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Sub-fertility Causes &Management Dr. Yousef Gadmour Professor, Al-fateh university Senior consultant, Al-Jalla Hospital Senior consultant, Al-Jalla Hospital.

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Presentation on theme: "Sub-fertility Causes &Management Dr. Yousef Gadmour Professor, Al-fateh university Senior consultant, Al-Jalla Hospital Senior consultant, Al-Jalla Hospital."— Presentation transcript:

1 Sub-fertility Causes &Management Dr. Yousef Gadmour Professor, Al-fateh university Senior consultant, Al-Jalla Hospital Senior consultant, Al-Jalla Hospital Tripoli, Libya

2 Definitions: Sub fertility- Involuntary failure to conceive within 12 months of commencing unprotected sexual intercourse. Sub fertility- Involuntary failure to conceive within 12 months of commencing unprotected sexual intercourse. Primary infertility - No previous pregnancy. Primary infertility - No previous pregnancy. Secondary infertility- previous pregnancy. (whatever the outcome) Secondary infertility- previous pregnancy. (whatever the outcome)

3 Causes (and approximate incidence) 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

4 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.

5 History - General Both couples should be present. Both couples should be present. Age. Age. Previous pregnancies by each partner. Previous pregnancies by each partner. Length of time without pregnancy. Length of time without pregnancy. Sexual history : Sexual history : Frequency and timing of intercourse Frequency and timing of intercourse Use of lubricants Use of lubricants Impotence, anorgasmia, dysparunia Impotence, anorgasmia, dysparunia Contraceptive history Contraceptive history

6 History - Male Infections; gonorrhea, tuberculosis. Infections; gonorrhea, tuberculosis. Radiation, toxic exposures,drugs. Radiation, toxic exposures,drugs. Mumps orchitis. Mumps orchitis. Testicular injury/surgery. Testicular injury/surgery. occupation (Excessive heat exposure). occupation (Excessive heat exposure). Smoking. Smoking. Diabetes mellitus. Diabetes mellitus.

7 History - Female Detailed menstrual history ; Irregular menses, amenorrhea. Detailed menstrual history ; Irregular menses, amenorrhea. Hirsutism. Hirsutism. Galactorrhoea. Galactorrhoea. Previous pregnancies and mode of deliveries. Previous pregnancies and mode of deliveries. Ectopic pregnancy history. Ectopic pregnancy history. PID. PID.

8 History - Female Appendicitis. Appendicitis. IUCD use. IUCD use. Endometriosis. Endometriosis. Stress. Stress. Weight changes. Weight changes. Excessive exercise. Excessive exercise. Cervical and uterine surgery. Cervical and uterine surgery.

9 Physical Examination - Male Weight & Height (BMI). Weight & Height (BMI). Size of testicles (orchidometry). Size of testicles (orchidometry). Testicular descent. Testicular descent. Varicocele. Varicocele. Outflow abnormalities (hypospadias, etc). Outflow abnormalities (hypospadias, etc). General look- Klinefelter syndrome (47XXY). General look- Klinefelter syndrome (47XXY). Weight & Height (BMI). Weight & Height (BMI). Size of testicles (orchidometry). Size of testicles (orchidometry). Testicular descent. Testicular descent. Varicocele. Varicocele. Outflow abnormalities (hypospadias, etc). Outflow abnormalities (hypospadias, etc). General look- Klinefelter syndrome (47XXY). General look- Klinefelter syndrome (47XXY). Kallmann syndrome (delayed puberty,normal stature, no smell ). Kallmann syndrome (hypothalamic hypogonadism) (delayed puberty,normal stature, no smell ).hypothalamichypogonadism

10 Physical Examination - Female Weight & Height (BMI) Weight & Height (BMI) Hirsutism Hirsutism Thyroid examination Thyroid examination Abdominal examination Abdominal examination Speculum examination - HVS, endocervical swap Speculum examination - HVS, endocervical swap Vaginal examination- Uterosacral nodularity, Uterine mobility Vaginal examination- Uterosacral nodularity, Uterine mobility USS-(Vaginal) USS-(Vaginal)

11 General laboratory investigations: Female FBS(GTT). FBS(GTT). TFT. TFT. chlamydial antibody titer. chlamydial antibody titer. Rubella antibody titer (If negative, immunize and advise not to try for pregnancy for 3 months). Rubella antibody titer (If negative, immunize and advise not to try for pregnancy for 3 months). HIV,HBV,HCV. HIV,HBV,HCV.

