Basic infertility rx 17.02.2016
•Download as PPTX, PDF•
5 likes•1,039 views
This document summarizes male and female infertility treatments. It discusses common causes of infertility like hormonal imbalances, anatomical abnormalities, genetic factors, etc. It provides details on initial lifestyle modifications and treatments for specific etiologies. Treatments mentioned include counseling, surgery, medication, assisted reproduction techniques like IUI, IVF, ICSI, and donor gametes. The document is intended as an educational guide for residents on evaluating and managing infertility cases.
Recommended
More Related Content
What's hot
What's hot (20)
Viewers also liked
Viewers also liked (11)
Similar to Basic infertility rx 17.02.2016
Similar to Basic infertility rx 17.02.2016 (20)
Recently uploaded
Recently uploaded (20)
Basic infertility rx 17.02.2016
- 1. Maneenuch Sripha, 1st year resident Chayanis Tinsopharat, 2nd year resident Adviser : Assist. Prof. Matchuporn Sukprasert
- 2. Objectives • Recall etiologies of male and female infertility • Approach to infertility management by etiology • Treatment of common causes of male & female factors • Assisted reproductive technologies : basic pharmacology & procedures
- 3. Etiology Berek & Novak's Gynecology, 15th edition Male factor Female factor Both Unexplained 10-40% 10-20% 40-55% 20-30%
- 4. Initial : Lifestyle modifications Smoking cessation Reducing excessive caffeine and alcohol consumption Appropriate frequency of coitus (every one to two days around the expected time of ovulation)
- 6. Male factor • Physiology Male reproductive tract
- 9. Sperm transport • 70 days: complete spermatocyte stage • 12-21 days : testisepididymis ejaculatory duct Ejaculated semen • mature spermatozoa, fluid from the prostate gland, seminal vesicles and bulbourethral gland Capacitation • remove of inhibitory mediator
- 10. Fertilization Acrosome reaction • hydrolytic enzyme Sperm binds to and penetrates zona pellucida Cortical reaction • oocyte release cortical granules Stop binding to new sperm and inhibit penetration of previously bound sperm
- 11. Azoospermia Obstructive •Normal sperm production Non obstructive •Decreses or absence spermatogonosis
- 12. Etiologies in male factor infertility Pretesticular • Endocrine • Coital disorder Testicular • Genetic • Congenital • Infection • Anti- spermatogeni c agent • vascular • Immunologic Posttesticular • Obstructive • Epididymal hostility • Acc. gland infection • Immunologic
- 13. Pretesticular Hypothalamic- pituitary disorder • Congenital Kallmann Syndrome • Tumors • Infiltrative diseases • Hyperprolactinemia • Drugs GnRH analogs, androgens, estrogens, glucocorticoids, opiates • Critical illness or injury • Chronic systemic illness or malnutrition • Obesity
- 14. Testicular Genetic Klinefelter syndrome Y chromosome deletions Congenital Cryptorchidism Vascular Varicoceles Infections Mumps, leprosy,TB,gonorrhea, chlarmydia Antispermatogenic agent heat, chemotherapy, drugs, irradiation smoking, alcohol, cocaine
- 15. Post testicular Epididymis • Congenital Young syndrome Kartagener syndrome • Infection • Epididymal obstruction or dysfunction Vas deferens • genetic CBAVD • Vasectomy • Ejaculatory dysfunction (e.g., spinal cord disease)
- 16. Treatment of male infertility
- 17. Treatment of Male factor 1. Lifestyle modification in all cases 2. Treat underlying/identificable causes Varicocele repair Post-vasectomy reversal 3. Assisted reproductive technologies Sperm collection : autologous sperm from surgical sperm recovery (MESA, PESA, TESE, TESA) , donor sperm Fertilization : Artificial insemination, ICSI
- 18. • 15% in male population. 40% in infertile • Improve semen parameter BUT not clear to improve fertility • Consider in • Palpable varicocele • Abnormal semen analysis Varicocele repair
- 19. • Method • Surgical • Percutaneous embolization • Complication Infection Varicocele: persist, recurrent Hydrocele Varicocele repair
- 20. Vasectomy reversal • Microsurgical vasovasostomy or vasoepididymostomy • 100%patency • 80%subsequent pregnancy rate • Rate of patency and pregnancy inverse variation from time that vasectomy (esp. 15yr or more) • Azoospermia 6mo after reversal considered failure => sperm aspiration with ICSI
- 21. • repeat sperm retrievals, minimum interval between is 3-6mo for adequate healing. Surgical sperm recovery for ICSI
- 22. • Placement of whole semen or processed sperm into female reproductive tract • Treat – unexplained infertility and male factor infertility • Technique: IUI (intrauterine insemination) Intracervical insemination Insemination processing Artificial insemination
- 23. • Pregnancy rate -10.5%/cycle -38% after 4-6 cycles • Single IUI a single cycle IUI(intrauterine insemination) • 0.3-0.5 ml washed, processed, and concentrated sperm • Intrauterine placement through transcervical catheterization
