infertility obg Nursing Kerala University of health science PPT

Nursing students

1. INFERTILITY

2. DEFINITION Failure to conceive within one or more years of regular unprotected coitus Inability of a sexually active non contracepting couple to achieve pregnancy in one year

3. TYPES

4. PRIMARY INFERTILITY Who have never conceived

5. SECONDARY INFERTILITY Previous pregnancy but failure to conceive subsequently

6. INCIDENCE 10- 14% of indian population affected High in urban 1/6 couples WHO – 3.9 to 16.8% in India Kerala – 41.91%

7. MALE INFERTILITY

8. ETIOLOGY

9. DEFECTIVE SPERMATOGENESIS

10. CONGENITAL Undescended testis Kartagener syndrome – loss of ciliary function and sperm motility Hypospadiasis – failure to deposite sperm high in vagina

11. THEMAL FACTORS Scrotal temperature should be 1 – 2 F less than body temperature

12. INFECTIONS Mumps Orchitis – infection of testis Bronchiectasis – quantity of sperm affected Bacterial or viral infection of seminal vesicle and prostste depress sperm count Mycoplasma or Chlamydia trachomatis

13. GENERAL FACTORS Malnutrition Smoking – decrease spermatogenesis Alcohol – supress Leydig cell synthesis of testosterone and supress gonadotropins level Other health problems

14. ENDOCRINE Kallmanns syndrome – testicular deficiency due to gonadotropins deficiency Sertoli – cell – only syndrome – FSH in idiopathic testicular failure with germ cell hypoplasia Hyper prolactinemia

15. GENETIC Chromosomal abnormality in Klinefelters syndrome 47XXY

16. IATROGENIC Radiation Cytotoxic drugs Nitrofurantoin Cimetidine Beta blockers Antihypertensives Anticonvulsants Antidepressants

17. IMMUNOLOGICAL Antibody against spermatozoal surface antigen

18. OBSTRUCTION OF EFFERENT DUCT SYSTEM Efferent duct is obstructed by infection, surgical trauma and vasectomy Young’s syndrome – epidydimal obstruction Bronchiectasis

19. FAILURE TO DEPOSIT SPERM HIGH IN VAGINA Ejectile dysfunction Ejaculatory defect – premature retrograde (semen enters bladder instead of emerging through penis) or absence of ejaculation Hypospadiasis Sperm abnormality

20. ERRORS IN THE SEMINAL FLUID High or low volume Low fructose content High prostaglandin content Undue viscosity

21. DIAGNOSTIC EVALUATION History Physical examination – BMI, Hair growth, Size and consistency of testis, Testicular Volume, gynaecomatia Investigations – Rotine & Semen Serum FSH, LH, testosterone, prolactin , TSH

22. DIAGNOSTIC EVALUATION Fructose content in seminal fluid – absence indicate congenital absence of semial vesicle or portion of the ductal system or both Vasogram Karyotyping Immunological test

23. DIAGNOSTIC EVALUATION Testicular biopsy Trans Rectal ultra sound (TRUS) – visualize semial vesicle, prostste and ejaculatory duct obstruction Post coital test Pus cell analysis

24. NORMAL SEMEN ANALYSIS PARAMETERS NORMAL VALUES Volume 2.0 ml or >1.5 ml Ph 7.2 – 7.8 Viscosity <3 Sperm concentration 20 million/ml Total sperm count >40 million/ejaculation Motility >50% forward motility Morphology >14% normal form Viability 75% or more living Leucocytes <1 million/ml Round cells <5 million/ml Sperm agglutination <10% spermatozoa with adherent particle

25. NOMENCLATURES Aspermia Failure of emission of semen Hypospermia Low semen volume Oligospermia / Oligozoospermia Sperm count <20 million/ml Polyzoospermia Sperm count >350 million/ml Azoospermia No spermatozoa in semen Asthenozoospermia Reduced sperm motility Leucocytospermia Increase white cells in semen Necrozoospermia Dead or motion less spermatozoa Teratozoospermia >70% spermatozoa with abnormal morphology Oligoasthenoteratozoospermia All together

26. MANAGEMENT COUPLE INSTRUCTION AND GENERAL CARE Assurance Body weight Smoking & Alcoholism Coital problems Stop medication Improvement of general health

27. MANAGEMENT HYPOGONADOTROPHIC HYPOGONADISM hCG – 5000 IU once or twice a week. Improves testosterone production hMG – 75 – 150 IU Dopamine agonist ( Cabergoline ) for hyper prolactinemia Pulsatile GnRH therapy – Kallmann’s syndrome