12 General laboratory investigations: Female Day 2 FSH, LH. Day 2 FSH, LH. Serum prolactin (fasting). Serum prolactin (fasting). Day 21 serum progesterone. Day 21 serum progesterone.

13 General laboratory investigations: Male HIV,HBV,HCV. HIV,HBV,HCV. FBS (GTT). FBS (GTT). TFT. TFT. Serum Testosterone, FSH, PRL levels. Serum Testosterone, FSH, PRL levels.

14 Routine investigation in the female Assessment of Ovulation Basal body temperature Basal body temperature Mid luteal serum progesterone Mid luteal serum progesterone Endometrial biopsy Endometrial biopsy Ultrasound monitoring of ovulation Ultrasound monitoring of ovulation

15 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 the nadir. 98% of women will ovulate within 3 days of the nadir. 4. Biphasic profiles can also be seen with LUF syndrome.

16 Luteal Phase Progesterone Pulsatile release, thus single level may not be useful unless elevated. Pulsatile release, thus single level may not be useful unless elevated. Performed 7 days after presumptive ovulation ( day 21 ). Performed 7 days after presumptive ovulation ( day 21 ). If done properly, level >15 ng/ml consistent with ovulation. If done properly, level >15 ng/ml consistent with ovulation.

17 Endometrial Biopsy Invasive, but the only reliable way to diagnose luteal phase defect (LPD). Invasive, but the only reliable way to diagnose luteal phase defect (LPD). Performed around 2 days before expected menstruation (= day 28 by definition). Performed around 2 days before expected menstruation (= day 28 by definition). Lag of >2 days is consistent with LPD. Lag of >2 days is consistent with LPD. Must be done in two different cycles to confirm diagnosis of 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. 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) 48 hours of male abstinence before test No lubricants Evaluate 8-12h after coitus (overnight is ok!) Remove mucus from cervix (forceps, syringe)

19 Postcoital test (PK test) PK (normal values in yellow) PK (normal values in yellow) Quantity (very subjective) Quantity (very subjective) Quality (spinnbarkeit) (>8 cm) Quality (spinnbarkeit) (>8 cm) Clarity (clear) Clarity (clear) Ferning (branched) Ferning (branched) Viscosity (thin) Viscosity (thin) WBC ’ s (~0) WBC ’ s (~0) progressively motile sperm/hpf (5-10/hpf) progressively motile sperm/hpf (5-10/hpf)

20 Problems with the PK test Subjective. Subjective. Timing varies; may need to be repeated. Timing varies; may need to be repeated. In some studies, “ infertile ” couples with an abnormal PK conceived successfully during that same cycle. In some studies, “ infertile ” couples with an abnormal PK conceived successfully during that same cycle.

21 Tubal Function Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition. Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition. Tests: Tests: HSG HSG Laparoscopy Laparoscopy Falloposcopy (not widely available) Falloposcopy (not widely available)

22 Hysterosalpingography (HSG) Can be uncomfortable. Can be uncomfortable. Done at the end of menses. Done at the end of menses. Can detect intrauterine and tubal disorders but not always definitive. Can detect intrauterine and tubal disorders but not always definitive.

23 Laparoscopy Invasive; requires OT or office setting. Invasive; requires OT or office setting. Can offer diagnosis and treatment in one sitting. Can offer diagnosis and treatment in one sitting. Not necessary in all patients. Not necessary in all patients. Uses (examples): 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

24 Falloposcopy Hysteroscopic procedure with cannulation of the Fallopian tubes. Hysteroscopic procedure with cannulation of the Fallopian tubes. Can be useful for diagnosis of intraluminal pathology. Can be useful for diagnosis of intraluminal pathology. Promising technique but not yet widespread. Promising technique but not yet widespread.

25 Assessment of uterine cavity Hysteroscopy It is advisable to assess the uterine cavity pathology as submucous fibroid, polyps, uterine malformation, and others. 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 Outpatient hysteroscopy, hysterosalpingography are equivalent regarding evaluation of uterine cavity pathology

26 Routine investigation in the male Semen analysis Test after (~3) days abstinence from intercourse. Test after (~3) days abstinence from intercourse. If abnormal parameters, repeat twice, 2 weeks apart If abnormal parameters, repeat twice, 2 weeks apart Normal values: Normal values: Volume: 2 to 6 ml Volume: 2 to 6 ml Density: 20 to 250 million /ml Density: 20 to 250 million /ml Motility: > 50 % with forward motion within 2 hours Motility: > 50 % with forward motion within 2 hours Morphology: > 50 % normal sperm Morphology: > 50 % normal sperm

