SUBFERTILITY PART II. .pptx

Subfertility presentation
Pathological causes
Maternal factors which include :
Ovarian factors
Tunal factors
Uterine factors
Paternal factors
Other factors
Management :
Hx
Examination
Treatement

1. Dr. Ruaa Abduljabbar Hamid

2. O bjectives To understand: Different investigations in subfertile couples Medical and surgical treatments available for female subfertility.

3. Investigations of infertility: When to investigate Couples should be seen when a fertility problem is perceived to exist. Exclusion of obvious medical factors, explanation about normal patterns of conception & advice about lifestyle measures may be sufficient in many cases. Referral to a fertility clinic should take into account the age of the female partner & duration of infertility. In the absence of risk factors, couples who have been trying for 1 years should be investigated and seen in a dedicated fertility clinic.

4. . Earlier intervention is indicated in the presence of specific high-risk factors in either partner. In the male, history of azoospermia , testicular surgery, vasectomy or coital failure . In the in female include: >35 years old, oligoamenorrhoea , known endocrine conditions affecting ovulation, history of tubal disease, endometriosis or salpingectomy.

5. Female investigations 1.Blood hormone profile: In a woman with a regular menstrual cycle early follicular phase (D2-D3) : • follicular-stimulating hormone (FSH) • oestradiol • luteinizing hormone (LH). • Anti- Müllerian hormone (AMH). • A mid-luteal progesterone to confirm ovulation. In women with an irregular menstrual cycle : • thyroid function test. • Prolactin. • testosterone.

6. . 2.Transvaginal ultrasound (TVUSS): for assessment of pelvic anatomy, including uterine size & shape, the presence of any fibroids, ovarian size, position & morphology, PCO, follicular tracking, antral follicle count (AFC), pathology such as hydrosalpinges and endometriotic cysts can be detected & access to the ovaries ( ART) can be assessed.

7. . 3. Measurement of ovarian reserve: to predict the response to ovarian stimulation in ART. • (AFC) seen by TVS on (D3) is a good indicator of ovarian reserve (<4 low response, >16 high response ). • AMH is produced in the granulosa cells of ovarian follicles & does not change in response to gonadotrophins during the menstrual cycle.

8. . 4. Tubal patency & assessment of the uterine cavity are investigated by: • hysterosalpingography (HSG) using X-ray. • hysterocontrast synography ( HyCoSy ) using US • (3D) hysterocontrast synography .

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10. . laparoscopy & hysteroscopy: patients deemed at high risk of pelvic pathology could benefit from laproscope as a dual diagnostic & potentially therapeutic procedure currently there is as yet no effective test to check for tubal function .

11. . 5. Chlamydia testing: should be offered prior to any uterine instrumentation. 6. Screening for HIV & HBV & HCV If ART is to be offered.

12. . Male investigations: 1. Semen fluid analysis: the only routine investigation . Most centers recommend between a 2-4 day abstinence from ejaculation before providing the semen sample. if the initial SFA is abnormal it should be repeated 3 months later, to allow adequate time for spermatogenesis .

13. . 2 . Hormone profile : FSH, LH & T for men with a very low sperm count or azoospermia . 3. Karyotype & cystic fibrosis screen recommended for patients with low sperm count or azospermia . WHO parameters for semen analysis – 5th centile

14. . Aspermia : complete lack of semen Azospermia : absence of sperm cells in semen Oligospermia : decrease number of sperm cells in semen Asthenozospermia : reduced sperm motility Teratospermia : increase number of sperms with abnormal morphology Oligoasthenoteratozospermia : complex abnormalities.

15. Treatment of infertility All couples trying for a pregnancy will benefit from some general advice such as cessation of smoking and limiting alcohol intake. Pre-treatment counseling should include advice about general lifestyle measures including the need to achieve an optimum BMI. Periconceptual dietary supplement of folate shown to reduce the risk of NTD . The investigation will result in a number of diagnostic categories each with its own management pathway Regardless of the diagnosis, prolonged infertility refractory to conventional treatment is treated by IVF

16. Treatment of Anovulation Women should be made aware of potential risks of multiple pregnancy and ovarian hyperstimulation . Male factor problems and tubal pathology should be excluded.

17. HYPOGONADOTROPHIC HYPOGONADISM In women with weight loss associated amenorrhoea , treatment should be deferred until a target BMI of 20 kg/m2 is reached with pulsatile administration of GnRH agonists. Monitoring is by means of serum oestrogen & pelvic ultrasound. Side effects: multiple pregnancy & OHSS.

18. NORMOGONADOTROPHIC HYPOGONADISM (PCOS ) Weight loss and dietary measures : Weight loss should be the first line of treatment in obese women with anovulation due to PCOS.

