Infertility

Infertility and its Diagnosis and management

1. Infertility
RAJEEV BAHALL

2. Introduction
•What is Fertility?
•Fertility is the ability to conceive and bear children
•What is Fertilization?
•Fertilization is the process by which a male gamete is combined with a female
gamete to form a zygote
•Requirements of Fertilization?
•4 major ones

4. Definition
•Inability of a couple to conceive after regular unprotected
sexual intercourse
•< 35 years old:
•Failure to conceive after 12 months of unprotected intercourse
•>35 years old:
•Failure to conceive after 6 months of unprotected intercourse

5. Types
•Primary:
•A couple who has never conceived a pregnancy
•Secondary
•Failure to conceive, after previous pregnancy regardless of outcome

6. Incidence
•Affects 10-15% of all Couples
•8% will conceive eventually
•Remaining suffer from either Primary or secondary
infertility

7. Aetiology

8. Primary vs Secondary

9. Female Factor Infertility

11. Ovarian Causes
•Ovulatory Dysfunction:-
•Oligo-ovulation
•Anovulation
•Oocyte Aging
•↓ Fecundability with age due to ↓ in quantity and quality of oocytes
•Gradual oocyte lost with age

12. Anovulation
•WHO Classification
•Class 1:- Hypogonadotropic Hypogonadal Anovulation
( Hypothalmaic amenorrhea)
•Class 2:- Normogonadotropic normo-estrogenic anovulation
•Class 3:- Hypergonadotropic hypo-estrogenic anovulation
•Hyperprolactinemic anovulation

13. Fallopian Tube causes
•Cogenital Malformations
•Tubal Occlusion
•Pelvic Inflammatory Disease (PID)
•Endometriosis
•Abdominal/ Pelvic Surgery
•Abdominal Infection:- Peritonitis

14. Uterine Causes
•Mechanical or ↓endometrial receptivity
•Causes:
•Submucosal or Intracavitary Fibroids
•Congenital uterine abnormalities:- Septate Uterus
•Acquired uterine abnormalities:- Endometrial polyps

15. Endometriosis
•Cause anatomic distortion from pelvic adhesions
•Damage to ovarian tissue by endometrioma and surgical
resection
•Inflammatory response cause by ectopic tissue provide
hostile conditions for ovulation,fertilization and
implantation

16. Cervical Cause
•Chronic cervicitis
•Cone biopsy
•Obstetric trauma
•Previous cauterization

17. Male Factor Infertility
•Usually as a result of number of sperm and quality sperm
•Myriad of causes

19. Drugs that affect sperm

20. How Do You Evaluate?
•Should be done on both partners
•History and Examination
•Investigatory Test:
•semen analysis
•Assessment of ovulatory function
•Assessment of ovarian Reserve
•Assessment of Fallopian tube patency

21. When to Evaluate?
After 12
months
Women < 35 years old
After 6
months
Women 35- 40 years old
Initially upon
presentation
Women > 40 years old
Women with oligo/amenorrhea
Women with hx of chemo-/radiation therapy
Suspected/ Known Uterine/ Tubal disease
Women with partner with hx of groin surgery, mumps, sexual
dysfunction or previous sub-fertility in another relationship

22. History: Male
•Duration of Infertility
•Fertility in other relationships
•Medical and Surgical history
•Medications
•Social History
•Frequency of intercourse
•Previous infertility test and therapy
•Family History

23. History: Female
•Duration of infertility
•Number and outcome of prior pregnancy
•Gynaecologic history
•Menstrual history
•Medical and Surgical history
•Social History
•Frequency of intercourse
•Family History

24. Examination
•General:
•Body habitus, fat distribution, BMI
•2
o
sex characteristics
•Signs of androgen access
•Abdominal
•masses/ tenderness
•Bimanual
•nodules in posterior cul de sac or uterosacral ligaments
•vaginal/ cervical abnormalities/ discharge
•Uterine enlargement, irregularity, fixity

25. Investigatory Test

26. Semen Analysis

27. Assessment of Ovulatory Function
•Mid-Luteal Phase serum Progesterone
•Usually done on day 21 of a 28 day cycle
•Interpretation:
•> 3ng/mL indicates ovulation
•< 3ng/mL= further evaluation for anovulation
•Serum FSH, LH and estradiol

28. Assessment of Ovarian Reserve
•Day 3 FSH
•Clomiphene Citrate Challenge Test( CCCT)
•Antral Follicle Count( AFC)
•Anti-Müllerian Hormone
•best bichemical marker

