Presentation on theme: "Sub-fertility Causes &Management"— Presentation transcript:
1 Sub-fertility Causes &Management Dr. Yousef Gadmour Professor, Al-fateh universitySenior consultant, Al-Jalla HospitalTripoli , Libya
2 Definitions:Sub fertility- Involuntary failure to conceive within 12 months of commencing unprotected sexual intercourse.Primary infertility - No previous pregnancy.Secondary infertility- previous pregnancy (whatever the outcome)
3 Causes (and approximate incidence) 1. Idiopathic per cent2. Sperm defects or functional disorder - 25 per cent3. Ovulation failure per cent4. Tubal damage per cent5. Endometriosis per cent6. Coital failure per cent7. Cervical mucus defect per cent8. Obstruction of sperm ducts per cent
4 Principles of management: Deal with the sub fertile couple together.No one is at fault or to blame.Give good explanations of causes , prognosis and outline of treatment of sub fertility.Carry out investigations and treatments consistency in proper sequence.
5 History - General Frequency and timing of intercourse Both couples should be present.Age.Previous pregnancies by each partner.Length of time without pregnancy.Sexual history :Frequency and timing of intercourseUse of lubricantsImpotence, anorgasmia, dysparuniaContraceptive history
6 History - Male Infections; gonorrhea , tuberculosis. Radiation, toxic exposures ,drugs.Mumps orchitis.Testicular injury/surgery.occupation (Excessive heat exposure).Smoking.Diabetes mellitus.
7 History - FemaleDetailed menstrual history ; Irregular menses, amenorrhea.Hirsutism.Galactorrhoea.Previous pregnancies and mode of deliveries.Ectopic pregnancy history.PID.
8 History - Female Appendicitis. IUCD use. Endometriosis. Stress. Weight changes.Excessive exercise.Cervical and uterine surgery.
13 General laboratory investigations: MaleHIV,HBV,HCV.FBS (GTT).TFT.Serum Testosterone, FSH, PRL levels.
14 Routine investigation in the female Assessment of OvulationBasal body temperatureMid luteal serum progesteroneEndometrial biopsyUltrasound monitoring of ovulation
15 BBT Cheap and easy, but… Inconsistent results. Provides evidence after the fact.May delay timely diagnosis and treatment;98% of women will ovulate within 3 days of the nadir.Biphasic profiles can also be seen with LUF syndrome.
16 Luteal Phase Progesterone Pulsatile release, thus single level may not be useful unless elevated.Performed 7 days after presumptive ovulation ( day 21 ).If done properly , level >15 ng/ml consistent with ovulation.
17 Endometrial BiopsyInvasive, but the only reliable way to diagnose luteal phase 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 the endometrial biopsy in assessing the delay.
18 Postcoital test (PK tests) Scheduled around 1-2d before ovulation (increased estrogen effect)48hours of male abstinence before testNo lubricantsEvaluate 8-12h after coitus (overnight is ok!)Remove mucus from cervix (forceps, syringe)
20 Problems with the PK test Subjective.Timing varies; may need to be repeated.In some studies, “infertile” couples with an abnormal PK conceived successfully during that same cycle.
21 Tubal FunctionEvaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition.Tests:HSGLaparoscopyFalloposcopy (not widely available)
22 Hysterosalpingography (HSG) Can be uncomfortable.Done at the end of menses.Can detect intrauterine and tubal disorders but not always definitive.
23 Laparoscopy Invasive; requires OT or office setting. Can offer diagnosis and treatment in one sitting.Not necessary in all patients.Uses (examples):Lysis of adhesionsDiagnosis and excision of endometriosisMyomectomyTubal reconstructive surgeryTest of tubal patency by dye test
24 FalloposcopyHysteroscopic procedure with cannulation of the Fallopian tubes.Can be useful for diagnosis of intraluminal pathology.Promising technique but not yet widespread.
25 Assessment of uterine cavity HysteroscopyIt 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
26 Routine investigation in the male Semen analysisTest after (~3) days abstinence from intercourse.If abnormal parameters, repeat twice, 2 weeks apartNormal values:Volume: 2 to 6 mlDensity: 20 to 250 million /mlMotility: > 50 % with forward motion within 2 hoursMorphology: > 50 % normal sperm
27 Other Male Investigation Doppler USS (varicocele).Testicular Biopsy.
29 Ovarian Disorders Anovulation Central amenorrhea Clomiphene Citrate (CC) ± hCGHuman Menopausal Gonadotropin (hMG)Pure FSHCentral amenorrheaCC first, then hMGPulsatile GnRH
30 Ovarian Disorders Hyperprolactinaemia: Drugs :Bromocriptin, Carbegoline(Dostinex), Quinagolide (Norprolac)Surgery if macroadenomaPremature ovarian failure :? high-dose hMG (not very effective)Luteal phase defect:Progesterone suppositories during luteal phaseCC ± hCG
31 Ovulation Induction Clomiphene Citrate Compete with natural oestrogens by blocking receptors in target organs including the pituitary, 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 effect dominate.Multiple pregnancy rates 5-10%.Monitor effects with USS & D21 progesterone.
32 hMG LH +FSH (also FSH alone = Metrodin) For patients with hypogonadotrophic hypoestrogenism or normal FSH and E2 levelsClose monitoring essential, including estradiol levels & USS60-80% pregnancy rates overall, lower for PCOS patients10-15% multiple pregnancy rate
33 Risks CC Vasomotor symptoms Ovarian enlargement Multiple gestation NO risk of malformationshMGMultiple gestationOHSS (~1%)Can often be managed as outpatientDiuresisSevere cases fatal if untreated in ICU setting
35 Corpus Asherman syndrome Fibroids (rarely need treatment) Hysteroscopic Lysis of adhesions (scissor)Postop. ; IUCD, E2Fibroids (rarely need treatment)Myomectomy ( hysteroscopic, laparoscopic, open)??Uterine artery embolization.Uterine anomalies (rarely need treatment)Metroplasty.
36 Peritoneum (Endometriosis) From a fertility standpoint, excision beats medical management (Laser therapy ).Lysis of adhesions.GnRH-a (Not a cure and has side effects & expensive).Danazol (side effects, cost).Continuous OCP’s ( poor fertility rates ).Chances of pregnancy highest within months after treatment.
37 Male Factor Hypogonadotrophism Varicocoele Retrograde ejaculation hMG GnRHCC, hCG ( results poor )VaricocoeleLigation? ( No definitive data yet )Retrograde ejaculationEphedrine, imipramineAIH with recovered sperm
38 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
39 Unexplained Infertility 15-20% of couplesConsider PRL, laparoscopy, other hormonal tests, cultures, Antisperm Abs. testing, sperm penetration assay if not done.Review previous tests for validity.Empirical treatment:Ovulation inductionIUIConsider IVF and its variantsAdoption
40 Summary Sub fertility is a common problem. Sub fertility is a disease of couples.Evaluation must be thorough, but individualized.Treatment is available, including IVF, but can be expensive, invasive, and of limited efficacy in some cases.Consultation with a reproductive endocrinologist is advisable.