Preparation of the ampulla in intramural–ampullary or isthmic–ampullary anastomosis. A: The serosa over the tip of the ampullary stump is incised in a circular manner and excise B: The center point of the exposed muscularis is grasped and a small opening is made into
- 66. Isthmic–ampullary anastomosis in the presence of significant luminal disparity. A: Enlargement of the isthmic lumen. B: Placement of the 12-o’clock suture.
- 67. DISTAL TUBAL OCCLUSION FIMBRIOLYSIS : MILD CASES , SEPARATION OF AGGLUTINATED FIMBRIAE FIMBRIOPLASTY : MODERATE CASES , CORRECTION OF PHIMOSIS NEOSALPINGOSTOMY : SEVERE CASES , REOPENING OF COMPLETLY OBSTRUCTED FIMBRAE, DONE IN YOUNG PTS ONLY. IF THERE IS HYDROSALPHINX , IVF SUCCESS IS REDUCED BY 50% THEREFORE DO SALOHINGECTOMY THEN IVF. IF SALPINGECTOMY NOT POSSIBLE , DO CORNUAL LIGATION. ANOTHER OPTION : ESSURE —HYSTEROSCOPIC TUBAL OCCLUSION BEFORE IVF IN CASE OF HYDROSALPHINX . ESSURE IS 2MM THICK AND FORM A PLUG OF 4 CM.
- 68. Fimbrioplasty: to free agglutinated fimbriae. A: The 3-mm alligator-jawed forceps is introduced through the stenosed opening. B: The jaws of the forceps are opened within the tube. C: The forceps is gently withdrawn while the jaws are kept open.
- 69. Fimbrioplasty: correction of prefimbrial phimosis. A and B: An in- cision is placed at the antimesosalpingeal border of the tube. C: Completed procedure with flaps everted.
- 70. Salpingostomy. A: The occluded distal end of the tube usually has a centrally placed avascular area, from which avascular scarred lines extend in a cartwheel manner. B: The first incision is made along an avascular line toward the ovary. C: Avascular lines are incised by viewing from within the tube along the circumference of the initial opening. D: Cutting along the avascular lines is continued until a satisfactory stoma is fashioned. E: The flaps can be everted by placing two or three no. 6–0
- 71. PROXIMAL TUBAL OCCLUSION 1/4 TH CASES ARE FALSE +VE —-REPEAT HSG / CHROMOPERTUBATION TREATMENT : TUBAL CANNULATION [HYSTEROSCOPIC OR FLUROSCOPIC GUIDED] MULTIPLE BLOCKS / SALPINGITIS ISTHIMICA NODOSA—-IVF IS PREFERED B/L TUBAL BLOCKS —-IVF IS PREFERRED TUBAL CANNULATION 27% PREGNANCY RATE , 4% ECTOPIC RATE FAILURE OF TUBAL CANNUALATION ——— IVF TO BE CONSIDER
- 72. Microsurgical tubocornual anastomosis for proximal tubal disease. A: The tube is transected at the uterotubal function (UTF). Commencing at the UTF, serial cuts are made on the isthmus until patent and normal tube is identified. B: The intramural tube is dissected electrosurgically, by using a microelectrode, from the surrounding uterine muscle, 1 to 2 mm at a time, and (C and D) transected until patent and normal tube is reached. E: The first anastomotic suture of the inner musculoepithelial layer is placed at the 6-o’clock position. F: After the opposition of the inner layer, the seromuscularis of the uterus is joined to the serosa of the tube. G: The mesosalpinx is joined to the lateral aspect of the uterus.
- 74. UTERINE FACTORS
- 78. EVALUATION : D1 MENSTRUAL BLOOD FOR TB PCR / AFB/ CULTURE HSG for evaluation — shape of uterus , submucous fibroid , polyp TVS — endometrial lining Saline infusion sonography — best for submucus fibroid, polyp Hysteroscopy (GOLD STANDARD) — diagnostic as well as therapeutic. Hysteroscopy is therapeutic for — polypectomy , sub mucous myomectomy, septal resection, adhesiolysis [ after adhesiolysis —pediatric foleys is kept for 7 days + estrogen supplement for 1 cycle]
- 85. Resectoscopic metroplasty. A: A Foley catheter is placed in one cavity of a com- plete septate uterus (American Fertility Society class VA uterus). The resectoscope is inserted in the opposite cavity, and the septum is incised until the Foley is visualized. The septum can be easily incised with the resectoscope until both internal os are visible. B: A septate uterus with a single cervix. The septum can be incised with the straight loupe of the resectoscope.
- 86. Techniques of metroplasty. Wedge technique of Jones and Jones. Transverse fundal incision of Strassman. Median bivalving technique of Tompkins.
- 88. ANTI SPERM ANTIBODY IN CERVICAL MUCOUS CAUSES SPERM TO DIE. POST COITAL TEST ( SIMS HUHNER TEST) [NOT DONE ROUTINELY NOWADAYS] DONE ON DAY 13 OF CYCLE. OR DONE WHEN LH SURGE IS DETECTED IN URINE. OR DOMINANT FOLLICLE REACHES 18 MM ON FOLLICULOMETRY SAMPLE IS TAKEN 2-12 HOURS AFTER INTERCOURSE AND CERVICAL MUCOUS IS ASSESSED UNDER MICROSCOPY. CERVICAL MUCUS IS ASSESED FOR — CELLULARITY VISCOSITY MUCUS CLARITY SPERM NUMBER AND MOTILITY
- 89. IF ALL THE SPERMS ARE — AGGLUTINATED DENERATED NON MOTILE SHAKY MOTILITY < 10 MOTILE SPERMS IMMUNOLOGICAL INFERTILITY IF SEMEN ANALYSIS WAS NORMAL
- 90. BOVINE CERVICAL MUCUS SPERM INTERECTION TEST DONE TO DIFFERENTIATE WHETHER ANTIBODIES WERE ALREADY THERE IN SEMEN OR ITS CERVICAL MUCUS ANTIBODIES.
- 93. UNEXPLAINED INFERTILITY ; NORMAL SEMEN NORMAL OVULATION TESTS NORMAL UTERINE CAVITY NORMAL TUBAL PATENCY NO OTHER OBVIOUS CAUSE
- 94. CAUSES : LUT [ LEUTINIZED UNRUPTURED FOLLICLE SYNDROME] 25% CASES IMMUNOLOGICAL ANTISPERM ANTIBODIES DECREASED ENDOMETRIAL PERFUSION INFECTION : U. UREOLYTUCUM , M.GENTALUM UNDIAGNOSED PELVIC PATHOLOGY
- 95. HISTORY AND EXAMINATION OF BOTH PARTNERS IS VITAL COUNSELLING AT FIRST VISIT HAS A KEY ROLE TEST OF OVULATION AND TUBAL PATENCY CORELATE WITH PREGNANCY OUTCOME A REGULAR FOLLOWUP IS NEEDED AGE FACTOR IS IMPORTANT TO START EVALUATION EARLY TEST OF OVULATION RESERVE ARE NOT RECOMMENDED ROUTINELY TUBERCULOSIS TO BE RULED OUT IN TUBAL AND UTERINE FACTOR INFERTILITY TAKE HOME MESSAGE
- 96. REFERENCES Speroff's Clinical Gynecologic Endocrinology and Infertility Berek & Novak's Gynecology TELINDES GYNAECOLOGY
- 97. THANK YOU