Female infertility(part-1)Female infertility(part-1)

Dr. JASMINA BEGUMDr. JASMINA BEGUMASSOCIATE PROF. (O &G)ASSOCIATE PROF. (O &G)

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

DefinitionDefinition   • Infertility is the inability to achieve a

pregnancy after 12 months of unprotected regular intercourse

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

Secondary infertilitySecondary infertility• Secondary infertility describes

couples who have previously been pregnant at least once, but have not been able to achieve another pregnancy

causescauses

• Female factor 30%• Male factor 30%• Combined factor 30% • No cause 10%

• Female partner alone should not be

blamed

Female genital tractFemale genital tract

Female InfertilityFemale Infertility

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General factorsGeneral factors

Diabetes mellitusThyroid disordersAdrenal disease Significant liver, kidney disease Psychological factors

Hypothalamic-pituitary factorsHypothalamic-pituitary factors

Kallman syndromeHypothalamic dysfunctionHyperprolactinomaHypopituitarisum

First visitFirst visit• Have both come to all visits• Get a complete history• Sexual history• Educate/ Counselling

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….

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)

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

• 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

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

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…..

• Change medications to safer FDA pregnancy

category »Antihypertensives »Anti-epileptic drugs• Blood glucose control in diabetics

Visit 1: Counseling

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

• 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

Ultrasound scan showing follicleUltrasound scan showing follicle

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

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

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

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…..

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

Laproscopy findings Laproscopy findings • Uterus ---- fibroids uterine anamoly

• Tubes --- patency hydrosalpinx • Ovaries --- PCOS

chocolate cyst • POD --- endometriosis adhesions

Hysteroscopy findingsHysteroscopy findings

• Cervical canal --- polyps• Uterine cavity --- adhesions

polyps fibroids uterine anamoly

• Endometrium --- proliferative/hyperplastic• Tubal ostium --- visualised or not

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.

Fertility Treatment: OptionsFertility Treatment: Options

• Correct ovulatory dysfunction• Correct tubal or uterine abnormalities• Overcome subfertile sperm parameters• ART

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

SummerySummery

Tests of ovulationTests of ovulation• LH kit• Progesterone assay• Basal body temperature• Cervical mucus

•Spinnbarkit•fernning

• Vaginal epithelium cytology• Endometrial biopsy• TVS follicular monitoring

Tests of tubal patencyTests of tubal patency

• Hysterosalpingography (HSG)• Diagnostic laparoscopy• Sonosalpingography• Air insufflation• Falloposcopy

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?

Thank youThank you