female infertility - 1
TRANSCRIPT
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Female infertility(part-1)Female infertility(part-1)
Dr. JASMINA BEGUMDr. JASMINA BEGUMASSOCIATE PROF. (O &G)ASSOCIATE PROF. (O &G)
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Learning objectivesLearning objectives
• know definitions of primary and secondary infertility
• understand the causes of infertility• know the initial investigations of the
infertile couple• Test for ovulation• Test for tubal patency• Investigation role of laparoscopy and
hysteroscopy
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DefinitionDefinition
• Infertility is the inability to achieve a
pregnancy after 12 months of unprotected regular intercourse
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Primary infertilityPrimary infertility
• Primary infertility is the term used to describe a couple that has never been able to conceive a pregnancy, after at least 1 year of unprotected intercourse
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Secondary infertilitySecondary infertility
• Secondary infertility describes couples who have previously been pregnant at least once, but have not been able to achieve another pregnancy
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causescauses
• Female factor 30%• Male factor 30%• Combined factor 30% • No cause 10%
• Female partner alone should not be
blamed
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Female genital tractFemale genital tract
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Female InfertilityFemale Infertility
1
23
4
6
5
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General factorsGeneral factors
Diabetes mellitusThyroid disordersAdrenal disease Significant liver, kidney disease Psychological factors
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Hypothalamic-pituitary factorsHypothalamic-pituitary factors
Kallman syndromeHypothalamic dysfunctionHyperprolactinomaHypopituitarisum
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First visitFirst visit• Have both come to all visits
• Get a complete history
• Sexual history
• Educate/ Counselling
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Visit 1: Female HistoryVisit 1: Female History
• Prior infertility; evaluation, treatments
• Hx of PID; postpartum/ post TB infection
• Pelvic pain, dysmenorrhea;
endometriosis
• Medical: diabetes, thyroid; pelvic surgery
• Medications, alcohol, street drugs
Contd….
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Visit 1: Female HistoryVisit 1: Female History
• Cigarette smoking
• Galactorrhea
• Menstrual patterns
• Cycle length range (best 25-35 days
apart)
• Moliminal symptoms (if present,
ovulating)
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Visit 1: Female ExaminationVisit 1: Female Examination
• Weight, BMI, waist circumference (PCOS)
• Skin: axial hirsuitism, acne, male-pattern
balding (PCOS)
• Breasts: galactorrhea ( prolactin)▲
• Cervix: mucus, friability (infection)
• Uterine corpus
• Size, shape (fibroids, uterine anomalies)
• Corpus tenderness (PID)
• Fixed retroflexion (EM)
• Adnexa: tenderness (PID, EM), mass
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• Time intercourse just before ovulation
• Use menstrual calendar to predict
ovulation
• Shortest cycle length minus 14 days
• Ovulation prediction kit to confirm
ovulation
Visit 1: CounselingVisit 1: Counseling
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Coital frequency and TechniqueCoital frequency and Technique
• Every other day intercourse starting 4-5
days before expected ovulation
• Lay supine with knees up x 20 minutes
after intercourse
• No sperm-toxic lubricants
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Visit 1: CounselingVisit 1: Counseling
• Stop smoking (both partners)
• If BMI > 30, recommend/assist with weight
loss
• Preconceptional care
Folic acid 400 mcg PO per day
Rubella serology; immunize if seronegative
Contd…..
