sub fertility

8/2/2019 Sub Fertility

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Definitions:

Sub fertility- Involuntary failure to conceivewithin 12 months of commencing unprotectedsexual intercourse.

Primary infertility - No previous pregnancy.

Secondary infertility- previous pregnancy.

(whatever the outcome)


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(and approximate incidence)Causes

1. Idiopathic - 25 per cent

2. Sperm defects or functional disorder - 25 per cent

3. Ovulation failure - 20 per cent

4. Tubal damage - 15 per cent

5. Endometriosis - 5 per cent

6. Coital failure - 5 per cent

7. Cervical mucus defect - 3 per cent

8. Obstruction of sperm ducts - 2 per cent


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Principles of management:

1. Deal with the sub fertile couple together.

2. No one is at fault or to blame.

3. Give good explanations of causes ,

prognosis and outline of treatment of sub

fertility.4. Carry out investigations and treatments

consistency in proper sequence.


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General-History

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 Impotence, anorgasmia, dysparuniaContraceptive history


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Male-History

Infections; gonorrhea , tuberculosis.

Radiation, toxic exposures ,drugs.

Mumps orchitis. Testicular injury/surgery.

occupation (Excessive heat exposure).

Smoking. Diabetes mellitus.


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Female-History

Detailed menstrual history ; Irregular menses,amenorrhea.

Hirsutism. Galactorrhoea.

Previous pregnancies and mode of deliveries.

Ectopic pregnancy history.

PID.


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Female-History

Appendicitis.

IUCD use.

Endometriosis. Stress.

Weight changes.

Excessive exercise.

Cervical and uterine surgery.


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Male-Physical Examination

Weight & Height (BMI).

Size of testicles (orchidometry).

Testicular descent.Varicocele.

Outflow abnormalities (hypospadias, etc).

General look- Klinefelter syndrome (47XXY).

Weight & Height (BMI).

Size of testicles (orchidometry).

Testicular descent.Varicocele.

Outflow abnormalities (hypospadias, etc).

General look- Klinefelter syndrome (47XXY).

Kallmann syndrome (hypothalamichypogonadism)(delayed puberty ,normal stature, no smell ).
http://en.wikipedia.org/wiki/Hypothalamushttp://en.wikipedia.org/wiki/Hypogonadismhttp://en.wikipedia.org/wiki/Hypogonadismhttp://en.wikipedia.org/wiki/Hypothalamus


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Female-Physical Examination

Weight & Height (BMI)

Hirsutism

Thyroid examinationAbdominal examination

Speculum examination - HVS, endocervical

swapVaginal examination-

Uterosacral nodularity, Uterine mobility

USS-(Vaginal)


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General laboratory investigations:

Female

FBS(GTT).

TFT. chlamydial antibody titer.

Rubella antibody titer (If negative, immunize

and advise not to try for pregnancy for 3months).

HIV,HBV,HCV.


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Female

Day 2 FSH, LH. Serum prolactin (fasting).

Day 21 serum progesterone.


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Male

HIV,HBV,HCV.

FBS (GTT).TFT.

Serum Testosterone, FSH, PRL levels.


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Routine investigation in the femaleAssessment of Ovulation

Basal body temperature

Mid luteal serum progesterone

Endometrial biopsy

Ultrasound monitoring of ovulation


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BBT

Cheap and easy, but

1. Inconsistent results.

2. Provides evidence after the fact.3. May delay timely diagnosis and treatment;

98% of women will ovulate within 3 days of thenadir.

4. Biphasic profiles can also be seen with LUFsyndrome.


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Luteal Phase Progesterone

Pulsatile release, thus single level may not beuseful unless elevated.

Performed 7 days after presumptive ovulation( day 21 ).

If done properly , level >15 ng/ml consistent

with ovulation.


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Endometrial Biopsy

Invasive, but the only reliable way to diagnose lutealphase defect (LPD).

Performed around 2 days before expected menstruation

(= day 28 by definition). Lag of >2 days is consistent with LPD.

Must be done in two different cycles to confirm diagnosis

of LPD. Controversy exists over the relevance of luteal phase

defect as a cause of infertility and the accuracy of theendometrial biopsy in assessing the delay.


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Postcoital test (PK tests)

Scheduled around 1-2d before ovulation(increased estrogen effect)

48hours of male abstinence before test

No lubricants

Evaluate 8-12h after coitus

(overnight is ok!) Remove mucus from cervix

(forceps, syringe)


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Postcoital test (PK test)

PK(normal values in yellow)

Quantity(very subjective)

Quality (spinnbarkeit) (>8 cm)

Clarity(clear)

Ferning(branched)

Viscosity(thin)

WBCs (~0)

progressively motile sperm/hpf(5-10/hpf)


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Problems with the PK test

Subjective.

Timing varies; may need to be repeated.

In some studies,infertile

couples with anabnormal PK conceived successfully during that

same cycle.


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Tubal Function

Evaluate tubal patency whenever there is ahistory of PID, endometriosis or otheradhesiogenic condition.

