infertility-200520021915 (1).pptx2222222

Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus.
 
Primary infertility – denotes those patients who have never conceived.
Secondary infertility – It there has been a pregnancy, whatever the outcome. (or) It indicates previous pregnancy but failure to conceive subsequently within one or more years of unprotected regular intercourse.

1. INFERTILITY BY TANUSRI BARUI Assistant Professor College of Nursing Asia Heart Foundation

2. DEFINITION Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus.   Primary infertility – denotes those patients who have never conceived. Secondary infertility – It there has been a pregnancy, whatever the outcome. (or ) It indicates previous pregnancy but failure to conceive subsequently within one or more years of unprotected regular intercourse.

3. INCIDENCE 80% of the couples achieve conception if they so desire, within one year of having regular intercourse with adequate frequency (4-5 times a week). Another 10% will achieve the objectives by the end of second year. As such 10% remain infertile by the end of second year.

4. FACTORS RESPONSIBLE FOR FERTILITY Healthy spermatozoa should be deposited high in the vagina. The spermatozoa remain healthy and penetrate into the uterine cavity and thence into the uterine tubes. The ovum finds its way into the uterine tube where it can be fertilized by a spermatozoan . The fertilized ovum migrates into the uterus and the endometrum must be in a state, suitable for the implantation.

5. CAUSES OF INFERTILITY In 1/3 rd of cases, male factors are responsible. Another 1/3 rd of cases, female factors are responsible. Remaining 1/3 rd of cases – combination of both male and female factors are responsible.

6. FAULTS IN THE MALE Causes due to…… Defective Spermatogenisis Obstruction of efferent duct. Coital problems (Failure to deposit high in vagina) Defect in sperm and seminal fluid .

7. MALE REPRODUCTIVE ORGAN

8. Undescended testictes . Bilateral vasdeferens is absent in about 1-2% of infertile males. Infection ( Orchitis as a complication of mumps) Genetics (47 XXY) ( Klinefelter's syndrome) Testicular toxins (Iatrogenic) (Radiation) Drugs like antihyperten-sive , anticonvulsant and antidepressant cimetidine Thermal Factor e.g. In varicocoele . The scrotal temperature becomes 1-2 F less then the body temperature. Endocrinal Thyroid dysfunction gonadotropin deficiency, ( Kallmanns syndrome) Idiopathic testicular failure. FSH level is raised with germ cell hypoplasia . ( Sertoli cell only syndrome) Hyper prolactinaemia is associated with importance. General factors Chronic debilitating diseases, malnutrition or heavy smoking reduce spermatogene -sis. Alcohol inhibits spermatogenesis either by suppressing Leydig cell synthesis or by suppressing gonadotrophin levels. DEFECTIVE SPERMATOGENISIS

9. VARICOCELE

10. OBSTRUCTION OF EFFERENT DUCT Congenital : Absence of Vasdeferens . Young's Syndrome. Acquired Infective (Tuberculosis) gonorrhoea . Surgical trauma. Herniorrhapy

11. COITAL PROBLEMS ( Failure To Deposit High In Vagina ) Impotency Absent or premature ejaculation Retrograde ejaculation Hypospadias Psychosexual Erectile dysfunction or impotence

12. Retrograde ejaculation

13. DEFECT IN SPERM AND SEMINAL FLUID Kartagener syndrome ( autosomal disease) where there is loss of ciliary function and sperm motility. Sperm abnormality Loss of sperm motility ( asthenozoospermia ) Abnormal sperm monphology (round headed sperm, teratozoopsermia ) Low fructose content. High prostaglandin content. Undue viscocity . Immunological factor - (Sperm antibodies) Antibodies against spermatozoal surface antigen may be the cause of infertility. This result in clumping of spermatozoa after ejaculation.

14. FAULTS IN FEMALE Ovarian factors (30 - 40%). Tubal and peritoneal factors (25 - 35%). Uterine factors Cervical factors Vaginal factors

15. OVARIAN FACTOR Anovulation or Oligo ovulation Decreased ovarian reserve Luteral Phase defect (LPD ) Lutenised unruptured follicular syndrome (trapped ovum)

16. Decreased ovarian reserve

17. TUBAL & PERITONEAL FACTORS Pelvic infections causing - Peritubal adhesions. Endosalpingeal damage . Previous tubal surgery or sterilization Salpingitis isthmica nodosa . Tubal endometriosis. Polyps or mucous debris within the tubal lumen, or tubal spasm.

18. UTERINE FACTORS Uterine hypoplasia . Inadequate secretary endometrium , Fibroid uterus, Endometritis (tubercular in particular) Uterine Synechiae or Congenital malformation of uterus. ( pic )

19. CERVICAL FACTORS Anatomic Congenital elongation of the cervix. Second degree uterine prolapse . Acute retroverted uterus. Physiologic The fault lies in the composition of the cervical mucous, so much that the spermatozoa fail to penetrate the mucus. The mucus may be scanty following amputation, conisation , or deep cateheterization of the cervix. The abnormal constituents include excessive, viscous or purulent discharge as in chronic cervicitis . Presence of antisperm or sperm immolising antibodies maybe implicated as immunological factors of infertility.

