Professional Documents
Culture Documents
Dr. Yousef Gadmour Professor, Al-fateh university Senior consultant, Al-Jalla Hospital Tripoli , Libya
Definitions:
Sub fertility- Involuntary failure to conceive within 12 months of commencing unprotected sexual intercourse. Primary infertility - No previous pregnancy. Secondary infertility- previous pregnancy. (whatever the outcome)
Principles of management:
1. 2. 3.
4.
Deal with the sub fertile couple together. No one is at fault or to blame. Give good explanations of causes , prognosis and outline of treatment of sub fertility. Carry out investigations and treatments consistency in proper sequence.
History - General
Both couples should be present. Age. Previous pregnancies by each partner. Length of time without pregnancy. Sexual history :
Frequency
and timing of intercourse Use of lubricants Impotence, anorgasmia, dysparunia Contraceptive history
History - Male
Infections; gonorrhea , tuberculosis. Radiation, toxic exposures ,drugs. Mumps orchitis. Testicular injury/surgery. occupation (Excessive heat exposure). Smoking. Diabetes mellitus.
History - Female
Detailed menstrual history ; Irregular menses, amenorrhea. Hirsutism. Galactorrhoea. Previous pregnancies and mode of deliveries. Ectopic pregnancy history. PID.
History - Female
Appendicitis. IUCD use. Endometriosis. Stress. Weight changes. Excessive exercise. Cervical and uterine surgery.
Weight & Height (BMI). Size of testicles (orchidometry). testicles (orchidometry). Testicular descent. Varicocele. Outflow abnormalities (hypospadias, etc). General look- Klinefelter syndrome (47XXY). Kallmann syndrome (hypothalamic hypogonadism) (delayed puberty ,normal stature, no smell ).
Weight & Height (BMI) Hirsutism Thyroid examination Abdominal examination Speculum examination - HVS, endocervical swap Vaginal examinationUterosacral nodularity, Uterine mobility USS-(Vaginal)
Basal body temperature Mid luteal serum progesterone Endometrial biopsy Ultrasound monitoring of ovulation
BBT
Cheap and easy, but
1. Inconsistent results.
2. Provides evidence after the fact. 3. May delay timely diagnosis and treatment;
98% of women will ovulate within 3 days of the nadir. 4. Biphasic profiles can also be seen with LUF syndrome.
Pulsatile release, thus single level may not be useful unless elevated. Performed 7 days after presumptive ovulation ( day 21 ). If done properly , level >15 ng/ml consistent with ovulation.
Endometrial Biopsy
Invasive, but the only reliable way to diagnose luteal phase defect (LPD). Performed around 2 days before expected menstruation (= day 28 by definition). Lag of >2 days is consistent with LPD. Must be done in two different cycles to confirm diagnosis of LPD. Controversy exists over the relevance of luteal phase defect as a cause of infertility and the accuracy of the endometrial biopsy in assessing the delay.
Subjective. Timing varies; may need to be repeated. In some studies, infertile couples with an abnormal PK conceived successfully during that same cycle.
Tubal Function
Evaluate tubal patency whenever there is a history of PID, endometriosis or other adhesiogenic condition. Tests:
HSG Laparoscopy Falloposcopy (not widely available)
Hysterosalpingography (HSG)
Can be uncomfortable. Done at the end of menses. Can detect intrauterine and tubal disorders but not always definitive.
Laparoscopy
Invasive; requires OT or office setting. Can offer diagnosis and treatment in one sitting. Not necessary in all patients. Uses (examples): 1. Lysis of adhesions 2. Diagnosis and excision of endometriosis 3. Myomectomy 4. Tubal reconstructive surgery 5. Test of tubal patency by dye test
Falloposcopy
Hysteroscopic procedure with cannulation of the Fallopian tubes. Can be useful for diagnosis of intraluminal pathology. Promising technique but not yet widespread.
Treatment Options
Ovarian Disorders
Anovulation
Clomiphene Citrate (CC) hCG Human Menopausal Gonadotropin (hMG) Pure FSH
Central amenorrhea
CC first, then hMG Pulsatile GnRH
Ovarian Disorders
Hyperprolactinaemia: Drugs :Bromocriptin, Carbegoline(Dostinex), Quinagolide (Norprolac) Surgery if macroadenoma Premature ovarian failure : ? high-dose hMG (not very effective) Luteal phase defect:
Progesterone suppositories during luteal phase CC hCG
Ovulation Induction
Clomiphene Citrate Compete with natural oestrogens by blocking receptors in target organs including the pituitary, leading to increased FHS levels. 70% induction rate, ~40% pregnancy rate. Patients should typically be normoestrogenic. Induce menses and start on day 2 for 5 days. With high dosages, antiestrogen effect dominate. Multiple pregnancy rates 5-10%. Monitor effects with USS & D21 progesterone.
hMG
LH +FSH (also FSH alone = Metrodin) For patients with hypogonadotrophic hypoestrogenism or normal FSH and E2 levels Close monitoring essential, including estradiol levels & USS 60-80% pregnancy rates overall, lower for PCOS patients 10-15% multiple pregnancy rate
Risks
CC Vasomotor symptoms Ovarian enlargement Multiple gestation NO risk of malformations hMG Multiple gestation OHSS (~1%)
Can often be managed as outpatient Diuresis Severe cases fatal if untreated in ICU setting
Fallopian Tubes
Tuboplasty IVF
Corpus
Asherman syndrome
Hysteroscopic Lysis of adhesions (scissor) Postop. ; IUCD, E2
Metroplasty.
Peritoneum (Endometriosis)
From a fertility standpoint, excision beats medical management (Laser therapy ). Lysis of adhesions. GnRH-a (Not a cure and has side effects & expensive). Danazol (side effects, cost). Continuous OCPs ( poor fertility rates ). Chances of pregnancy highest within 6 -12 months after treatment.
Male Factor
Hypogonadotrophism
hMG GnRH CC, hCG ( results poor )
Varicocoele
Retrograde ejaculation
Ephedrine, imipramine AIH with recovered sperm
Male Factor
Idiopathic oligospermia
No effective medical treatment IVF (in-vitro fertilization) ICSI ( Intra- cytoplasmic sperm injection ) TESE( Testicular Sperm Extraction ) MESA(Microsurgical Epididymal Sperm Aspiration) ?? donor insemination
Unexplained Infertility
15-20% of couples Consider PRL, laparoscopy, other hormonal tests, cultures, Antisperm Abs. testing, sperm penetration assay if not done. Review previous tests for validity. Empirical treatment:
Adoption
Summary
Sub fertility is a common problem. Sub fertility is a disease of couples. Evaluation must be thorough, but individualized. Treatment is available, including IVF, but can be expensive, invasive, and of limited efficacy in some cases. Consultation with a reproductive endocrinologist is advisable.
Thanks