Tests:

HSG

Laparoscopy

Falloposcopy (not widely available)


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Hysterosalpingography (HSG)

Can be uncomfortable.

Done at the end of menses.

Can detect intrauterine and tubal disorders butnot always definitive.


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Laparoscopy

Invasive; requires OT or office setting.

Can offer diagnosis and treatment in one sitting.

Not necessary in all patients.

Uses (examples):

1. Lysis of adhesions

2. Diagnosis and excision of endometriosis

3. Myomectomy

4. Tubal reconstructive surgery

5. Test of tubal patency by dye test


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Falloposcopy

Hysteroscopic procedure with cannulationof the Fallopian tubes.

Can be useful for diagnosis of intraluminalpathology.

Promising technique but not yet widespread.


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Assessment of uterine cavity

Hysteroscopy

It is advisable to assess the uterine cavity

pathology as submucous fibroid, polyps,

uterine malformation, and others .

Outpatient hysteroscopy,

hysterosalpingography are equivalent

regarding evaluation of uterine cavity

pathology


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Routine investigation in the male

Semen analysis

Test after (~3) days abstinence from intercourse.

If abnormal parameters, repeat twice, 2 weeks apart

Normal values:

Volume: 2 to 6 ml

Density: 20 to 250 million /ml

Motility: > 50 % with forward motion within 2 hoursMorphology: > 50 % normal sperm


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Other Male Investigation

Doppler USS (varicocele).

Testicular Biopsy.


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Treatment Options


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Ovarian Disorders

Anovulation

Clomiphene Citrate (CC) hCG

Human Menopausal Gonadotropin (hMG)

Pure FSH

Central amenorrhea

CC first, then hMG

Pulsatile GnRH


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Ovarian Disorders

Hyperprolactinaemia:

Drugs :Bromocriptin, Carbegoline(Dostinex),Quinagolide (Norprolac)

Surgery if macroadenoma

Premature ovarian failure :

? high-dose hMG (not very effective)

Luteal phase defect:

Progesterone suppositories during luteal phase

CC hCG


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Ovulation Induction

Clomiphene Citrate Compete with natural oestrogens by blocking

receptors in target organs including thepituitary, leading to increased FHS levels.

70% induction rate, ~40% pregnancy rate.

Patients should typically be normoestrogenic.

Induce menses and start on day 2 for 5 days.

With high dosages, antiestrogen effectdominate.

Multiple pregnancy rates 5-10%.

Monitor effects with USS & D21 progesterone.


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hMG

LH +FSH (also FSH alone = Metrodin)

For patients with hypogonadotrophic

hypoestrogenism or normal FSH and E2 levels Close monitoring essential, including estradiol

levels & USS

60-80% pregnancy rates overall, lower forPCOS patients

10-15% multiple pregnancy rate


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Risks

CC

Vasomotor symptoms

Ovarian enlargement

Multiple gestation

NO risk ofmalformations

hMG

Multiple gestation

OHSS (~1%)

Can often be managedas outpatient

Diuresis

Severe cases fatal if

untreated in ICUsetting


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Fallopian Tubes

Tuboplasty

IVF


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Corpus

Asherman syndrome

Hysteroscopic Lysis of adhesions (scissor)

Postop. ; IUCD, E2

Fibroids (rarely need treatment)

Myomectomy ( hysteroscopic, laparoscopic, open)

??Uterine artery embolization.

Uterine anomalies (rarely need treatment)

Metroplasty.


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Peritoneum (Endometriosis)

From a fertility standpoint, excision beats medicalmanagement (Laser therapy ).

Lysis of adhesions. GnRH-a (Not a cure and has side effects & expensive).

Danazol (side effects, cost).

Continuous OCPs ( poor fertility rates ).

Chances of pregnancy highest within 6 -12 months aftertreatment.


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Male Factor

Hypogonadotrophism

hMG

GnRH

CC, hCG ( results poor )Varicocoele

Ligation? ( No definitive data yet )

Retrograde ejaculation Ephedrine, imipramine

AIH with recovered sperm


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Male Factor

Idiopathic oligospermia

No effective medical treatment

IVF (in-vitro fertilization)

ICSI ( Intra- cytoplasmic sperm injection )

TESE( Testicular Sperm Extraction )

MESA(Microsurgical Epididymal Sperm Aspiration)

?? donor insemination


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Unexplained Infertility

15-20% of couples

Consider PRL, laparoscopy, other hormonal tests,cultures, Antisperm Abs. testing, sperm penetrationassay if not done.

Review previous tests for validity.

Empirical treatment:

Ovulation induction IUI

Consider IVF and its variants

Adoption


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Summary

Sub fertility is a common problem.

Sub fertility is a disease ofcouples.

Evaluation must be thorough, but individualized.Treatment is available, including IVF, but can be

expensive, invasive, and of limited efficacy insome cases.

Consultation with a reproductive endocrinologistis advisable.


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Thanks

sub fertility

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