fawaz edris md, ardms, aaacs, frcsc, facog. background definition: 1 yr unprotected coitus without...
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Fawaz Edris MD, ARDMS, AAACS, FRCSC, FACOG
Background
Definition:1 yr unprotected coitus without conception
10-15% couples affected Etiology
Couples:○ 35% Tubal and pelvic pathology○ 35 % Male problems○ 15% Ovulatory dysfunction○ 10% Unexplained○ 5% unusual causes
Background Etiology
Women:○ 40% Tubal and pelvic pathology○ 40% Ovulatory dysfunction○ 10% Unexplained Infertility○ 10% Unusual causes
Normal couple:25-30% chance of pregnancy per ovulatory
cycle
Fertility decreases with age
Infertility
Time of Exposure % Pregnant
3 months 60%
6 months 70%
1 year 85%
18 months 90%
Approach to Infertility
DDX Hx Px Tests/Inv Dx Rx
Approach to Infertility
Production Storage Delivery
Male Infertility1. Production:
HypothalamusAnterior PituitaryTestes
Hypothalamic-Pituitary-Gonadal Axis
Male Infertility 1. Production
Hypothalamus○ Congenital abnormalities of hypothalamus
e.g. Kallman’s syndrome
○ Starvation, stress or severe illness○ Tumors (craniopharyngioma, metastatic tumor)○ Head injury○ Inflammation (sarcoidosis)○ Infection (tuberculosis)○ XRT○ Drugs: marijuana,
Male Infertility 1. Production:
Pituitary○ Endocrine: thyroid, prolactin○ Tumors○ Inflammation: sarcoidosis, meningitis○ Infiltration○ Infarction○ Trauma/XRT○ Drugs: anabolic steroids
Male Infertility Production:
Testes:○ Congenital: Klinefelters (XYY), developmental
disorders○ Disorders of gonadal steroidgenesis○ Infection: chlamydia, prostatitis, mumps orchitis○ Autoimmune○ Cryptorchidism○ Tumors; chemo/XRT○ Drugs / alcohol○ Vascular: testicular torsion
Male Infertility
2. Storage:Temperature
○ Rise in scrotal temperature○ Occupation○ Varicocoele
Male Infertility
3. Delivery:Impotence/Ejaculation
○ Neurogenic: medications (α-blockers, methyldopa)
○ Endocrine: diabetes○ Congenital: absence vas deferens (CF)○ Genetic: cystic fibrosis○ Primary ciliary dyskinesia: Kartagener syndrome○ Hypospadia○ Vasectomy
Male Infertility History:
Previous childrenInfections: prostatitis, STD, mumps orchitisTrauma to head or testiclesSurgery to testicles or herniaOccupation (sitting, bio hazards, XRT)Chemo or Radio therapyEthanol or SmokingMedicationMedical history (DM, HTN)Previous investigations
Male Infertility
PhysicalAnatomy (meatus)Testicular sizeVaricocele (valsalva)Rectal exam (protatitis, discharge)
Male Infertility
Investigations:semen analysis
○ Abstain 2-4 days prior○ At least 2 samples over different period of
time If abnormal:
○ Blood work: FSH, LH, TSH, testosterone, PRL○ Testicular U/S ○ Chromosomal analysis
Male Infertility
Semen analysis:WHO (1992)
○ Volume > 2.0 mL○ Sperm > 20 million/mL○ Motility > 50% forward progression or
> 25% rapid progression within 60 min
○ Morphology > 30% normal forms○ WBC < 1 million/mL
Male Infertility
Tx / Interventions:Treat underlying causesIntrauterine Insemination (IUI)Intracytoplasmic Sperm Injection (ICSI)
Female Infertility
Fecundability: probability of achieving a pregnancy within 1 menstrual cycle (25%)
Fecundity: ability to achieve a live birth within 1 menstrual cycle (6%)
Female Infertility
Production Storage Delivery
Female Fertility Production:
HypothalamusPituitaryOvary
Hypothalamic-Pituitary-Gonadal Axis
Female Infertility Hypothalamus:
Stress Exercise Eating disorders Psychogenic Congenital/genetic: Kallman’s syndrome (hyposmia &
hypoplasia olfactory lobes of brain) Starvation/stress or severe illness Tumors (craniopharyngioma, metastatic tumor) Head injury Inflammation (sarcoidosis) Infection (tuberculosis) XRT Drugs
Female Infertility
Pituitary:Sheehan syndromeTumors: Pituitary adenoma, metastaticEmpty sella syndromeInappropriate gonadal steroid feedback:
○ estrogen excess: obesity/ tumors○ estrogen deficiency: aromatase deficiency/ ER gene
mutation○ androgen excess: adrenal or ovarian○ PCOS
Testicular feminization (46 XY) - absence androgen receptors
Female Infertility
OvaryGonadal dysgenesis - Turner’s Syndrome
45XO or mosaics 46 XX/45 XOTesticular feminizationXRT / Chemo for childhood malignanciesPremature ovarian failure
Female Infertility
Storage (R.P.L. unless severe)Uterine abnormalitiesMullerian Agenesis: Mayer-Rokitansky-
Kuster-Hauser syndromeAsherman’s syndromeLeiomyoma Luteal phase deficiency
Female Infertility
Delivery:Uterine abnormalitiesVaginal septumTubal Disease
○ Infections/ STD/PID○ Ruptured appendix○ Septic abortion
Endometriosis
Female Infertility History:
AgeGTPALRegulatory of periodProlactin S/SThyroid S/SInfections, SurgeriesMedication, Smoking, EthanolMedical history Previous investigations
Female Infertility
Examination:ThyroidBreast (milk)Abdomen (masses, scars)Vaginal (abnormalities)Bimanual (Uterus, masses)
Investigations Blood work:
TSHPRLD3 FSHD3 LHLuteal phase Progesterone
Imaging:Pelvic UltrasoundHSG
DiagnosticLaparoscopy (later)
Treatment
Treat the underlying cause Medical Surgical
Treatment Anovulation:
Clomiphene induction IUIGonadotropin IUI
IVFBilateral tubal diseaseUnexplained infertility after Gonadotropin + IUI
failure.Failure of the above
ICSIMale factorUnexplained infertility
Take Home Points
DDx – Hx – Px – Inv - Rx Age is important factor for female Hypothalamic-Pituitary-Gonadal axis
central in working up both male and female infertility
Investigations:Male: SpermsFemale: Tubes (HSG) + Ovaries (FSH, LH,
PRL, TSH)
Thank you