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Subfertility
- 1. Dr Athula Kaluarachchi MBBS,MS,MRCPI,FRCOG,FSLCOG “Try not to become a man of success but rather to become a man of value ” Albert Einstein
- 2. Chances of conception Unprotected intercourse for 1 year – 80% Unprotected intercourse for 1.5 years – 90% Wait for one year before investigating
- 3. Erection Penetration Ejaculation & deposit in the right place No cervical hostility Normal uterus Normal fallopian tubes Normal ovulation
- 5. After ovulation, the egg usually lives for up to 24 hours. After ejaculation, sperm can survive for up to seven days in the genital tract and some times even longer. The decline with age in rates of conception is seen after age 30 years of age and is more marked after 35 years. The effect of age on male fertility is less clear.
- 6. The best sperm motility has been found in semen emission every three to four days on average. Coitus every two to three days is likely to maximise the overall chance of natural conception, as spermatozoa survive in the female reproductive tract for up to seven days after insemination. The highest estimated conception rates associated with intercourse two days before ovulation.
- 7. Depends on cycle length 1 14 28 1 21 35 - 18 Short cycle to -10 Long cycle 1 10 25
- 8. Alcohol Excessive alcohol consumption can be detrimental to the semen quality but the effect is reversible and there is no evidence of causal association between moderate alcohol consumption and poor semen quality.
- 9. There is a significant association between smoking and reduced fertility among female smokers. There is an association in men between smoking and reduced semen parameters.
- 10. Women with BMI over 30 kg/m 2 take longer to conceive, compared with women with lower BMI There is reduced number of normal motile sperm cells in men who are overweight (BMI 25 – 30) and obese (BMI greater than 30) when compared with men of normal weight (BMI 20 – 24). Obesity may have a deleterious effect on erectile function of men with existing vascular risk
- 11. Important determinants of testicular temperature such as a sedentary work position and occupational heat exposure have been associated with abnormal semen quality.
- 12. Prescribed drug use Nonsteroidal anti-inflammatory drugs inhibit ovulation. Immunosuppressive and ant-inflammatory drugs for rheumatic disease may affect conception. In a case-control study, women who had ever used thyroid replacement hormones, antidepressants, tranquilizers or asthma medication were reported to have elevated risks of anovulatory infertility.
- 13. Recreational drugs The use of recreational drugs or drugs abuse such as marijuana and cocaine can adversely affect ovulatory and tubal function. The use of drugs such as anabolic steroids and cocaine can adversely affect semen quality.
- 16. Coital problems Vaginismus Endometriosis Distortion of pelvic anatomy Disorders in ovulation Peritoneal factors
- 17. Tubal disease Endosalpingitis leading to obstruction Pelvic adhesions – distorting tubal anatomy Uterine factors Uterine anomalies Endometrial disease
- 18. Ovulatory disorders WHO classification of ovulatory disorders a. Hypothalamic pituitary failure (10%) b. Hypothalamic pituitary dysfunction (85%) - PCOD c. Ovarian failure (4%)
- 21. Problems of Delivery Ejaculatory dysfunction Erectile dysfunctions Obstruction Problems of Production Count Motility Morphology Volume
- 23. Finding Cause Abnormal count Azoospermia Klinefelter's syndrome or other genetic disorders Sertoli-cell-only syndrome Seminiferous tubule or Leydig cell failure Hypogonadotrophic hypogonadism Ductal obstruction, including Young's syndrome Varicocele Exogenous factors Oligozoospermia Genetic disorder Endocrinopathies, including androgen receptor defects Varicocele and other anatomic disorders Maturation arrest Hypospermatogenesis Exogenous factors – Alcohol,Smoking Abnormal volume No ejaculate Ductal obstruction Retrograde ejaculation Ejaculatory failure Hypogonadism Low volume Obstruction of ejaculatory ducts Absence of seminal vesicles and vas deferens Partial retrograde ejaculation Infection High volume Unknown factors Abnormal motility Immunologic factors Infection Varicocele Defects in sperm structure Metabolic or anatomic abnormalities of sperm Poor liquefaction of semen Abnormal viscosity Etiology unknown Abnormal morphology Varicocele Stress Infection Exogenous factors Causes of Semen Abnormalities • The characteristics of semen may vary over time and undergo normal biological variability, if an abnormality is found, it is best to repeat the test on two or three occasions.
