Treatment and causes of female infertility.pptx

Treatment & Causes of
FEMALE INFERTILITY
TOPIC:
- Dr. Dimple Gajraj
Saturday, October 21, 2023

• Infertility = Failure to achieve a clinical pregnancy after 12
months or more of regular unprotected sexual intercourse
Under 35 year :No conception after one year of
unprotected intercourse
Over 35 year :No conception after 6months
of unprotected intercourse
When do I consult a doctor ?
PRIMARY INFERTILITY :Patients who have never conceived before
SECONDARY INFERTILITY :Previous pregnancies irrespective of the
outcome, but failure to conceive subsequently

Am I doing
something
wrong ?
Why I am
not able to
conceive ?
Should I
see a
doctor ?
Irregular
Cycle what
to do ?
What is the
right time to
conceive ?
Based on the study conducted by
United Nations “”World Fertility And
Family Planning 2020” – The global
fertility rate decline from 3.2 live births
per women in 1990 to 2.5 in 2019.

CAUSES OF INFERTILITY & PREVALENCE
•Ovulatory disorders - 25%
•Endometriosis - 15%
•Pelvic adhesions - 12%
•Tubal blockage - 11%
•Other tubal/uterine abnormalities -
11%
•Hyperprolactinemia - 7%
•Cervical/other - 5%
•Unexplained - 10%
•Advanced Age
According to a study performed
by WHO, the most common
identifiable factors of female
infertility are :

Abnormality Causes
Hypothalamic Dysfunction or
Hypogonadotropic hypogonadal anovulation
Functional hypothalamic amenorrhea
Wt loss, stress, severe prolonged illness, excessive exercise
Congenital GnRH deficiency
Inflammatory or Infiltrative disease
Brain tumors – craniopharyngioma
Pituitary stalk dissection or compression
Cranial irradiation
Brain Injury – trauma, hemorrhage, hydrocephalus
Other syndrome – Prader-Willi, Kallmann Syndrome, etc.
Pituitary Dysfunction Hyperprolactinemic anovulation
Other pituitary tumors (acromegaly, corticotropic adenoma)
Other tumors (meningioma, glioma)
Empty Sella syndrome
Pituitary infarct or apoplexy
Ovarian dysfunction
Normogonadotropic normoestrogenic anovulation
PCOD or PCOS (polycystic ovarian disease &/ syndrome)
Hypergonadotropic hypoestrogenic anovulation
Premature Ovarian failure (menopause)(G III Ovulation Disorder)
 Ovulatory disorders being the most common make up 25% of the known causes of female
infertility. Oligo-ovulation or anovulation results in infertility because less/no oocyte will be released
monthly. In the absence of an oocyte, there is less/no opportunity for fertilization and pregnancy.

• Endometriosis may influence
different aspects of reproductive
physiology including folliculogenesis,
ovulation, embryo quality, and
fertilization and implantation
• Recent data demonstrate that patients
with endometriosis-associated infertility
undergoing in vitro fertilization (IVF) have a
reduction of pregnancy rates compared to
women with other indications for IVF.
 Endometriosis
 Uterine Causes
• Uterine leiomyomas (fibroids) - submucosal or
intracavitary fibroids
• Congenital uterine abnormalities (CUA)
• Menstrual irregularities
• Endometriosis
• Adenomyosis
• Asherman Syndrome
• Thin endometrium
• Polyps
• Hypoplastic uterus
• Etc…
 Pelvic/Tubal
• Pelvic and tubal adhesions
• Endometriosis
• Pelvic inflammatory disease (PID)
• Tubal obstruction/ blockage (unilateral/
bilateral)
• Hydrosalpinges (unilateral/ bilateral)
• Sexually Transmitted Diseases (STDs),
Asherman Syndrome

Apart from these, some of the potent stressors
of embryos & gametes are lifestyle factors –
very young or older age, obesity, sexually
transmitted infection, drugs, diet imbalance,
vitamin deficiency and psychological stress
addiction to smoking or alcoholism, sedentary
existence
• Social Stigmatization-disapproval of, or
discrimination
• Economic Strain
• Marital Discord
DISRUPTION OF NORMAL OVULATION
DISRUPTION OF MENSTRUAL CYCLES
• Pandemic Covid 19
• Hypo/ hyperthyroidism
• Hyperprolactinemia
• Obesity
• Cervical Or Vaginal factors
• Advanced Age
 OTHER CAUSES

 UNEXPLAINED INFERTILITY

Whom should I consult ?
• RMP
• Gynecologist
• Infertility Specialist
What can I do I am anxious to conceive ?