20. Vaginal Factors Atresia vagina (Partial or complete) tranverse vaginal septum, spetavagina or narrow introitus causing dyspareunia

21. Combined factors General factors. Infrequent intercourse. Apareunia and dyspareunia . Anxiety and apprehension. Use of lubricants during intercourse Immunological factors.

22. GENERAL INVESTIGATION A full history including occupation Medical history - STDs etc. In the man, secondary infection following mumps may lead to orchitis . In woman, previous pelvic or abdominal surgery raises the possibility of adhesion. Each partner should be given the opportunity to elaborate individually about fertility to date. Regular menstruation, dysmanorrhoea and " mittelschmerz (transient mid cycle pain in the iliac fossa ). If periods are erratic or in frequent ( oligomenorrhoea ). A compete medical examination of both the partners Genitalia is done to disclose variococle Hydrocele Testicular volume In woman, hirutism Obsesity may be suggestive of endocrine disorders. A biannual and speculum examination.

23. SPECIFIC INVESTIGATIONS OF MALE AND FINDINGS SEMEN ANALYSIS This is the basic test for male infertility. Average values are assessed on three samples produced over several weeks. Specimens are produced by masturbation after 2-3 days abstinence. Examined in the laboratory within 1 hour. Normal Values (WHO 1988) : Volume – 2 -6 ml. Total Sperm Count – More than 40x10 6 per ml. Motality – Moe than 60% of the sperm moving forward. Morphology – More than 60% of the sperm should appear normal on examination.

24. SPECIFIC INVESTIGATIONS OF MALE AND FINDINGS Contd.. AGGLUTINATION OF SPERM may be due to – Antisperm antibodies Intrauterine insemination with the washed sperm may be successful. Infection – viral or bacterial . Azoospermia Biopsy of the testes Chromosome studies Oligospermia - ( Oligoasthenoteratozoospermia ) Blood test for hormone level POSTCOITAL TEST TRANSRECTAL ULTRASOUND (TRUS) VASOGRAM KARAYOTYPE ANALYSIS IMMUNOLOGICAL TESTS

25. History A general medical history The surgical history Menstrual history Previous obstetric history Contraceptive Practice Sexual Problems SPECIFIC INVESTIGATIONS OF FEMALE AND FINDINGS

26. SPECIFIC INVESTIGATIONS OF FEMALE AND FINDINGS Contd.. DIAGNOSIS OF OVULATION Indirect i ) Menstrual history ii ) Evaluation of peripheral or endorgan changes – BBT (Basal Body Temperature ) Cervical mucus study Spinnbarkeit - ( Stretchability or elasticity) Fern Test Vaginal Cytology Hormonal estimation Serum progesterone Serum LH Serum Oestradiol Urine LH Endrometrial biopsy. (iii) Sonography Direct - Laparoscopy. Conclusive – Pregnancy

27. SPECIFIC INVESTIGATIONS OF FEMALE AND FINDINGS Contd.. TUBAL FACTORS Dilatation and insufflation test (DI) Hysterosalpingography (HSG) Laparoscopy Sonohysterosalpingography Salpingosocpy

28. CERVICAL FACTORS Post Coital Test (PCT) (Sims Huhner Test) Sperm Cervical mucus contact test (SCMCT) SPECIFIC INVESTIGATIONS OF FEMALE AND FINDINGS Contd..

29. UNEXPLAINED INFERTILITY Defined when no obvious cause for infertility has been detected following all standard investigations. These include semen analysis, ovulation detection, tubal and peritoneal factors, endocrinopathy and PCT. Overall incidence is 10-20 percent, With expectant management, about 60 pecent of couples with unexplained infertility will conceive within a period of three years. IVF and ET may be an option for those who fail to respond.

30. TREATMENT FOR MALE INFERTILITY General Care : Improvement of general health Use of vitamins E,C,D, B 12 & Folic acid as antioxidants to improve Spermatogenesis is of doubtful value. Iatrogenic effect on spermatogenesis like Radiation, cytotoxic drugs, nitrofurantoin , cimetidine ,  -blockers, anti-hypertensive, anticonvulsant and anti-depressant drugs are better avoided. In hypogonadotrophic - hypogonadism , the disorders of spermatogenesis can be treated with the following therapy. hCG 5000 IU intramascularly once or twice a week is given to stimulate endogenous testosterone production. hMG is added to hCG when there is no sperm in the ejaculation with hCG alone. Dopamine agonist ( Cabergoline ) is given in hyperprolactinaemia to restore normal prolactin and testosterone level. This improves libido, potency and fertility. Pulsatile GnRH therapy in infertile male with GnRH deficiency ( kallmann's Syndrome) is effective. It is administered by minipump infusion. Cases with hypogonadotropic hypogonadism may also respond with GnRH therapy.

