Infertility Investigation and management.pptx

Obstetrics and gynaecology

1. Infertility Reproductive Failure 5 th year. 22/11/18

2. What is Infertility? Definition: Inability to achieve a pregnancy after at least 1 year of regular unprotected ejaculatory vaginal sexual intercourse with an adult of the opposite sex . If woman is > 35 yrs ; 6 months.

3. S ubfertility …..a reduced capacity for conception but not exactly unattainable.

4. Introduction Infertility is a global problem affecting (5-20%) of couples. In Africa, infertility is often masked by a high fertility rate and high population density . African has a low capacity and technologies to handle these two problems.

5. Introduction (classification) cont. Infertility may be primary or secondary . Primary infertility occurs when the couple has not achieved any pregnancy . Secondary infertility occurs in a couple who have had at least a pregnancy irrespective of the outcome.

6. Introduction cont. Clinic based studies: In our environment, 20-30% is primary while 70-80% of cases is secondary . In the developed countries primary is 80% as against secondary of 20 %. Population based studies suggest that secondary infertility is more than primary infertility worldwide.

7. Introduction cont. This reflect marked differences in the causative factors . Voluntary infertility often over shadows involuntary infertility in developed countries . Desire for a large family size increases the burden of infertility in developing countries . In Africa, the prevalence of infertility tend to follow the pattern of pelvic infections.

8. ….trends There is an overall increase in prevalence of infertility in the last 3 decades compared to 3 decades before that. Coincide with increase in the prevalence of STD and ectopic pregnancy. The problems of infertility is often born by the woman .

9. Gender Distribution Female factors 30% Male factors 30% Mixed 30% Unexplained 10%

10. Female Factors Cervical 10% Uterine 15% Tubal 25% Ovarian 40% Peritoneal 10%

11. Male Infertility Pre-testicular 34% Hypothalamic disease Pituitary disease Growth hormone deficiency Testicular 33% Chromosomal Testis injury etc. Post-testicular 33% Reproductive obstructive disease Sperm function disorder Disorder of coitus

12. Evaluation of Infertility. Normal Reproductive Efficiency; ……time required for conception in couples who will attain Pregnancy . Time of Exposure % Pregnant 3 months 57% 6 months 72% 1 year 85 % 2 years 93%

13. What factors affect fertility? Age : 9-16 years – due to irregularity of menstrual cycle . Desire to achieve a vocation . age > 35 years – reduction in ovulation potential. Increased risk of chromosomal abnormalities .

14. Factors affecting fertility cont. Social / Nutritional status / Income. Education – educated women tend to delay conception . Marital status. Occupation – Foundry workers, agriculturists. Exposure to environmental toxicants e.g. benzene , heavy metals. Fertility rate has dropped by 3% worldwide due to uncertain factors.

15. What are the causes of infertility? (Female) Vaginal factors : gynaetresia Uterine factors Fibroids at the corpus or cervix Endometriosis Uterine Synaechae Cervical incompetence. Cervical hostility. Aplasia / dysplasia .

16. What are the causes of infertility cont’d.? Tubal disease blockage and adhesion . Anovulation – Regular Oligo- ammenorrhae Secondary “ Primary “ Pituitary High prolactin level

17. Tubal Blockage

18. Fibroids

19. Causes of infertility cont. (Male) Testicular varicose Genital infections Mumps orchitis Previous groin/scrotal surgery Heavy smoking/chronic alcohol intake Chronic and serious systemic illness

20. Medical History (Female) frequency of intercourse menstrual history: irregularities surgical history: abdominal / pelvic surgery history of weight changes, hirsutism and acne contraception :IUCDs cervical smear symptoms (past or present) : STD , galactorrhea, thyroid symptoms obstetric history

21. Medical History (Male) Genital tract infection : mumps, Orchitis , prostatitis. History of impotence , premature ejaculation, change in libido . Surgical history of testicular torsion, undescended or mal-descended testis, prostate surgery, hernia repair. Trauma : genital or inguinal region Exposure to lead , cadmium, mercury

22. Investigations The male partner should normally have two semen analyses performed during the initial investigation. While regular menstruation is strongly suggestive of ovulation , this should be confirmed by the measurement of serum progesterone in the mid luteal phase. The female partner should normally have a test of tubal patency during the initial investigation of infertility.

23. Semen analysis Volume 2.0 - 5.0 mL pH >7.2 Concentration > 20 million / mL Total sperm number > 40 million / ejaculate Motility > 50% Forward progression > 2 (scale 0-4) Sperm morphology > 30% normal (WHO 1992) > 14% normal (WHO 1999

24. Hysterosalpingography (HSG) Normal Blocked Tubes

25. Management Both partners should be seen together Privacy and sufficient clinical time Classical history taking with emphasis on exploring a couple’s anxieties Counseling is very important and essential Routine examination is not necessary unless indicated by the history

26. General Advise (Female) F olic acid whilst trying to conceive and during the first 12 wks of pregnancy to prevent neural tube defects. Reduce body weight in obese women Stop smoking Avoid excessive alcohol

27. General Advise (Male) Stop smoking. Avoid excessive alcohol. Men with poor quality sperm advised to wear loose fitting underwear and trousers. A void occupational or social situations that might cause testicular hyperthermia

28. Ovulation Induction Oral Clomiphene ( Clomid ) or Letrozole ( Femara ) Pregnancy rate is 10% per cycle (higher in PCOS patients). Risk of twins 8-10% and risk of triplets or more less than 1% Side Effects : hot flushes, nausea , headaches , mood swings, blurred vision, thin uterine lining, poor cervical mucus.

29. Ovulation induction cont. Injectable medications: Gonadotropins ( FSH, LH ) Pregnancy rate is 10-20% each cycle ( controversial) Risk of twins up to 30% and risk of triplets or more 5-10% Side effects of medication are minimal because it is a natural hormone. Chance of overstimulation and canceling cycle.

30. Assisted Reproduction These techniques have revolutionized the management of infertile couples. Entry guidelines should be followed The women should be less than 40 years old and in good health. The couple should be aware of the emotional and financial strain.

31. Intra Uterine Insemination

32. Bad habits that should be broken to enhance conception. Staying up late Too many cups of coffee Over or under exercise Over eating and junk food binges Procrastination Drinking too much alcohol Smoking Unsafe sex