Female infertility (2)

Female infertility 2)

1. Female infertility(part-1)Female infertility(part-1)
Dr. JASMINA BEGUMDr. JASMINA BEGUM
ASSOCIATE PROF. (O &G)ASSOCIATE PROF. (O &G)

2. Learning objectivesLearning objectives
•know definitions of primary and secondary
infertility
•understand the causes of infertility
•know the initial investigations of the
infertile couple
•Test for ovulation
•Test for tubal patency
•Investigation role of laparoscopy and
hysteroscopy

3. DefinitionDefinition

•Infertility is the inability to achieve a
pregnancy after 12 months of
unprotected regular intercourse

4. Primary infertilityPrimary infertility
•Primary infertility is the term used to
describe a couple that has never
been able to conceive a pregnancy,
after at least 1 year of unprotected
intercourse

5. Secondary infertilitySecondary infertility
•Secondary infertility describes
couples who have previously been
pregnant at least once, but have not
been able to achieve another
pregnancy

6. causescauses
•Female factor 30%
•Male factor 30%
•Combined factor 30%
•No cause 10%

•Female partner alone should not be
blamed

7. Female genital tractFemale genital tract

8. Female InfertilityFemale Infertility
1
23
4
6
5

10. General factorsGeneral factors
Diabetes mellitus
Thyroid disorders
Adrenal disease
Significant liver, kidney disease
Psychological factors

11. Hypothalamic-pituitary factorsHypothalamic-pituitary factors

Kallman syndrome
Hypothalamic dysfunction
Hyperprolactinoma
Hypopituitarisum

12. First visitFirst visit
•Have both come to all visits
•Get a complete history
•Sexual history
•Educate/ Counselling

13. Visit 1: Female HistoryVisit 1: Female History
•Prior infertility; evaluation, treatments
• Hx of PID; postpartum/ post TB infection
• Pelvic pain, dysmenorrhea;
endometriosis
• Medical: diabetes, thyroid; pelvic surgery
• Medications, alcohol, street drugs
Contd….

14. Visit 1: Female HistoryVisit 1: Female History
•Cigarette smoking
• Galactorrhea
• Menstrual patterns
•Cycle length range (best 25-35 days
apart)
•Moliminal symptoms (if present,
ovulating)

15. Visit 1: Female ExaminationVisit 1: Female Examination
•Weight, BMI, waist circumference (PCOS)
• Skin: axial hirsuitism, acne, male-pattern
balding (PCOS)
• Breasts: galactorrhea ( prolactin)
▲
•Cervix: mucus, friability (infection)
•Uterine corpus
•Size, shape (fibroids, uterine anomalies)
•Corpus tenderness (PID)
• Fixed retroflexion (EM)
•Adnexa: tenderness (PID, EM), mass

16. •Time intercourse just before ovulation
• Use menstrual calendar to predict
ovulation
•Shortest cycle length minus 14 days
• Ovulation prediction kit to confirm
ovulation
Visit 1: CounselingVisit 1: Counseling

17. Coital frequency and TechniqueCoital frequency and Technique
•Every other day intercourse starting 4-5
days before expected ovulation
•Lay supine with knees up x 20 minutes
after intercourse
• No sperm-toxic lubricants

18. Visit 1: CounselingVisit 1: Counseling
•Stop smoking (both partners)
•If BMI > 30, recommend/assist with weight
loss
• Preconceptional care
Folic acid 400 mcg PO per day
Rubella serology; immunize if seronegative
Contd…..

19. • Change medications to safer FDA
pregnancy
category
»Antihypertensives
»Anti-epileptic drugs
•Blood glucose control in diabetics
Visit 1: Counseling

20. Investigations of female Investigations of female
•General Hb, urine RE, Blood group,sugar VDRL,
HIV, Hbsag, Mx, Urea, creatinine
•Semen analysis (report must before further work
up is taken)
•Tests for ovulation
•Tubal patency
•FSH, LH, Thyroid function, prolactin
•Screen for gonorrhea, chlamydia (if indicated)
•Microscopy of cervical mucus

21. •Diagnostic pelvic ultrasound
• >10 to 12 follicles per ovary (PCOS)
• Persistent hemorrhagic cysts with low-level
echoes (endometriosis)
•Anatomical conditions: fibroids, polyps, and
•Müllerian anomalies (uterine septum)
•Decreased ovarian volume and reduced antral
follicle count associated with reduced fertility
•Serial TV ultrasound used to document
ovulation
Visit 1: Pelvic UltrasoundVisit 1: Pelvic Ultrasound