31. TREATMENT FOR MALE INFERTILITY Contd.. General Care : In hypergonadotrophic - hypogonadism , no form of medical treatment can improve fertility in men. Chompiphene citrate 25 – 50 mg orally daily for 25 days with rest for 5 days for 3 cycles is given. It increases serum level of FSH, LH and testosterone. In presence of antisperm antibodies in the male, currently intrauterine insemination (IUI) with washed spermatozoa is the choice of treatment for such cases. Genital tract infection needs prolonged course of antibodies. Generally doxycycline or erythromycin is given for a period of 4-6 weeks depending on the response. In retrograde ejaculation – Phenylephrine (  adrenergic agonist) is used to improve the tone of internal sphincter. Sperm may be recovered from the neutralized urine. Processed spermatozoa could be used for IUI. In genetic abnormality – artificial insemination with donor sperm (AID) is the option as no other treatment is available.

32. TREATMENT FOR MALE INFERTILITY Contd.. SURGICAL : Surgery for vericocole for improvement of fertility is not helpful. Hydrococle is corrected by surgery. Orchidopexy in undescended testes should be done between 2-3 years of age to have adequate spermatogenesis in later life. IMPOTENCY : Psychosexual treatment may be of help. Hyperprolactinaemia needs further investigation and treatment. For erectile dysfunction sildenafil (25-100mg) or tadelafil (10 – 20 mg) is currently advised. A single dose (depending on response) is given orally one hour before sexual activity. In unresponsive cases, artificial insemination to be thought of. ASSISTED REPRODUCTIVE TECHNOLOGY (ART) FOR MALE INFERTILITY :

33. Induction of ovulation General Drugs Surgery Tuboplasty TREATMENT FOR FEMALE INFERTILITY

34. STIMULATION OF OVULATION Clomiphene citrate (CC) Letrozole hMG ( Humegon , Pergon ) (FSH 75 IU + LH 75 IU) FSH purified urinary FSH highly purified urinary FSH ( Metrodin HP) recombinant FSH ( Gonal - F, Recagon ) hCG ( Profasi , Pregnyl ) recombinant hCG GnRH GnRH analogues CORRECTION OF BIOCHEMICAL ABNORMALITY: Androgen excess - Dexamethasone Prolactin raised - Bronocriptine HyperInsulinaemia - Metormin SUBSTITUTION THERAPY Hypothyroidism - Thyroxin Diabetes mellitus - Anti diabetic drugs TREATMENT FOR FEMALE INFERTILITY Contd..

35. ASSISTED REPRODUCTIVE TECHNOLOGY (ART ) ART encompasses all the procedures that assist the process of reproduction by retrieving oocytes from the ovary or sperm from the testis or epididymis . Artificial Insemination (Ai) IUI - Intrauterine insemination AIH AID In Vitro Fertilization And Embryo Transfer ( IVF-ET ) Gamete Intra Fallopian Transfer (GIFT) Zygote Intra-fallopian Transfer (ZIFT) Intracytoplasmic Sperm Injection (ICSI)

36. LEGAL ISSUES 1 . Clinics should be registered 2. Code of Practice Staff Facilities Confidentiality Information to patient Consent Counseling Use of gametes and embryos Storage and handling of gametes and embryos Research Complaints

37. LEGAL ISSUES Contd … 3 . Responsibilities of the Clinic Give adequate information . Maintain , detailed record . Take DNA fingerprints . Keep all information about donors, recipients and couples confidential and secure . Display the charges . Ensure that no technique is used on a patient for which demonstrated expertise does not exist with the staff of the clinic . Be totally transparent in all its operations.

38. LEGAL ISSUES Contd.. 4 . Information and Counseling to be given to Patients - Basis , limitations and possible outcome . Side-effects and the risks of treatment to the women and the child. Need to reduce the number of viable foetuses Possible disruption of the patient's domestic life during the treatment Techniques involved , and possible pain and discomfort Cost (with suitable break-up) Importance of informing the clinic of the result of the pregnancy Right of the child born through ART’