28. MANAGEMENT HYPERGONADOTROPHIC HYPOGONADISM No treatment IVF with ICSI Clomiphene citrate 25mg PO daily for 3 months. Improves FSH, LH and Testosterone

29. MANAGEMENT ANTISPERM ANTIBODIES IUI LEUKOCYTOSPERMIA Antibiotics – Doxycycline / Erythromycine for 4 – 6 weeks RETROGRADE EJACULATION Phenyl ephrine IUI

30. MANAGEMENT TERATOZOOSPERMIA& ASTHENOZOOSPERMIA Donor insemination GENETIC ABNORMALITY Artificial insemination

31. MANAGEMENT IMPOTENCY – ERRECTILE DYSFUNCTION Sildenafil 25 – 100 mg or Tadalafil 10 – 20 mg Single dose one hour before coitus

32. SURGICAL MANAGEMENT Obstruction with normal spermatozoa – Vasoepididymostomy or Vasovasotomy Surgery for vericocele , hydrocele Orchidopexy for undescended testis

33. ASSISTED REPRODUCTIVE TECHNOLOGY (ART) IUI – Intra Uterine Insemination  TESA – Testicular Sperm Aspiration PESA – Percutaneous Epidydimal Sperm Aspiration MESA – Microsurgical Epidydimal Sperm Aspiration ICSI – Intra Cytoplasmic Sperm Injection

34. FEMALE INFERTILITY

35. ETIOLOGY

36. OVARIAN FACTORS

37. ANOVULATION/ OLIGO OVULATION HPO axis dysturbances Thyroid dysfuction Adrenal dysfuction Others – PCOS, Elderly women, Premature ovarian failure, Resistant ovarian syndrome

38. DECREASED OVARIAN RESERVE Decreased quality and quantity of egg

39. LUTEAL PHASE DEFECT Inadequate function and growth of corpus luteum Inadequate progesterone secretion Life span of corpus luteum <10 days Inadequate secretory changes in the endometrium which hinder implantation

40. LUTEAL PHASE DEFECT Also due to Defective folliculogenesis Drug induced ovulation Decresed FSH & LH Hyper prolactinemia Hypothyroidism Older women DUB Endometriosis

41. LUTEINIZED UNRUPTURED FOLLICULAR SYNDROME Also called trapped ovum Follicles are present but FSH receptor absent or resistant Ovum is trapped inside follicle due to Endometriosis, Hyper prolactinemia , Resistant ovarian syndrome

42. TUBAL FACTORS

43. TUBAL OBSTRUCTION Due to Pelvic Infection Previous Tubal Surgery Sterilzation Salphingitis Tubal endometriosis Polyp/ mucus debris Tubal spasm

44. PERITONEAL FACTORS Due to Peritubal adhesion Endometriosis

45. UTERINE FACTORS Uterine hypoplasia Inadequate secretory endometrium Fibroid Endometritis Uterine synechiae Congenital malformation

46. CERVICAL FACTORS

47. ANATIMICAL Prevent sperm ascent. The causes are, Congenital elongation Secondary uterine prolapse

48. PHYSIOLOGICAL Fault in composition of cervical mucus – Spermatozoa fails to penetrate mucus Scanty mucus due to Amputation, Conization , Deep Cauderization Abnormal constituents – Excessive viscous, purulent discharge Antisperm / Sperm Immobilizing Antibody

49. VAGINAL FACTORS

50. CONGENITAL Atresia Trans vaginal septum Septate vagina Narrow introitus

51. ACQUIRED Vaginitis Purulent discharge Dyspareunia

52. COMBINED FACTORS Advaned age >35 yrs Inadequate intercourse Dyspareunia / Apareunia Anxiety Use of lubricants – Spermicidal Immunological factors

53. DIAGNOSTIC EVALUATION HISTORY Medical Surgical – Abdominal/Pelvic Menstrual Contraceotive Previous OB Sexual problems

54. DIAGNOSTIC EVALUATION PHYSICAL EXAMINATION General BMI Obesity Hirsuitism Acne Acanthosis Nigricans   - Skin condition that causes a dark discoloration in body folds and creases Under development of secondary sexual character

55. DIAGNOSTIC EVALUATION PHYSICAL EXAMINATION Systemic DM HPTN Heart disease Renal Thyroid Endocrinopathies

56. DIAGNOSTIC EVALUATION PHYSICAL EXAMINATION Gynaecological Hymen opening Infections Elongation & tear of cervix Uterine size Speculum examination Congenital anomalies

57. SPECIAL INVESTIGATIONS

58. OVARIAN FACTORS

59. INDIRECT METHOD Calender method Basal body temperature Cervical mucus study Vaginal cytology Hormone estimation Endometrial biopsy

60. BASAL BODY TEMPERATURE Biphasic variation of temp. variation in ovulatory cycle due to increase progesterone and nor epineohrine . Both are thermogenic . Oral temp. in the morning – increase 0.5 - 1 F (0.2 – 0.5 C) following ovulation and falls about 2 days prior to periods.