- 24. • injection of a live sperm into the oocyte • Bypassing limitation of -sperm motility -defect in capacitation -acrosome reaction -sperm binding to zona pellucida ICSI : Intracytoplasmic Sperm Injection Offer for < 2 million motile sperm < 5% motility Or surgically recovered sperm used
- 25. ICSI Risk of ICSI • Oocyte degeneration 30-50% • Higher congenital anomaly risk (4.2% compared with IVF 2-3%) • Higher risk of sex chromosome abnormality & translocation Counsel for infertility/ abnormality risk in offspring • Y chromosome deletion • abnormal karyotype • cystic fibrosis mutation • congenital absence of vas deferens
- 26. Donor insemination • Donor sperm screening • Screen for HIV infection, HBV, HCV, syphilis, gonorrhea, chlamydia, CMV infection • Cryopreserved sample guarantee for 6mo, donor replace for HIV before clinical use of specimen
- 28. Etiology Berek & Novak's Gynecology, 15th edition Ovulatory dysfunction 20-40% Tubal/peritoneal 20-40% Others 10-15% Uterine Endometrium Cervix
- 29. Age & Decreased Ovarian Reserve • Starts at early 30's, accelerated at early 40's • Oocyte quality & quantity Ovarian reserve assessment FSH Basal estradiol CCCT Inhibin B AMH Antral follicle count
- 30. • Aging endometrium does not effect fertility • Treatment Autologous IVF Donor oocyte/embryo Adoption Age & Decreased Ovarian Reserve Donor eggs Nondonor eggs
- 31. Quiz : The most common ovulatory factor ?
- 32. Weight reduction • Obesity ➡ poor infertility treatment outcome • 5% weight loss improve pregnancy rate 1) Lifestyle modification : diet & exercise 2) Pharmacologic treatment 3) Weight-loss surgery
- 33. Ovulation induction Preovulatory monitoring hCG Triggering SI/IUI 40 hr after hCG SI q 2-3 d after last CC -Serum progesterone -Urine LH -U/S follicles
- 34. Ovarian stimulation Ovulation induction Superovulation Controlled ovarian stimulation Patient Anovulatory Ovulatory or anovulatory Objective One mature follicle > one Multiple Method Stimulation Stimulation • Down regulation • Stimulation • Prevent premature LH surge Example PCOS IUI IVF
- 36. Gonadotropin • Fail to ovulate or conceive with oral agents • hMG (Repronex, Menopur) • FSH (Follistim, Gonal-F, Bravelle) • LH (Luveris) • Dose : 37.5-75 IU/day • Monitor : Estradiol or TVS follicle • Increase dose by 50% next cycle
- 37. “hCG ovulation triggering” • Induce final follicular maturation & ovulation • After clomiphene citrate cycle If dominant follicle develops, but no LH surge • After gonadotropin cycle When 1-2 follicles are 16-18 mm & E2 level 150-300 pg/ml/dominant follicle • Ovulation within 40 hr later • SI within 24-48 hr • IUI at 24-36 hr
- 38. Quiz : Surgical treatment ? Laparoscopy Hydro-laparoscopy
- 39. Other anovulatory disorders • Hyperprolactinemia • 1st line treatment : Dopamine agonist • Normalize prolactin level & induce ovulation 80-90% • Hypogonadotrophic hypogonadism • Hypothalamic-pituitary axis dysfunction Kallmann syndrome GnRH, Gonadotropin therapy CNS tumor Sx Stress/weight loss/anorexia/excessive exercise/low BMI Encourage good nutrition and optimal body weight
- 40. Quiz : Hysterosalpingogram Diagnosis ? Management ? Expectant Cannulation Diagnostic Laparoscopy Reconstructive Surgery IVF
- 41. Proximal tubal obstruction • Proximal tubal catheterization & cannulation via HSG or hysteroscopy • 85% success rate • 30% reocclusion Candidate : • Muscle spasm • Stromal edema • Amorphus debris • Mucosal agglutination • Viscous secretion Non-responder : • Luminal fibrosis • Failed tubal reanastomosis • Fibroids • Congenital atresia • Tuberculosis
- 43. Quiz : Failed catheterization ? Diagnostic laparoscopy Reconstructive surgery ART
- 44. Reconstructive microsurgery for proximal tubal occlusion Isthmus excision & reimplantation into uterine cornua
- 45. Quiz : Hysterosalpingogram Diagnosis ? Management ? Expectant Cannulation Diagnosis Laparoscopy Reconstructive Surgery IVF
- 46. Distal tubal obstruction • 85% of tubal factor • Infection, endometriosis, prior abdominal/pelvic surgery • Microsurgery vs. IVF Microsurgery candidate • Age < 35 years old • Mild distal tubal disease • Normal tubal mucosa • Absent/minimal pelvic adhesion IVF • Older than 35 • Decrease ovarian reserve • Proximal & distal disease • Severe adhesion • Tubal damage
- 47. Reconstructive microsurgery for distal tubal occlusion Salpingo-ovariolysis Salpingoneostomy Fimbrioplasty: to free agglutinated fimbriae Fimbrioplasty: correction of prefimbrial phimosis
- 48. Quiz : Management ? Right adnexa Left adnexa
- 49. Hydrosalpinx • From distal tubal obstruction • Fuid = Toxin • Embryo development • Implantation • Decrease IVF pregnancy rate Salpingectomy prior to IVF Laparoscopic tubal occlusion
- 50. Quiz : Management ?