22. Ultrasound scan showing follicleUltrasound scan showing follicle

23. Infertility workup calender
Identification
of factor
Methods employed Day of cycle Observation
Ovulation
•BB T
•Endometrial
biopsy
•Cervical mucus
Nature
Threadability
Fern pattern
•Serum
progesterone
•Serum LH
• Urinary LH
•Serial
transvaginal
sonography
•Laparoscopy
Throughout
cycle
D 21–23
D 12–14 and
D 21–23
D 8 and D 21
Midcycle daily
(D 12–14)
D 12–14
Secretory
phase
Biphasic pattern
Secretory
endometrium
Clear, watery
Thick, viscid
D-8 < 1 ng/ml
D-21 > 6ng/ml
Ovulation: About
10–12 hours after
LH surge
DominantFollicle
20 mm
Recent corpus
luteum

24. Identification
of factor
Methods
employed
Day of
cycle
Observation
Tubal factor
HSG
Laparoscopy
and dye test
Sonohysterosal
pingography
Proliferative
Phase D6-
D10
Proliferative
Phase D6-
D10
Proliferative
phase
Spillage of dye into
the peritoneal
Cavity
Peritubal pathology
• Pelvic pathology
(Endometriosis)
• Ovulation
• Tubal patency by
dye spillage from
both the tubes
Better than HSG for
detection of
intrauterine
pathology

26. Identification
of factor
Methods
employed
Day of
cycle
Observation
Cervical •Postcoital test
(PCT)

• Sperm cervical
mucus
contact test
(SCMCT
Around
ovulation
(D 12–14)
(D 12–14)
Presence of
progressive motile
sperm
(10 per high power
field)
Sperm antibodies

27. Role of LaparoscopyRole of Laparoscopy
• Controversial as to whether to include it in
the basic evaluation or not
• Studies indicate that it may demonstrate
previously undetected stage I or II
endometriosis, periovarian or peritubal
adhesions.
Contd…..

28. Role of LaparoscopyRole of Laparoscopy
• This may alter treatment plans such as
surgery for endometriosis or directly IVF
for peritubal adhesion
• Can be avoided in women with a normal
HSG in patients who may need IVF

29. Laproscopy findings Laproscopy findings
•Uterus ---- fibroids
uterine anamoly
•Tubes --- patency
hydrosalpinx
•Ovaries --- PCOS
chocolate cyst
•POD --- endometriosis
adhesions

30. Hysteroscopy findingsHysteroscopy findings
•Cervical canal --- polyps
•Uterine cavity --- adhesions
polyps
fibroids
uterine anamoly
•Endometrium --- proliferative/hyperplastic
•Tubal ostium --- visualised or not

31. Fertility Treatment: GoalsFertility Treatment: Goals
•To ensure patient safety
•To help a couple experience a healthy
pregnancy and birth or an alternative
way to build a family
•To use as little of a couple’s resources
as necessary.

32. Fertility Treatment: OptionsFertility Treatment: Options
•Correct ovulatory dysfunction
•Correct tubal or uterine abnormalities
•Overcome subfertile sperm parameters
•ART

33. Management of infertility in women >30 years Management of infertility in women >30 years
For couples who
do not desire
medical
intervention
• Ovarian stimulation with IUI
• Ovarian stimulation with IVF
(own eggs)
• Ovarian stimulation with IVF
(donor eggs)
• Surrogacy
• Adoption
Conservative Active

34. SummerySummery

35. Tests of ovulationTests of ovulation
•LH kit
•Progesterone assay
•Basal body temperature
•Cervical mucus
•Spinnbarkit
•fernning
•Vaginal epithelium cytology
•Endometrial biopsy
•TVS follicular monitoring

36. Tests of tubal patencyTests of tubal patency
•Hysterosalpingography (HSG)
•Diagnostic laparoscopy
•Sonosalpingography
•Air insufflation
•Falloposcopy

38. Expected Short answerExpected Short answer
•Define primary infertility and list any five
female factors responsible for it?
•List the tests for ovulation ?.
•List any two indications and any three
contraindications of
hysterosalphingography?
•List the who criteria for semen analysis?

39. Thank youThank you