19. . 1. Clomifene citrateis an orally active synthetic non-steroidal compound with oestrogenic & anti- oestrogenic properties , used to treat anovulation in women with PCOS. It displaces oestrogen from its receptors in the hypothalamic-pituitary axis , reduces the negative feedback effect of oestrogen and encourages GnRH secretion.

20. . Dose: daily dose of 50 mg on days 3–7 of the cycle, can be increased by a maximum of 150 mg / day. A course of 6 to 12 cycles can be used. follicular tracking by US minimize the risk of multiple pregnancy. Side effects: hot flushes. abdominal distension , pain, nausea, vomiting, headache, breast tenderness and reversible hair loss, multiple pregnancy 7–10 %, OHSS is rare <1%.

21. . 2. Aromatase inhibitors : e.g letrozol have been used as alternatives to clomifene in view of their lack of anti- oestrogenic effects. They suppress oestrogen production and mimic the central reduction of negative feedback by ovarian oestrogen . Dose: 2.5 mg given on days 3-7 of the cycle . follicular tracking by US minimize the risk of multiple pregnancy Side effects: hot flushes, headache gastric upset

22. . 3. Gonadotrophins : used for patients with low oestrogen or clomifene -resistant PCOS Either recombinant FSH or purified urinary human menopausal gonadotrophin which contains FSH & LH . Dose: starting dose of 75 IU given as injections, on day 3 of the cycle followed by small incremental dose increases, until 1–2 leading follicles>17–18mm are identified by US. Side effects: 34 % risk of multiple pregnancy and 4.6% risk of OHSS.

23. . 4. Insulin sensitizers (Metformin): used in women with PCOS may achieve spontaneous ovulation, can be combined with clomifene citrate to increase efficacy, It decreases insulin , total and free androgen levels and improves the clinical sequelae of hyperandrogenism . Dose : 500mg three times per day. Side effects: nausea , vomiting & other GIT disturbances weight loss is more effective than insulin sensitizers for spontaneous ovulation.

24. . Triggering of ovulation is achieved with a SC or IM single injection of ( hCG ) 5000-10000 IU When the follicle size > 17–18mm .This mimics endogenous LH surge, due to crossover of the alpha-subunits of the two hormones

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26. . 5. Laparoscopic ovarian drilling: Aims to restore ovulation in clomiphene citrate resistant PCOS patient , It is effective as gonadotropins in terms of pregnancy & live birth rate without the risk of OHSS & multiple pregnancies. it’s effect lasts 12–18 months if successful.

27. . Most surgeons perform (4) punctures per ovary each for 4 seconds at 40 w ( rule of 4) delivering the lowest effective dose recommended .

28. HYPERGONADOTROPHIC HYPOGONADISM Patients with premature ovarian failure will have poor response to OI agents & Egg donation may be the only option for these patients .

29. . H yperprolactenemic anovulation 1. Bromocriptine : a dopamine agonist needs to be administered two to three times a day. Side effects : nausea, headache vertigo , postural hypotension, fatigue & drowsiness can be minimized by initiating treatment with a low dose (1.25 mg) at bedtime with a snack, & gradually increasing up to 2.5 mg three times a day with food over 2 to 3 weeks.

30. . 2. Cabergoline : A newer dopamine agonist with Fewer side effects & longer half-life allow a twice weekly dose initially 0.25 mg may increase gradually up to 1 mg. Side effects: nausea, headache , dizziness, fatigue, somnolence. Treatment of hyperprolactinaemia is mainly medical. In rare cases surgery may be considered in women with pituitary tumours who despite normalization of prolactin levels do not show adequate tumour shrinkage.

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32. Surgery Most fertility surgery is currently performed using MAS e.g : laparoscopy or hysteroscopy, Surgery to treat subfertility can be helpful in different scenarios: • Investigation of infertility & tubal patency by (MAS) undertaken if the patient is symptomatic or if specific therapeutic treatment is planned. • Laparoscopic ablation of endometriosis can help improve natural conception rates.

33. . • A djunct to ART : For example: removal of hydrosalpinges is associated with a significant improvement in ( IVF) success rates.

34. . • Some practitioners still recommend a more traditional open laparotomy for very large uterine fibroids or for the use of tubal microsurgery in reversal of sterilization, proximal or distal tubal microsurgery. • Submucosal fibroids, endometrial polyps, Asherman syndrome and some congenital uterine anomalies, such as a septum, are usually managed hysteroscopically .

35. Reference 1. Gynecology by ten teachers 2. OXFORD HANDBOOK OF OBSTETRICS & GYNECOLOGY 3. COMPREHENSIVE GUIDELINES SUMMARY 4. DEWHURST’S TEXTBOOK OF OBSTETRICS & GYNAECOLOGY

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