39. LEGAL ISSUES Contd.. 5 . Desirable Practices/Prohibited Scenarios There would be no bar to the use of ART by a single woman who wishes to have a child, and no ART clinic may refuse to offer its services. The ART clinic must not be a party to any commercial element. A surrogate mother carrying a child biologically unrelated to her must register as a patient in her own name. A third-party donor and a surrogate mother must relinquish in writing all parental rights concerning the offspring and vice versa. No ART procedure shall be done without the spouse's consent. The provision or otherwise of AIH or ART to an HIV-positive woman would be governed by the implications of the decision of the Supreme court in the case of X – vs – Hospital 2 (1998) 8 Sec. 269 or any other relevant judgment of the Supreme Court, or law of the country, whichever is the latest. The accepted age for a sperm donor shall be between 21- 45 yrs and for the donor woman between 18-35 yrs. Sex selection at any stage after fertilization, or abortion of foetus of any particular sex should not be permitted, except to avoid the risk. Collection of gametes from a dying person will only be permitted if widow wishes to have a child. No more than three eggs or embryos should be placed in a woman during any one treatment cycle, regardless of the procedure used, excepting under exceptional circumstances {such as elderly women (above 37 years), poor implantation (more than three previous failures, advanced

40. PRESENT INDIAN SCENARIO The Indian scenario in this field is quite bleak. Delhi artificial insemination (Human) Act 1995 is the only statutory act prevailing in India . 1. Litigation against doctors – doctors can face few litigations like- a. Not taking proper informed consent: After duly counseling the couple and / or oocytes / semen donor and informed and written consent should be taken from both the spouses as well as donor. They should be explained various risk factors including risks involve in ovarian hyper stimulation, anaesthetic procedures, invasive procedures like laparoscopy, aspiration of ovum etc. in simple language using the words that they can understand well. They should be explained the possibility of multiple pregnancies, ectopic gestation, increased rate of spontaneous abortion, premature birth, higher perinatal and infant mortality as well as growth related problems. b. Following the birth of a defective child: To avoid this, the donor's chromosomes must be thoroughly screened for possible genetic defect, and should also inform all the likely possibilities at the time of taking informed consent.

41. PRESENT INDIAN SCENARIO Contd.. 2 . Legitimacy - The child born by ART is considered legitimate with all the rights of parentage, support and inheritance, provided he is born during lawful wedlock and with consent of both the spouses. Sperm or oocyte donors shall have no parental rights or duties in relation to the child. A child can be given status of legitimacy also by adoption In a case, on the wife's petition for divorce and custody of the child, a question was raised before the court: whether the child, who is born to her consequent to AID, consented to by husband, is legitimate and belongs to mother only? Court held that a child so conceived was not a child born in wedlock and therefore illegitimate. As such it was the child of mother alone and the husband had no rights or interest in the child, not even that of visitation. The husband is not the actual father of the child and, therefore the child is illegitimate. 3. Inheritance of property – Since the child is illegitimate if born out of AID, it cannot inherit the property of his father. Any attempt to conceal this fact by registering the husband, as the father amounts to perjury.

42. PRESENT INDIAN SCENARIO Contd.. 4 . Consummation of marriage – Conception of the wife by AI (AIH or AID) does not amount to consummation of marriage, if there is no successful sexual act due to the impotency of husband. The decree of nullity may still be granted in favor of the wife on the ground of impotency of the husband or his willful refusal to consummate the marriage. However, such a decree could be excluded on the grounds of approbation. However in this situation the child will be illegitimate. 5. Rights of an unmarried woman to AID : There is no legal bar on an unmarried woman going for AID. A child born to a single woman through AID would be deemed to be legitimate. However, AID should normally be performed only on a married woman and that too, with the written consent of her husband, as a two-parent family would be always better for the child than a single parent one, and the child's interests must outweigh all other interests 6. Ground for divorce and judicial separation – Mere AI is not a ground for nullity of marriage and divorce since sterility is not a ground, however if AI is due to impotence of husband, it becomes the ground. AID without husbands consent can be a ground for divorce and judicial separation. 7. Maintenance and custody of child – Under Hindu Adoption and Maintenance Act 1956 the maintenance of the dependents is the responsibility of the parents, whether legitimate or illegitimate, till the son remains minor and daughter is unmarried.

43. PRESENT INDIAN SCENARIO Contd.. 8 . Insemination after the death of the husband – This is seen when semen of the husband is cryo -preserved by various methods and the women is inseminated after death of the husband. Such Posthumous child is said to be legitimate because the semen is of husband, although the complexity arises since conception is not during the continuance of marriage. 9. Relation between AIH / AID child with subsequent Natural / Adopted child of same family - If the child is born of natural course some times after the birth of the child through AI, the status will remain same for AI child but the natural child born will remain legitimate. 10. Charge of Adultery - AID does not amount to adultery, even if it was done without the consent of husband. For adultery to be committed both parties should be physically present and engage in sexual act and sexual union involving some degree of penetration of the female organ by the male organ should take place. AI is not equivalent to sexual intercourse. Under section 497 of IPC 1860 , For the charge of adultery two things must be proved, sexual intercourse took place with another person's wife and no consent or connivance from another man was granted. 11. Incestous relationship – There is high risk of such relationship between naturally born child and child born out of AID of the same parent.

44. Thank you