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• Change medications to safer FDA
pregnancy
category
»Antihypertensives
»Anti-epileptic drugs
• Blood glucose control in diabetics
Visit 1: Counseling
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Investigations of female Investigations of female
• General Hb, urine RE, Blood group,sugar VDRL, HIV, Hbsag, Mx, Urea, creatinine
• Semen analysis (report must before further work up is taken)
• Tests for ovulation• Tubal patency• FSH, LH, Thyroid function, prolactin• Screen for gonorrhea, chlamydia (if indicated)• Microscopy of cervical mucus
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• Diagnostic pelvic ultrasound
• >10 to 12 follicles per ovary (PCOS)
• Persistent hemorrhagic cysts with low-level echoes (endometriosis)
• Anatomical conditions: fibroids, polyps, and
• Müllerian anomalies (uterine septum)
• Decreased ovarian volume and reduced antral follicle count associated with reduced fertility
• Serial TV ultrasound used to document ovulation
Visit 1: Pelvic UltrasoundVisit 1: Pelvic Ultrasound
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Ultrasound scan showing follicleUltrasound scan showing follicle
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Infertility workup calenderIdentificationof factor
Methods employed Day of cycle Observation
Ovulation
•BB T
•Endometrial biopsy
•Cervical mucusNatureThreadabilityFern pattern
•Serum progesterone
•Serum LH• Urinary LH
•Serial transvaginalsonography•Laparoscopy
Throughout cycle
D 21–23
D 12–14 and D 21–23
D 8 and D 21
Midcycle daily (D 12–14)
D 12–14
Secretory phase
Biphasic pattern
Secretory endometrium
Clear, watery Thick, viscid
D-8 < 1 ng/ml D-21 > 6ng/ml
Ovulation: About 10–12 hours afterLH surge
DominantFollicle 20 mmRecent corpus luteum
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Identificationof factor
Methods employed
Day of cycle
Observation
Tubal factor
HSG
Laparoscopy and dye test
Sonohysterosalpingography
ProliferativePhase D6-D10
ProliferativePhase D6-D10
Proliferative phase
Spillage of dye into the peritonealCavity
Peritubal pathology• Pelvic pathology (Endometriosis)• Ovulation• Tubal patency by dye spillage fromboth the tubes
Better than HSG for detection of intrauterinepathology
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Identificationof factor
Methods employed
Day of cycle
Observation
Cervical •Postcoital test (PCT)
• Sperm cervical mucuscontact test (SCMCT
Around ovulation(D 12–14)
(D 12–14)
Presence of progressive motile sperm(10 per high power field)
Sperm antibodies
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Role of LaparoscopyRole of Laparoscopy
• Controversial as to whether to include it in
the basic evaluation or not
• Studies indicate that it may demonstrate
previously undetected stage I or II
endometriosis, periovarian or peritubal
adhesions.
Contd…..
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Role of LaparoscopyRole of Laparoscopy
• This may alter treatment plans such as
surgery for endometriosis or directly IVF
for peritubal adhesion
• Can be avoided in women with a normal
HSG in patients who may need IVF
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Laproscopy findings Laproscopy findings
• Uterus ---- fibroids uterine anamoly
• Tubes --- patency hydrosalpinx • Ovaries --- PCOS
chocolate cyst • POD --- endometriosis adhesions
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Hysteroscopy findingsHysteroscopy findings
• Cervical canal --- polyps
• Uterine cavity --- adhesions
polyps
fibroids
uterine anamoly
• Endometrium --- proliferative/hyperplastic
• Tubal ostium --- visualised or not
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Fertility Treatment: GoalsFertility Treatment: Goals
• To ensure patient safety
• To help a couple experience a healthy
pregnancy and birth or an alternative
way to build a family
• To use as little of a couple’s resources
as necessary.
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Fertility Treatment: OptionsFertility Treatment: Options
• Correct ovulatory dysfunction
• Correct tubal or uterine abnormalities
• Overcome subfertile sperm parameters
• ART
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Management of infertility in women >30 years Management of infertility in women >30 years
For couples who do not desire
medical intervention
• Ovarian stimulation with IUI
• Ovarian stimulation with IVF (own eggs)
• Ovarian stimulation with IVF (donor eggs)
• Surrogacy
• Adoption
Conservative Active
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SummerySummery
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Tests of ovulationTests of ovulation
• LH kit• Progesterone assay• Basal body temperature• Cervical mucus
•Spinnbarkit•fernning
• Vaginal epithelium cytology• Endometrial biopsy• TVS follicular monitoring
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Tests of tubal patencyTests of tubal patency
• Hysterosalpingography (HSG)• Diagnostic laparoscopy• Sonosalpingography• Air insufflation• Falloposcopy
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Expected Short answerExpected Short answer
• Define primary infertility and list any five female factors responsible for it?
• List the tests for ovulation ?.• List any two indications and any three
contraindications of hysterosalphingography?
• List the who criteria for semen analysis?
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Thank youThank you