27 Other Male Investigation  Doppler USS (varicocele).  Testicular Biopsy.

28 Treatment Options

29 Ovarian Disorders Anovulation Clomiphene Citrate (CC) ± hCG Clomiphene Citrate (CC) ± hCG Human Menopausal Gonadotropin (hMG) Human Menopausal Gonadotropin (hMG) Pure FSH Pure FSH Central amenorrhea CC first, then hMG CC first, then hMG Pulsatile GnRH Pulsatile GnRH

30 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 Progesterone suppositories during luteal phase CC ± hCG CC ± 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) LH +FSH (also FSH alone = Metrodin) For patients with hypogonadotrophic hypoestrogenism or normal FSH and E 2 levels For patients with hypogonadotrophic hypoestrogenism or normal FSH and E 2 levels Close monitoring essential, including estradiol levels & USS Close monitoring essential, including estradiol levels & USS 60-80% pregnancy rates overall, lower for PCOS patients 60-80% pregnancy rates overall, lower for PCOS patients 10-15% multiple pregnancy rate 10-15% multiple pregnancy rate

33 Risks CC Vasomotor symptoms Vasomotor symptoms Ovarian enlargement Ovarian enlargement Multiple gestation Multiple gestation NO risk of malformations NO risk of malformations hMG Multiple gestation OHSS (~1%) Can often be managed as outpatient Diuresis Severe cases fatal if untreated in ICU setting

34 Fallopian Tubes Tuboplasty Tuboplasty IVF IVF

35 Corpus Asherman syndrome Hysteroscopic Lysis of adhesions (scissor) Hysteroscopic Lysis of adhesions (scissor) Postop. ; IUCD, E 2 Postop. ; IUCD, E 2 Fibroids (rarely need treatment) Myomectomy ( hysteroscopic, laparoscopic, open) Myomectomy ( hysteroscopic, laparoscopic, open) ??Uterine artery embolization. ??Uterine artery embolization. Uterine anomalies (rarely need treatment) Metroplasty. Metroplasty.

36 Peritoneum (Endometriosis) From a fertility standpoint, excision beats medical management (Laser therapy ). From a fertility standpoint, excision beats medical management (Laser therapy ). Lysis of adhesions. Lysis of adhesions. GnRH-a (Not a cure and has side effects & expensive). GnRH-a (Not a cure and has side effects & expensive). Danazol (side effects, cost). Danazol (side effects, cost). Continuous OCP ’ s ( poor fertility rates ). Continuous OCP ’ s ( poor fertility rates ). Chances of pregnancy highest within months after treatment. Chances of pregnancy highest within months after treatment.

37 Male Factor Hypogonadotrophism hMG hMG GnRH GnRH CC, hCG ( results poor ) CC, hCG ( results poor ) Varicocoele Ligation? ( No definitive data yet ) Ligation? ( No definitive data yet ) Retrograde ejaculation Ephedrine, imipramine Ephedrine, imipramine AIH with recovered sperm AIH with recovered sperm

38 Male Factor Idiopathic oligospermia No effective medical treatment No effective medical treatment IVF (in-vitro fertilization) IVF (in-vitro fertilization) ICSI ( Intra- cytoplasmic sperm injection ) ICSI ( Intra- cytoplasmic sperm injection ) TESE( Testicular Sperm Extraction ) TESE( Testicular Sperm Extraction ) MESA(Microsurgical Epididymal Sperm Aspiration) MESA(Microsurgical Epididymal Sperm Aspiration) ?? donor insemination ?? donor insemination

39 Unexplained Infertility 15-20% of couples 15-20% of couples Consider PRL, laparoscopy, other hormonal tests, cultures, Antisperm Abs. testing, sperm penetration assay if not done. Consider PRL, laparoscopy, other hormonal tests, cultures, Antisperm Abs. testing, sperm penetration assay if not done. Review previous tests for validity. Review previous tests for validity. Empirical treatment: Empirical treatment: Ovulation induction Ovulation induction IUI IUI Consider IVF and its variants Consider IVF and its variants Adoption Adoption

40 Summary Sub fertility is a common problem. Sub fertility is a common problem. Sub fertility is a disease of couples. Sub fertility is a disease of couples. Evaluation must be thorough, but individualized. Evaluation must be thorough, but individualized. Treatment is available, including IVF, but can be expensive, invasive, and of limited efficacy in some cases. Treatment is available, including IVF, but can be expensive, invasive, and of limited efficacy in some cases. Consultation with a reproductive endocrinologist is advisable. Consultation with a reproductive endocrinologist is advisable.

41 Thanks


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