Presentation on theme: "Sub-fertility Causes &Management"— Presentation transcript:
1Sub-fertility Causes &Management Dr. Yousef Gadmour Professor, Al-fateh universitySenior consultant, Al-Jalla HospitalTripoli , Libya
2Definitions: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)
3Causes (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
4Principles 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.
5History - 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
13General laboratory investigations: MaleHIV,HBV,HCV.FBS (GTT).TFT.Serum Testosterone, FSH, PRL levels.
14Routine investigation in the female Assessment of OvulationBasal body temperatureMid luteal serum progesteroneEndometrial biopsyUltrasound monitoring of ovulation
15BBT 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.
16Luteal 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.
17Endometrial 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.
18Postcoital 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)
20Problems 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.
21Tubal FunctionEvaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition.Tests:HSGLaparoscopyFalloposcopy (not widely available)
22Hysterosalpingography (HSG) Can be uncomfortable.Done at the end of menses.Can detect intrauterine and tubal disorders but not always definitive.
23Laparoscopy 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
24FalloposcopyHysteroscopic procedure with cannulation of the Fallopian tubes.Can be useful for diagnosis of intraluminal pathology.Promising technique but not yet widespread.
25Assessment 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
26Routine 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
27Other Male Investigation Doppler USS (varicocele).Testicular Biopsy.
29Ovarian Disorders Anovulation Central amenorrhea Clomiphene Citrate (CC) ± hCGHuman Menopausal Gonadotropin (hMG)Pure FSHCentral amenorrheaCC first, then hMGPulsatile GnRH
30Ovarian 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
31Ovulation 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.
32hMG 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
33Risks 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
35Corpus 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.
36Peritoneum (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.
37Male Factor Hypogonadotrophism Varicocoele Retrograde ejaculation hMG GnRHCC, hCG ( results poor )VaricocoeleLigation? ( No definitive data yet )Retrograde ejaculationEphedrine, imipramineAIH with recovered sperm
39Unexplained 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
40Summary 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.