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Dr Atin Singhai Assistant Professor Department of Pathology KGMU, Lucknow.

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Presentation on theme: "Dr Atin Singhai Assistant Professor Department of Pathology KGMU, Lucknow."— Presentation transcript:

1 Dr Atin Singhai Assistant Professor Department of Pathology KGMU, Lucknow

2  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

3  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

4 Time of Exposure % Pregnant 3 months60% 6 months70% 1 year85% 18 months 90%

5  DDX  Tests/Inv  Dx  Rx

6  Production  Storage  Delivery

7 1. Production: ◦ Hypothalamus ◦ Anterior Pituitary ◦ Testes

8

9  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)  Drugs: marijuana

10  1. Production: ◦ Pituitary  Endocrine: thyroid, prolactin  Tumors  Inflammation: sarcoidosis, meningitis  Infiltration  Infarction  Trauma/XRT  Drugs: anabolic steroids

11  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

12  2. Storage: ◦ Temperature  Rise in scrotal temperature  Occupation  Varicocoele

13  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

14  History: Previous children Infections: prostatitis, STD, mumps orchitis Trauma to head or testicles Surgery to testicles or hernia Occupation (sitting, bio hazards) Chemo or Radio therapy Ethanol or Smoking Medication Medical history (DM, HTN) Previous investigations

15  Physical ◦ Anatomy (meatus) ◦ Testicular size ◦ Varicocele (valsalva) ◦ Rectal exam (protatitis, discharge)

16  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

17  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

18  Tx / Interventions: ◦ Treat underlying causes ◦ Intrauterine Insemination (IUI) ◦ Intracytoplasmic Sperm Injection (ICSI)

19  Fecundability: probability of achieving a pregnancy within 1 menstrual cycle (25%)  Fecundity: ability to achieve a live birth within 1 menstrual cycle (6%)

20  Production  Storage  Delivery

21  Production: ◦ Hypothalamus ◦ Pituitary ◦ Ovary

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24  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

25  Pituitary: Sheehan syndrome Tumors: Pituitary adenoma, metastatic Empty sella syndrome Inappropriate 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

26  Ovary ◦ Gonadal dysgenesis - Turner’s Syndrome 45XO or mosaics 46 XX/45 XO ◦ Testicular feminization ◦ XRT / Chemo for childhood malignancies ◦ Premature ovarian failure

27  Storage (R.P.L. unless severe) ◦ Uterine abnormalities ◦ Mullerian Agenesis: Mayer-Rokitansky-Kuster- Hauser syndrome ◦ Leiomyoma ◦ Luteal phase deficiency

28  Delivery: ◦ Uterine abnormalities ◦ Vaginal septum ◦ Tubal Disease  Infections/ STD/PID  Ruptured appendix  Septic abortion ◦ Endometriosis

29  History: Age GTPAL Regulatory of period Prolactin S/S Thyroid S/S Infections, Surgeries Medication, Smoking, Ethanol Medical history Previous investigations

30  Examination: ◦ Thyroid ◦ Breast (milk) ◦ Abdomen (masses, scars) ◦ Vaginal (abnormalities) ◦ Bimanual (Uterus, masses)

31  Blood work: TSH PRL D3 FSH D3 LH Luteal phase Progesterone  Imaging: Pelvic Ultrasound HSG  Diagnostic Laparoscopy (later)

32  Treat the underlying cause  Medical  Surgical

33  Anovulation: ◦ Clomiphene induction  IUI ◦ Gonadotropin  IUI  IVF ◦ Bilateral tubal disease ◦ Unexplained infertility after Gonadotropin + IUI failure. ◦ Failure of the above  ICSI ◦ Male factor ◦ Unexplained infertility

34  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: Sperms ◦ Female: Tubes (HSG) + Ovaries (FSH, LH, PRL, TSH)

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36  Infertility is defined as unprotected coitus for ___ months, without conception : a. 3 b. 6 c. 9 d. 12

37  Spermatogenesis and sperm maturation is regulated by : a. Leydig Cells b. Sertoli Cells c. Vas Deferens d. Intermediate Cells

38  Cause/s of male infertility is / are : a. Kallaman’s syndrome b. Craniopharyngioma c. Marijuana abuse d. All of the above

39  Normal semen count is ___ million / ml a. ≥ 15 b. ≥ 20 c. ≥ 25 d. ≥ 30

40  Indication/s for semen analysis is / are : a. Investigation for infertility b. to check effectiveness of vasectomy c. for selection of donor for artificial insemination d. All of the above

41 Thank you


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