infertility by as. stelmakh o.. objectives define primary and secondary infertility describe the...
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InfertilityInfertility
By as. Stelmakh O.
ObjectivesObjectives
• Define primary and secondary infertility
• Describe the causes of infertility
• Diagnosis and management of infertility
Infertility - StatisticsInfertility - Statistics
• causes are identified in 90 % of patients• pregnancy results in 40 % of those• 30 % of couples have male AND female factors• Of 100 subfertile couples the break down is as
follows:• 40 % male factor etiology• 20 % female hormonal imbalance• 30 % female peritoneal factor• 5 % ‘hostile’ cervical environment• 5 % unexplained• psychological impact can be significant
InfertilityInfertility• Primary infertility
– a couple that has never conceived
• Secondary infertility– infertility that occurs after previous pregnancy regardless of
outcome
Causes for infertilityCauses for infertility• Male
– Drugs
– Tobacco
– Health problems
– Radiation/Chemotherapy
– Age
– Enviromental factors
• Pesticides
• Lead
• Female– Age – Stress– Poor diet– Athletic training– Over/underweight– Tobacco
– STD’s– Health problems
Causes of InfertilityCauses of Infertility• Anovulation (10-20%)• Anatomic defects of the
female genital tract (30%)• Abnormal spermatogenesis
(40%)• Unexplained (10%-20%)
Evaluation of the Infertile Evaluation of the Infertile couplecouple
• History and Physical exam• Semen analysis• Thyroid and prolactin evaluation• Determination of ovulation
– Basal body temperature record– Serum progesterone– Ovarian reserve testing
• Hysterosalpingogram
Abnormalities of Abnormalities of SpermatogenesisSpermatogenesis
NormalNormal
• Sperm made in seminiferous
tubules• Travel to
epididymis to
mature
• Sperm exit through vas deferens
• Semen produced in prostate gland, seminal glands, cowpers glands
• Sperm only 5% of ejaculation
• Sperm can live 5-7 days
NormalNormal
Semen Analysis (SA)Semen Analysis (SA)
• Obtained by masturbation• Provides immediate information
– Quantity– Quality– Density of the sperm– Morphology– Motility
• Abstain from coitus 2 to 3 days • Collect all the ejaculate• Analyze within 1 hour• A normal semen analysis excludes male factor
90% of the time
Normal Values for SANormal Values for SA
Volume
Sperm Concentration
Motility
Viscosity
Morphology
pH
WBC
– 2.0 ml or more– 20 million/ml or more– 50% forward progression
25% rapid progression– Liquification in 30-60 min– 30% or more normal forms– 7.2-7.8– Fewer than 1 million/ml
Causes for male infertilityCauses for male infertility
• 42% varicocele– repair if there is a low count or decreased
motility
• 22% idiopathic
• 14% obstruction
• 20% other (genetic
abnormalities)
Abnormal Semen AnalysisAbnormal Semen Analysis
• Azoospermia– Klinefelter’s (1 in 500)– Hypogonadotropic-
hypogonadism– Ductal obstruction
(absence of the Vas deferens)
• Oligospermia– Anatomic defects– Endocrinopathies– Genetic factors– Exogenous (e.g. heat)
• Abnormal volume– Retrograde ejaculation– Infection– Ejaculatory failure
Evaluation of OvulationEvaluation of Ovulation
Female Reproductive SystemFemale Reproductive System
• Ovaries– Two organs that
produce eggs– Size of almond– 30,000-40,000 eggs– Eggs can live for
12-24 hours
MenstruationMenstruation• Ovulation occurs 13-14 times per year• Menstrual cycles on average are Q 28 days with
ovulation around day 14• Luteal phase
– dominated by the secretion of progesterone– released by the corpus luteum
• Progesterone causes– Thickening of the endocervical mucus– Increases the basal body temperature (0.6° F)
• Involution of the corpus luteum causes a fall in progesterone and the onset of menses
Menstrual cycleMenstrual cycle
Serum ProgesteroneSerum Progesterone