FEMALE INFERTILITY TREATMENT
• Fertility Enhancing Surgeries with/without medication
 Laparoscopy
 Hysteroscopy
• IUI
• IVF/ ICSI
• Blastocyst Culture
• LAH, IVM, Embryoscope (TLM), PGS
• Oocyte/Embryo Vitrification
• Ovarian tissue cryopreservation
• Surrogacy
• Womb transplant (Swedish surgeons have performed the first womb transplant
operation)
There have been 23 babies born so far , with womb transplant.
• Creating three parent embryos / Mitochondrial Donation Technique
• ERA, PRP, G-CSF, Stem cell therapy,
• Adoption
Any many more in line………

CLOMIPHENE CITRATE - FOR OVULATION INDUCTION IN WOMEN WITH UNEXPLAINED INFERTILITY
 MEDICATION AND /OR
HORMONAL THERAPY
• Clomiphene Citrate
• Letrozole
• Gonadotropins or Human Chorionic Gonadotropin (hCG)
• Bromocriptine or Cabergoline
• Estrogen & Progesterone (oral/SC/vaginal)
• Sildenafil Citrate
• Pentoxifylline (vasodilator) & vitamin E (antioxidant)
• etc…
 TIMED INTERCOURSE
• Is the act of having sexual relations on the most fertile days of a woman’s monthly
cycle
• A good approach is to have sex one to two days before ovulation and again on the
day of ovulation

 LAPAROSCOPY (Diagnostic &
Operative )
 to evaluate for pelvic
disease,
 such as endometriosis
 check patency of
fallopian tubes
 HYSTEROSCOPY (Diagnostic
& Operative )
 to evaluate condition of
uterine
 cavity (polyps, fibroids)
HYSTEROSAPINGOGRAPHY
- HSG- May be used as a
screening test for tubal
patency in low risk couples
 FERTILITY ENHANCING SURGERY


IUI IVF ICSI
INDICATIONS OF IUI
• Abnormal semen profile
• Cervical factor
• Immunological factor
• Unexplained Infertility
• Mild Endometriosis
• Unilateral tubal defect
• Ovulatory dysfunction
• Others- Erectile dysfunction, Hypospadias,
Vaginismus, pt. bedridden, Neurological
disorder, Husband away for ‘long period
• HIV +ve partner
• defination
• is a process by which an egg
is fertilised by sperm
outside the body
INDICATIONS of IVF/ICSI
• Tubal factor
• Severe male factor
• Diminished ovarian reserve
• Endometriosis
• Advanced age
• Third party reproduction
• Unexplained infertility
• INDICATION
• Same as IVF
• Failed IVF
• Testicular sperm
This procedure is most
commonly used to
overcome male factor
infertility

 ASSISTED LASER HATCHING
1.Age >38 years
2. Zona thickness >15 microns
3.Repeated IVF failures
4.Post thaw Embryo transfer (frozen ET)
5. Prior to PGD
Routine use in all patients does not improve
Pregnancy Rates.
 PGS :
• FISH (Fluorescence in situ hybridization) and
CGH(Comparative genomic hybridization)
microarray
• Identify normal healthy embryos with
improved implantation rate
• Increase the PR
• Reduce miscarriages
• Ideal for RIF and older women

 EMBRYOSCOPE: TIME LAPSE IMAGING
Chen. Practical application of
time-lapse markers. Fertility
Sterility 2013

Embryo Vitrification
Conditions hostile for ET
• Endometrium < 7mm or > 14mm
• Fluid collection within uterine cavity
• Spotting
• Serum P > 1.5 ng/ml in normal responders
Greisinger G et al Fertil & steril 2013
• Applebaum score < 14 (USG parameters & Doppler analysis of uterine blood flow)
Ovarian tissue cryopreservation
• Ovarian cortex is cut into strips and preserved using cryoprotectants
• For women's undergoing radio &/ chemotherapy, ovarian tissue called the
ovarian cortex can preserved. The tissue can be transplanted years later to
make pregnancy possible
• OTC has been indicated mainly to safeguard fertility in cancer patients at
risk of ovarian insufficiency and infertility due to gonadotoxic treatments
 CRYOPRESERVATION
Ellen Cristina, Transfus Med Hemother 2019