61. BIPHASIC VARIATION OF TEMPERATURE

62. CERVICAL MUCUS STUDY Physico chemical properties of the cervical mucus due to oestrogen and progesterone Appearance of fern pattern of cells which present in midcycle is suggestive of ovulation.

63. FERN PATTERN – CERVICAL MUCUS

64. VAGINAL CYTOLOGY Microscopic examination of cells from the  vaginal epithelium  because the vaginal epithelium  changes in response to sex hormone

65. HORMONE ESTIMATION Progesterone – Increase from <1ng/ml to >6ng/ml indicate ovulation LH – Ovulation after 34-36 hrs after LH surge Oestradiol – Peak at 24 hrs prior to LH surge to ovulation and about 24-36 hrs prior to ovulation Urinary LH

66. ENDOMETRIAL BIOPSY Thickness evaluation 21-23 day of cycle

67. DIRECT METHOD Laproscopy Sonography – TVS ovum(18-20mm) & endometrial thickness >8mm

68. OVARIAN FACTORS LUTEAL PHASE DEFECT BBT Endometrial biopsy S.Progesterone LUTEINIZED UNRUPTURED FOLLICULAR SYNDROME Sonography Laproscopy Biopsy

69. TUBAL FACTORS Insufflation test/ Rubin’s test Hystero salphingography (HSG) Sono Hystero salphingography Falloposcopy Salphingoscopy Laproscopy chromopertubation

70. INSUFFLATION TEST/ RUBIN’S TEST Cervical canal is in continuity with the peritoneal cavity through tubes CO 2 into peritoneal cavity when pushed trans cervically under pressure Done 2 days after stoppage of menstrual bleeding

71. INSUFFLATION TEST/ RUBIN’S TEST OBSERVATIONS Fall in pressure when raised >120mm of Hg Hissing sound on auscultation on either iliac fossa Shoulder pain due to irritation of diaphragm by air

72. HYSTERO SALPHINGOGRAPHY (HSG) Same as Rubin’s test Instead of CO 2 methylene blue dye is used

73. SONO HYSTERO SALPHINGOGRAPHY Normal saline is pushed in uterine cavity with a paediatric foley’s catheter. The catheter balloon is inflated at the level of cervix to prevent fluid leak. USG of uterus and fallopian tube done

74. FALLOPOSCOPY Study the entire length of tubal lumen. Using fine and flexible fibro optic device

75. SALPHINGOSCOPY Study of tubal lumen by introducing a rigid endoscope through the fimbrial end of the tube

76. CHROMOPERTUBATION As part of a laparoscopy, a blue dye solution ( methylene blue or indigo carmine) is introduced into the uterine cavity. The dye solution flows through the fallopian tubes into the abdominal cavity and becomes visible on laproscopy . If the fallopian tube fills with the dye solution, but does not drain, there is a distal occlusion of the fallopian tube. If a filling drains out, there may be a closure in a part of the fallopian tube close to the uterus, or a spasmodic reaction

77. UTERINE FACTORS USG HSG Hysteroscopy Laproscopy

78. CERVICAL FACTORS Post coital test (Sims Huhner test) Sperm cervical mucus contact test (SCMCT) Endocrinopathies Immunology

79. POST COITAL TEST (SIMS HUHNER TEST) 8- 12 hrs after coitus Progressive motile sperm is detected in cervical mucus 10 progressive motile sperm is positive

80. SPERM CERVICAL MUCUS CONTACT TEST (SCMCT) Detect antispermal antibodies Equal quantities of sperm and mucus is mixed If there is antispermal antibodies present more than 25% sperm shows shaky movement Cross checking the cervical mucus with donor semen to confirm antibodies are from cervical or seminal