• Progesterone starts rising with the LH surge– drawn between day 21-24
• Mid-luteal phase– >10 ng/ml suggests ovulation
Salivary Estrogen: Salivary Estrogen: Ovulation Tester- 92% Ovulation Tester- 92%
accurateaccurate
Add Saliva SampleAdd Saliva Sample
Non-Ovulatory Saliva Non-Ovulatory Saliva PatternPattern
High Estrogen/ Ovulatory High Estrogen/ Ovulatory Saliva PatternSaliva Pattern
AnovulationAnovulation
Anovulation Symptoms Anovulation Symptoms Evaluation Evaluation**
• Irregular menstrual cycles
• Amenorrhea
• Hirsuitism
• Acne
• Galactorrhea
• Increased vaginal secretions
• Follicle stimulating hormone
• Lutenizing hormone
• Thyroid stimulating hormone
• Prolactin
• Androstenedione
• Total testosterone
*Order the appropriate tests based on the clinical indications
FertilizationFertilization
ImplantationImplantation
Anatomic Disorders of the Anatomic Disorders of the Female Genital TractFemale Genital Tract
Congenital Anatomic AbnormalitiesCongenital Anatomic Abnormalities
HysterosalpingogramHysterosalpingogram
• An X-ray that evaluates the internal female genital tract– architecture and
integrity of the system
• Performed between the 7th and 11th day of the cycle
• Diagnostic accuracy of 70%
HysterosalpingogramHysterosalpingogram
• The endometrial cavity– Smooth– Symmetrical
• Fallopian tubes– Proximal 2/3 slender– Ampulla is dilated
• Dye should spill promptly
HSG: Tubal InfertilityHSG: Tubal Infertility
Some women have trouble getting pregnant because scar tissue prevents Some women have trouble getting pregnant because scar tissue prevents eggs from traveling down the fallopian tubes. This scarring can be caused by eggs from traveling down the fallopian tubes. This scarring can be caused by
endometriosis, the overgrowth of tissue that lines the uterus, a history of endometriosis, the overgrowth of tissue that lines the uterus, a history of
pelvic infections, or previous surgeriespelvic infections, or previous surgeries
Treatment of the Infertile Treatment of the Infertile CoupleCouple
Inadequate Inadequate SpermatogenesisSpermatogenesis
• Laparoscopy surgery• Eliminate alterations of thermoregulation• Clomiphene citrate is occasionally used for
induction of spermatogenesis– 20% success
• In vitro fertilization may facilitate fertilization• Artificial insemination with donor sperm is
often successful
Intrauterine insemination Intrauterine insemination (artificial insemination)(artificial insemination)
Artificial InseminationArtificial Insemination
• Sperm donation or sperm aspiration
In Vitro FertilizationIn Vitro Fertilization
IVF ProtocolIVF Protocol
• GnRH agonist (e.g. Lupron) for 7 days• FSH agonist (follistim, Gonal-F,
Repronex) until follicles measure 17-20 mm in diameter
• hCG given to induce egg maturation• Egg retrieval (transvaginally) 34-35 h
later
IVF Protocol, cont’d.IVF Protocol, cont’d.
• 3 to 5 embryos are injected to increase chances of pregnancy
• woman given progestagen to prevent miscarriage
Surrogate motherSurrogate mother
– Woman unable to have children may have IVF in another woman who has the child
IVF With Donor EggsIVF With Donor EggsWomen who are over 40, have poor egg quality, or have not had Women who are over 40, have poor egg quality, or have not had
success with previous IVF cycles may consider IVF with donor success with previous IVF cycles may consider IVF with donor eggseggs
Primary Diagnosis of Women Undergoing ART- 1998
26%
27%
12% 15%
9%
2%
9%
Tubal factorMale factorOvulation dysfxnEndometriosisUnexplainedUterine factorOther
ConclusionConclusion• Infertility should be evaluated after one
year of unprotected intercourse.
• History and Physical examination usually will help to identify the etiology.
• If patients fail the initial therapies then the proper referral should be made to a reproductive specialist.