- 24. Age over 35 years Previous pelvic surgery History of endometriosis History of PID Disorders of ovulation Abnormal sperm parameters
- 25. Investigation of the male Seminal Fluid Analysis Seminal Fluid Culture/ABST Investigation of the female Hormonal Assay Tubal Patency assessment Assessment of pelvic pathology
- 26. This is a sensitive test (sensitivity of 89%), but has poor specificity. Analysis of repeat semen samples provides greater specificity in identifying semen abnormalities; a single-sample analysis will falsely identify about 10% of men as abnormal. But repeating the test reduces this to 2%. Always Repeat
- 27. Volume ≥ 2.0ml pH ≥ 7.2 Sperm concentration ≥20x106 spermatozoa/ml Total sperm number ≥ 40x106 spermatozoa per ejaculation Motility ≥ 50% motile or ≥ 25% with progressive motility (grade a) within 60 minutes of ejaculation Morphology ≥ 30% of normal morphology Vitality ≥50% live White blood cells <1x106 per ml
- 29. Assessing ovarian reserve An elevated basal D3 FSH is correlated with diminished ovarian reserve and associated with poor pregnancy rates after ovulation induction. Antral Folllicle count Anti mullerian factor
- 30. a. Hypothalamic pituitary failure (10%) b. Hypothalamic pituitary dysfunction (85%) c. Ovarian failure (4%)
- 31. Assessing ovulation Regular menstrual cycles - 26 to 36 days cycles are usually indicative of ovulation. In practice, testing for release of the oocyte by observing follicle rupture is impractical Serum Progesterone ovulation detection is based on the detection of circulating progesterone produced following leutinisation of the follicle. (measurement of serum progesterone in mid luteal phase, approximately on day 21st of a 28 day cycle.)
- 32. For women with irregular cycles this test may need to be performed later in the cycle (e.g. day 28 of a 35 day cycle) and repeated weekly until the next menstrual cycle starts.
- 33. Prolactin Measurement Estimation of prolactin level should be reserved for women with symptoms of an ovulatory disorder , galactorrhoea or a pituitary tumour. Assessment of Thyroid Function
- 35. Diagnosis of the PCOS requires the presence of at least two of the following three criteria. 1. Oligo- and/or anovulation 2. Clinical and/or biochemical hyperandrogenism 3. Polycystic ovaries, with the exclusion of other aetiologies.
- 36. The new definition for the diagnosis of a polycystic ovary (which is usually obtained from an ultrasound scan) requires the presence of at least 12 follicles measuring 2- 9 mm in diameter and/or an ovarian volume in excess of 10 cm3 . Polycystic ovaries are present in about 80- 90% of women with oligomenorrhoea and 30% of women with amenorrhoea.
- 38. Luteal phase defect is estimated to affect 3- 20% of the infertile population and 23-60% of women with current miscarriage. The benefit of treatment for luteal-phase defect on pregnancy rates has not been established.
- 39. systematic review of 11 observational studies showed that the postcoital has poor predictive power of fertility and lacks validity.
- 47. Primary Level Educate - Stop smoking alcohol occupation Educate - Fertile period Coital frequency Coital problems Seminal Fluid analysis
- 48. Secondary level Induction of ovulation ◦ Clomiphene citrate ◦ Clomiphene Citrate+ Gonadotrophins ◦ Metformin is used in patients with evidence of insulin resistance
- 49. Multiple pregnancy rates were seen in those women who conceived following laparoscopic drilling
- 51. Timed Sexual intercourse Intrauterine insemination
- 53. Male factor infertility Tubal disease Endometriosis Unexplained fertility problems treatment for cancer where cryopreserved semen is unsuitable for IUI. Ovarian failure requirement for egg donation
- 54. Male factor infertility Tubal disease Endometriosis Unexplained fertility problems treatment for cancer where cryopreserved semen is unsuitable for IUI. Ovarian failure requirement for egg donation
- 55. Pituitary down regulation Ovarian stimulation Egg collection followed by semen production or sperm recovery IVF/ICSI Transfer of resulting embryos to the uterus Luteal support (administration of hormones to aid implantation of embryos).
- 56. Long Protocol GnRH(Day 21) FSH HCG OPU Short Protocol GnRH FSH HCG OPU
- 57. Ultra Short Protocol GnRH agonists are used only for about 3-4 days
- 76. Obstructive azoospermia Nonobstructive azoospermia Infectious disease in the male partner (such as HIV) Severe deficits in semen quality in couples who do not to wish to undergo intracytoplasmic sperm injection. Certain cases where there is a high risk of transmitting a genetic disorder to the offspring.
- 77. Premature ovarian failure Gonadal dysgenesis including Turner syndrome. Bilateral oophorectomy Ovarian failure following chemotherapy or radiotherapy. Certain cases of in vitro fertilization treatment failure. Oocyte donation should also be considered in certain cases where there is a high risk of transmitting a genetic disorder to the offspring.