81. ENDOCRINOPATHIES TSH FSH Prolactine LH Testosterone Progesterone FBS PPBS dihydroepiandrosterone

82. IMMUNOLOGY Antigen – antibody reaction I g G , I g M , I g A I g G – cervical mucus, serum and semen

83. MANAGEMENT

84. OVULATORY DYSFUNCTION ANOVULATION Induction of ovulation by, GENERAL DRUGS SURGERY

85. GENERAL Psycho therapy Weight reduction Exercise counselling

86. DRUGS Clomiphene citrate – 50 to 250 mg daily for 5 days starting from 2 nd and 5 th day of menstruation Block oestrogen receptors in the hypothalamus Increase GnRH pulse amplitude Increase Oestrogen and Progesterone

87. DRUGS ADJUANT THERAPY Hyper insulinaemia – Metformine Elevated androgen – Dexamethazone 0.5mg for 10 days. Starting 1 st day of cycle and stop soon after ovulation Hypothyroidism – Eltroxin Hyper prolactinemia – Bromocriptine / Cabergoline

88. DRUGS ADJUANT THERAPY hCG – 5000 IU for 7 days after last dose of clomid Conjugat oestrogen – 1.25mg daily for 10 days. Start on 1 st day of cycle. Helps sperm penetration because clomid increase viscocity Aromatase inhibitors - Letrozole

89. DRUGS ADJUANT THERAPY GnRH analogue Increase LH Buserelin / Nafarelin S/C or IM Initially produce stimulation ofgonadotropin secretion known as Flare effect last for 2-3 wks

90. DRUGS ADJUANT THERAPY GnRH antagonist Block pituitary GnRH receptor Ovulation by luteal support with hCG / Progesterone

91. LUTEAL PHASE DEFECT Natural progesterone as orally or vginal suppositories 100mg TID. Start on day of ovulation continued until menstruation. If pregnancy occurs continued upto 10 wks hCG Clomiphene in unresponsive cases

92. LUTEINIZED UNRUPTURED FOLLICLE hCG – 5000 to 10000 IU IM Bromocriptine in case of hyperprolactinemia

93. SURGERY Laproscopic ovarian drilling Lasor vaporization Wedge resection Surgery for pituitary tumors Surgery for tumors Utero vaginal surgeries Bariatric surgery

94. BARIATRIC SURGERY Surgery to prevent obesity in PCOD clients An adjustable silicon band is placed around the upper part of stomach to create a small upper gastric pouch. This limit hunger and food intake by early feeling of fullness of stomach

95. TUBAL & PERITONEAL FACTORS PERITUBAL ADHESION Salphingo ovariolysis PROXIMAL TUBE BLOCK Salphingography Proximal tube cannulation Cannulation & Balloon tuboplasty MID TUBE BLOCK Reversal of tube ligation

96. TUBAL & PERITONEAL FACTORS DISTAL TUBE BLOCK Fimbrioplasty / Fimbriolysis Neosalphingostomy – Create a new tubal opening

97. TUBAL SURGERIES ADHESIOLYSIS (SALPHINGO OVARIOLYSIS) Seperation or division of adhesion FIMBRIOPLASTY Separation of the fimbrial adhesion to open up the abdominal ostium SALPHINGOSTOMY Create a new opening in a completely occluded tube

98. TUBAL SURGERIES TUBO TUBAL ANAESTHOMOSIS Connects the separated parts of the fallopian tube TUBO CORNUAL ANAESTHOMOSIS Connects the fallopian tube to cornua of uterus

99. ADJUANT THERAPIES Prophylatic antibiotics Hydro tubation – flush the tubal lumen by medicated fluids passed trans cervically through a cannula . The fluids contains antibiotics and Hydrocortisone ( Gentamycine – 80mg and D examethazone -4mg in 10ml sterile water)

100. UTERINE FACTORS Antibiotics for infections Myomectomy Metroplasty (Removal of septum) Adhesiolysis Surgery for uterine fibroid ART Surrogacy Uterine transplantation

101. CERVICAL FACTORS Conjugated oestrogen 1.25mg daily start on Day 8 for 5 days Doxycycline 100mg BD daily for 14 days for infections ART

102. CERVICAL FACTORS IMMUNOLOGICAL FACTORS Anti sperm antibodies - Dexamethazone -0.5mg HS ART

103. VAGINAL FACTORS Antibiotics for infections Enlargement of vaginal introitus Metroplasty (Removal of septum) Adhesiolysis Polypectomy ART Surrogacy

104. UNEXPLAINED INFERTILITY Both the partners have no complaints Investigations and treatment are same as above Treatment for both the partners