- 51. Post-sterilization • Reversal of sterilization Tubotubal Anastomosis • Approach : Minilaparotomy, laparoscopy, robotic- assisted laparoscopy • Pregnancy rate from 55% 81% • Most pregnancy occur within 18 months • Failure ART • Success predictors ? : • Younger than 35 • Isthmic- isthmic or ampulo-ampullar anastomosis • Final tubal length > 4 cm • Less destructive sterilization methods
- 52. SonohysterogramQuiz : TVS Management ? Hysteroscopy
- 53. Endometrial polyps • Risk factors : obesity, unopposed estrogen, PCOS • Mechanism : disordered endometrial receptivity • Treatment : Hysteroscopic Polypectomy • A prospective RCT : 2.1x higher pregnancy rate in women who underwent polypectomy prior to IUI
- 54. Quiz : Management ?
- 55. Myoma uteri • Mechanism : altered uterine contractility, impaired gamete transport, endometrial dysfunction • Location : Submucous and intramural myoma ↔ infertility • Size : Unclear • Cavity distortion : Intramural myoma regardless of cavity distortion related to decreased live birth rate
- 56. Myoma uteri • Myomectomy Removal of cavity-distorting intramural myomas & submucous myomas improves fertility Insufficient data for removal of non-cavity-distorting intramural myomas Transmyometrial approach : concern for uterine rupture during pregnancy
- 57. Quiz : Next management ? SonohysterogramHysteroscopy
- 58. Asherman’s Syndrome • Iatrogenic Uterine evauation Myomectomy Hysterotomy Diagnostic curettage C/S Tuberculosis Caustic abortifacients Uterine packing
- 59. Asherman’s Syndrome • Treatment : Hysteroscopic resection of synechiae Quiz : Postoperative prevention ? Estrogen therapy for 1 month or intraoperative intrauterine device for 1-2 weeks
- 60. • The patient should be involved in fertility treatment choices Infertility treatment
Editor's Notes
- Testis Epididymis Vas deferens Prostate Seminal vesicle Ejaculatory duct Bulbourethral gland urethra
- Spermatogonia (mitosis) spermatocyte(2n) (meiosis) spermatid(n) (spermiogenesis) spermatozoa Spermiogenesis nucleus condensation/formation of flagellum, acrosome
- Deficiency of GnRH or gonadotropins infertility -Kallmann The most common congenital cause isolated gonadotropin deficiency due to absent or defective GnRH secretion (resulting in sexual infantilism). extragonadal abnormalities: anosmia, red-green color blindness, midline facial defects (e.g., cleft palate), neurosensory hearing loss, synkinesis (mirror movements), or renal anomalies Hypothalamic and pituitary tumors (e.g., craniopharyngioma, macroadenoma) Infiltrative diseases (sarcoidosis, histiocytosis, transfusion siderosis, hemochromotosis) Obesity : aromatase activityestrogen
- Klinefelter Syndrome primary testicular failure,1 in 1,000 extra X chromosome (47,XXY)-common form translocation of the testis-determining gene (SRY) to an X chromosome CAG repeats on the androgen receptor gene :taller stature, lower BMD, gynecomastia, and decreased penile length, small, firm testes, resulting from damage to both seminiferous tubules and Leydig cells. Serum concentrations of FSH and LH are elevated and testosterone levels are decreased. Y Chromosome Deletions Microdeletions of the long arm of the Y chromosome . severe oligospermia and azoospermia affecting up to 20% of men with infertility – TRANSMIT TO SON IF CONCIEVE Cryptorchidism a failure of testicular descent,which is an androgen-dependent process. (Kallmann syndrome, androgen resistance) impaired spermatogenesis and an increased risk for developing testicular tumors. ↑FSH /↔LH The severity of the semen abnormality relates to the duration of time the testes have been outside of the scrotum Varicoceles dilation of the panpiniform plexus up to 30% infertile,more common on left than right increased testicular temperature, delayed removal of local toxins, hypoxia, and stasis Drug alkylating agents-cyclophosphamide, alcohol, anti-androgenspinorolactone, cimetidine Radiation - 15 rads – suppress spermatogenesis - 6 Gy – permanent azoospermia
