Infertility by Dr qaisar

3.  Infertility
 Inability of a couple to conceive after one year of
regular and unprotected intercourse (6 months for
women over 35?)
 Fertility
 Ability to conceive

4. 1. Primary infertility:
the couple have never achieved conception
before
2. Secondary infertility:
the couple who fails to achieve conception
after having conceived once or more

5.  80% of couples will conceive within 1 year
of unprotected intercourse
 ~86% will conceive within 2 years
 ~14-20% of US couples are infertile by
definition (~3 million couples)
 Origin:
 Female factor ~40%
 Male factor ~30%
 Combined ~30%

6.  Sperm disorders 30.6%
 Anovulation/oligoovulation 30%
 Tubal disease 16%
 Unexplained 13.4%
 Cervical factors 5.2%
 Peritoneal factors 4.8%

7.  PID
 Endometriosis
 Ovarian aging
 Spermatic varicocoele
 Toxins
 Previous abdominal surgery (adhesions)
 Cervical/uterine abnormalities
 Cervical/uterine surgery
 Fibroids

8.  Female
 Ovary
 Tube
 Corpus
 Cervix
 Peritoneum
 Male
 Sperm count and function
 Ejaculate characteristics, immunology
 Anatomic anomalies

11.  Both couples should be present
 Age
 Previous pregnancies by each partner
 Length of time without pregnancy
 Sexual history
 Frequency and timing of intercourse
 Use of lubricants
 Anorgasmia, dyspareunia
 Contraceptive history

12.  History of pelvic infection
 Radiation, toxic exposures (include drugs)
 Mumps
 Testicular surgery/injury
 Excessive heat exposure (spermicidal)

13.  Previous female pelvic surgery
 PID
 Appendicitis
 IUD use
 Ectopic pregnancy history
 Endometriosis

14.  Irregular menses, amenorrhea, detailed
menstrual history
 Stress
 Weight changes
 Cervical and uterine surgery

15.  Patient not sexually-active
 Patient not in long-term relationships
 Couple does not meet the definition of an
infertile couple

16.  Size of testicles
 Testicular descent
 Varicocoele
 Outflow abnormalities (hypospadias, etc)

17.  Pelvic masses
 Uterosacral nodularity
 Abdominopelvic tenderness
 Uterine enlargement
 Thyroid exam
 Uterine mobility
 Cervical abnormalities

19. Failure of ovulationFailure of ovulation
Tubal factorsTubal factors
Cervical factorsCervical factors
Uterine factorsUterine factors
Hormonal disordersHormonal disorders
MiscellaneousMiscellaneous

20.  Gonadotropin deficiencyGonadotropin deficiency
 Polycystic ovarian diseasePolycystic ovarian disease
 Ovarian failure:Ovarian failure:
I.I. Congenital (turner syndrome)Congenital (turner syndrome)
 HyperprolactenemiaHyperprolactenemia
 Weight changesWeight changes
 Drugs (tri-cyclic anti depressant, phenothiazine,Drugs (tri-cyclic anti depressant, phenothiazine,
methyldopa, reserpine)methyldopa, reserpine)

21. Fallopian tubes may be blocked in the followingFallopian tubes may be blocked in the following
conditioncondition ;
PIDPID
EndometriosisEndometriosis
Tubal surgery ( ectopic pregnancy, sterilization)Tubal surgery ( ectopic pregnancy, sterilization)
Ruptured AppendixRuptured Appendix
Ulcerative ColitisUlcerative Colitis
Crohn’s DiseaseCrohn’s Disease

22. The cervical mucus may interfere with sperm ascent inThe cervical mucus may interfere with sperm ascent in
the presence of ;the presence of ;
Reduced amount of thin cervical mucusReduced amount of thin cervical mucus
Anti-sperm-antibodiesAnti-sperm-antibodies

23. A fertilize ovum may fail to Implant in the presence ofA fertilize ovum may fail to Implant in the presence of
i) Multiple fibroids ii) Intra-uterine adhesions
(Asherman syndrome)

24.  Absence of menstruationAbsence of menstruation
 Early depletion of ovarian follicles before age 35Early depletion of ovarian follicles before age 35
 Fertilization problemFertilization problem
 Oocyte membrane proteinOocyte membrane protein
 The developing embryo may be mistaken for foreign body byThe developing embryo may be mistaken for foreign body by
deranged immune systemderanged immune system
 Developmental problemsDevelopmental problems
 1.Hard egg1.Hard egg
 2.Teratogens2.Teratogens

25.  OthersOthers
.. Medications (alcohol,thalidomide etc…..)Medications (alcohol,thalidomide etc…..)
.. Thyroid problems (mainly hypothyroid)Thyroid problems (mainly hypothyroid)
.. Sickle cell diseaseSickle cell disease
.. HIV/AIDSHIV/AIDS
.. Kidney diseaseKidney disease
.. DiabetesDiabetes

27.  Serum FSH, PRL levels(mainly FSH)
 Semen analysis
 Testicular biopsy
 Sperm penetration assay (SPA)

28.  Collected after 480
of abstinence
 Evaluated within one hour of ejaculation
 If abnormal parameters, repeat twice, 2 weeks
apart

29. Quality Normal Value
Volume >1 cc
Concentration >2 x 106
/cc
Initial Forward
Motility
>50%
Normal Morphology >60%

30.  Dynamic test of fertilization capacity of sperm
 False positives and negatives exist

31. According to cause
Ovulation inductionOvulation induction

clomiphene (clomiphene (drug of choice in normaldrug of choice in normal
gonadotropin and prolactin levelgonadotropin and prolactin level))
 tamoxifentamoxifen
 cylcofenil(cylcofenil(anti oestrogenic and also makeanti oestrogenic and also make
cervical mucus thin and copiouscervical mucus thin and copious))
 bromocriptin(bromocriptin(drug of choice indrug of choice in
hyperprolactinaemiahyperprolactinaemia))
 gonadotropins(gonadotropins(human menopausal gonadotropin,GnRHhuman menopausal gonadotropin,GnRH))

34.  General advice
 Reduce alcohol consumption
 Reduce smoking
 Should avoid testiculotoxic drugs etc.....
 Hypogonadotrophism
 GnRH
 hCG results poor
 Varicocoele
 Patient with varicocoele may be fertile or infertile but
the surgical procedures may not be affective
 Retrograde ejaculation
 Ephedrine, imipramine

35. Idiopathic oligospermia
 No effective treatment
 ?IVF
 donor insemination
Antisperm antibodies
 Treated with prednisolone

37. ((counselingrequiredcounselingrequired))
A. Intra-uterine inseminationA. Intra-uterine insemination
indications:indications:
i) unexplained infertilityi) unexplained infertility
ii) cervical factorsii) cervical factors
iii) poorsemen reportiii) poorsemen report
iv) impotenceiv) impotence

38. B. In-vitro fertilizationB. In-vitro fertilization
indicationsindications
i) tubal diseasetubal disease
ii)un-explained infertilityii)un-explained infertility
iii)endometriosisiii)endometriosis
iv)male factorsiv)male factors
v)failed intra-uterine inseminationv)failed intra-uterine insemination
vi)cervical hostilityvi)cervical hostility
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