Maximizing the potential of cryopreserved human ovarian strips
 Human ovarian biopsies taken for fertility preservation contain mainly primordial follicles. IMMATURE EGGS
 The challenge is to develop the immature eggs in the lab to maturation and fertilization
 Lab Grown eggs :In vitro Gametogenesis/Growth & maturation (IVG)
 Development of immature oocytes to maturity entirely in the lab (in vitro)
 Formation of new oocytes from stem cells
 The critical chain of events leading from Germinal vesicle break down to the expulsion of first polar body take place in vitro
& generation of metaphase II oocytes
Multi- step Culture system to support human oocyte development
In healthy adult tissue approx. 30 %of oocytes that complete the culture process can reach maturity
(Metaphase II)

 THIRD PARTY OPTIONS or UTERUS TRANSPLANTATION
• Recurrent Implantation failures
• Egg donation in case of failure to
produce eggs or yield of poor
quality eggs during IVF
IFFS surv 2010: allowed 31,not allowed
23 ,none: 5, total 59 countries
• Surrogacy in patients with poor
end organ problems such as
genital TB, severe Asherman,
adenomyosis underdeveloped or
maldeveloped uterus.
IFFS surveillance: allowed 28,not allowed
30, none :10 ,Total 71 countries

 ENDOMETRIAL RECONSTRUCTION FROM STEM CELLS

 ENDOMETRIAL RECEPTIVITY ARRAY (ERA)
Ruiz-Alonso, Fertil Steril et al. 2013
 MITOCHONDRIAL REPLACEMENT THERAPY (MRT)
MRT is a new form of reproductive technology (IVF) which works on the principle of replacing a women’s abnormal
mitochondrial DNA (mt-DNA) with the donor’s healthy one. MRT include different techniques like spindles transfer(ST),
pronuclear transfer(PNT) or polar body transfer (PBT).
• Transmission of defective mitochondrial DNA to next generation can be prevented using this
• The development of healthy baby free from genetic disorders & to terminate lethal mitochondrial disorders are chief motive
• In aged women, through IVF, MRT provides substitute of defective cytoplasm with cured one to enhance the expectation of pregnancy
rate.
ERA is based on analysis of expression of 238 genes,
thought to be involved in endometrial implantation ,
may lead to determination of personalized ‘Window of
Implantation’

 GRANULOCYTE- COLONY STIMULATING FACTOR (G-CSF)
Play important role in embryo implantation & continuation of pregnancy, can be used in patient with multiple implantation
failures and thin endometrium.
• Stimulates proliferation, differentiation and activation of granulocytes and monocytes
• Produced in oviduct and uterus of mouse, sheep, cow and human
• Released into uterine lumen in mouse prior to implantation
• Improves cow, sheep, mouse and human embryo development in vitro
 PRP- PLATELET RICH PLASMA
Intrauterine PRP infusion represents a new method for thin endometrium with poor response
PRP contains high concentration of growth factors & cytokines which promotes natural growth and regeneration such as:
• VEGF (Vascular endothelial growth factor)
• PDGF (Platelet derived growth factor)
• EGF (Epidermal growth factor)
• TGF (Transforming growth factor)
PRP can be used as an “ovarian rejuvenation treatment "to help women overcome premature menopause, low ovarian reserve &
advanced maternal age
 INVOCELL / VAGINCUBATOR
 OZONE SAUNA THERAPY

•Healthy eating habits-
•Adding more whole-grain products, fruits, vegetables.
•Limiting processed foods and foods with added sugars, eating a diet low in cholesterol and saturated fats
•Promote regular exercise
•No smoking (avoid passive smoking)
•Limit alcohol intake
•Maintain healthy weight
•Folic acid supplementation in women
•Advice on rubella vaccination if seronegative
•Treatment of Psycho-sexual problems
• ADOPTION - to be considered too…..
What can be done !!
• PSYCHOTHERAPY &
• COUNSELING

• According to a report conducted by the International Institute of Population Sciences, infertility is growing at an alarming
pace, especially in the cities.
• Out of around 250 million individuals estimated to be attempting parenthood at any given time, 13 to 19 million couples are
likely to be infertile.
• Primary Infertility rate among currently married women aged 20-49 married for above 5 years , National Family Health Survey
1998-99 and 2005-2006 has decreased from 2.01% to 1.85 % respectively. Infertility rate is higher among women in urban
areas, may be due to lifestyle or a later age at first marriage.
• Globally, the age-standardized prevalence rate of infertility increased by 0.370% per year for females & 0.291% per year for
males from 1990 to 2017. It was based on finding from 2017 study on the Global burden of disease(GBD), assessed infertility
in 195 countries & territories from 1990 - 2017
• Globally, infertility affects 15 % of couples of reproductive age (1990-2017).
GROWING INFERTILITY TREND IN INDIA & ABROAD

THANK -YOU

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