29. Assessment of Tube Patency
•Hysterosalpinography:-
•injection of radio-opaque medium through the cervical canal to the uterus
•evaluates uterine cavity and fallopian tubes
•done by fluroscopy
•best done 1 week after menstruation

30. Hysterosalpinography

32. Approach to Management

33. General Principles
•Involve both partners in evaluation and management
•Counsel both partners
•Perform fertility evaluation according to established
guidelines
•Identify causes of infertility
•Reversible:- medical or surgical therapy
•Irreversible:- reproductive technology,surrogacy, adoption

34. Counsel
•In normal young couples:
•60% conceive after six months
•80% conceive by one year
•90% conceive by 2 years
•Recommend lifestyle changes

35. Percentage Couple Conception

36. Ovulatory Dysfunction: Ovulation
Induction
•Weight Change:
•Obese: advise weight loss, exercise, diet modification
•↓Body weight: due to hypogonadotrophic hypogonadism ±
hypothalmic amenorrhea
•Excess exercise or eating disorders
•Advise behaviour modification

37. Ovulation Induction Agents
•Clomiphene Citrate:-
•Selective estrogen receptor modulator (SERM)
•Estrogen antagonist and agonist effects
•Acts on the hypothalamus
•Increases Gonadotrophin release
•Effective in Class II anovulation

38. •Gonadotropin therapy:
•Done when there is no response to clomiphene or concieve after 6-12 months
ovulatory cycles
•Recombinant FSH or Human menopausal gonadotropins (hMG)
•Metformin:
•Improves insulin sensitivity
•Correction of hyperinsulinemia
•Used in persons with PCOS
•Dopamine agonist
•Bromocriptine and cabergoline
•Used in hyper- prolactinemia
•Increase hypothalamic GnRH release

39. Ovarian Drilling
•Done by Laparoscopy
•Utilises diathermy or Laser
•Ovary is punctured 4-10 times
•Results:
•↓Testosterone, inhibin, androsterienedione, LH
•↑FSH
•MOA unknown
•Used in women with PCOS
•Success rate about 55%

40. Tubal Factor Infertility
•Distal Obstruction
•Corrected by lapascopy/laparotomy
•Fimbrioplasty- lysis of fimbrial adhesions and dilatation of fimbrial
structures
•Neo-salpingostomy:- creation of a new tubal opening distal to the
occluded tube

41. •Proximal obstruction:
•By hysteroscopic tubal catheterization
•Uses a double layered catheter
•Outer cather is directed into the tubal ostium
•If occlusion is observed, inner catherter is passed over a guide wire to
overcome the blockage

42. Assisted Reproductive Technology

44. IntraUterine Insemination

45. Advantages and Disadvantages
•Good for men with low
sperm count and
motility
•Good for women with
infertility due to
cervical factors
•Expensive
•Discomfort with
procedure
•Risk of ovarian
hyperstimulation
syndrome (OHSS)

46. Intracytoplasmic Sperm Injection

47. Advantages and Disadvantages
•Overcomes male
infertility
•Improves odds of
conception
•Option for persons
who have tried and
failed conventional IVF
•Eliminates natural
selection
•? children conceived
this way may be
subfertile or infertile

48. IVF
•Steps:
•Pre-stimulation treatment
•Ovarian stimulation with gonadotropins
•Monitor follicle development with US and serum hormone levels
•Final oocyte maturation and hCG administration
•Transvaginal oocyte retrieval
•Insemination
•Embryo Transfer
•Progesterone supplementation
•Pregnancy Test and early pregnancy follow up

50. In Vitro Fertilization

51. Advantages and Disadvantages
•Good per cycle
success rate
•Overcomes subfertility
•Site and extent of tubal
damage not important
to outcome
•High per cycle cost
•May require multiple
cycles
•Requires frequent
injections and
monitoring
•↑ risk of multiple
gestation
•Risk of OHSS

52. Ovarian Hyperstimulation
Syndrome
•Rare, iatrogenic complication of ovarian stimulation in
ART
•Characterized by:
•ovarian enlargement
•multiple cysts
•fluid shift into extravascular space
•Pathogenesis unknown

53. Risk Factors

54. Classification

55. Management
•Mild= Supportive and Observation
•Moderate
•Observation
•Bed rest
•Adequate fluid administration
•US monitoring of cysts
•Severe
•Fluid management
•Correction of hypovolemia
•Monitor I/O
•SC LMWH
•US guided abdominocentesis

56. Thank You