- Epididymis: obstruction and dysfunction--asthenoazoospermia Kartagener syndrome : primary ciliary dyskinesia/ Cilia structure and function in vas and epi/ bronchiectasis, pulm infection Young synd : inspissate secretion in Vas and epi Infections: causing obstruction of the vas deferens (e.g., gonorrhea, chlamydia, tuberculosis CBAVD : Congenital bilateral absence of the vas deferens –CFTR gene mutation
- Varicocele- abnormal dilation of the vein within spermatic cord Pathophysiology: Temp testis ที่สูงขึ้น, reflux metabolite fr. L adrenal or renal v, high reactive o2 species
- Varicocele- abnormal dilation of the vein within spermatic cord Pathophysiology: Temp testis ที่สูงขึ้น, reflux mebabolite fr. L adreanal or renal v, high reactive o2 species
- Washing specimen- remove seminal factor and isolate pure sperm Centifugation Sperm migration protocol Differential adherence procedure Phosphodiesterase inhibitor – enhance sperm motility, fertilization capacity, and acromase reactivity
- Total motile sperm should be 5 million or 10 million
- A single sperm to The mature metaphase II egg
- Higher pregnancy rates with fresh and ejaculated sperm Success rate affect by age of female partner & Oocyte quality
- Ovulatory dysfunction : Age & decrease ovarian reserve Ovulatory disorder : PCOS, hyperprolactinemia, hypothyroidism, hypothalamic dysfunction
- Ovarian reserve assessment
- CDC ART National Summary Report 2012 : successful live birth depend on age of eggs, not age of mother
- 5% weight reduction Diet : decrease calories 500 kcal/day
- Ovulation induction Weight reduction Clomiphene citrate/MFM/Letrozole Preovulatory monitoring SI q 2-3 d after last CC Midluteal serum progesterone d 7 Urinary LH d 5-12 or when hCG If no spontaneous LH surge Ovulation within 40 hr IUI 24 hr after LH surge 36 hr after hCG Sperm preparation
- CC :SERMs = Estrogen antagonist activity in CNS Intact hypothalamic-pituitary-ovarian axis Dose : CC 50 mg/day within day 5 (x5days) ➡ block ER in hypothalamus ➡ decrease negative feedback loop ➡ Rapid, low amplitude GnRH pulse ➡ increase FSH, LH ➡ Follicular growth & ovulation Increase 50 mg/day each next cycle Metformin: Biguanide Inhibit gluconeogenesis, increase peripheral glucose uptake PCOS ↔ Insulin resistance Metformin Biguanide Increase spontaneous ovulation in PCOS (3-6 mo) Dose : 500 mg tid, 850 mg bid, 1000 mg bid Warning : Induced withdrawal bleeding Beware risk of endometrial hyperplasia
- Administration at midcycle does not improve conception chance in patient using CC but useful in patient with known ovarian dysfunction Contraindication to gonadotropins for infertility treatment : Primary ovarian failure with elevated FSH levels Uncontrolled thyroid & adrenal dysfunction Organic intracranial lesion; pituitary tumor Undiagnosed abnormal uterine bleeding Ovarian cysts or enlargement not caused by PCOS Prior hypersensitivity to gonadotropin Sex hormone-dependent tumors of reproductive tract Pregnancy
- For CC-resistant pt. Ex : ov. Wedge resection ไม่นิยมทำ Now : ovarian drilling ลด ovarian androgen-producing tissue, กระตุ้น ovulation ข้อดี low risk to multiple pregnancy Drilling 3-15 puncture/ovary via laparoscopy using electrocautery/laser or vaginal hydro-laparoscopy
- Failed catheterization Diagnostic laparoscopy เห็น proximal blockage site repair Or ถ้า repair ไม่ได้ หรือ severe adhesion หรือมี distal blockage ด้วย shift to ART (IVF)
- ไม่ค่อยเป็นที่นิยมแล้ว
- Caustic = กัดกร่อน