OUTLINE MANGEMENT OF INFERTILITY

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OUTLINE MANGEMENT OF INFERTILITY
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DR.AHMED J. ALHARBI CONSULTANT OB
GYN. INFERTILTY SPECIALIST MB, CHB. DGO. MSc.
MRCOG.
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DEFINITION OF INFERTILITY

• THE INVOLUNTARY FAILURE TO
• CONCEIVE WITHIN EIGHTEEN
• MONTHES OF COMMENCING
• UNPROTECTED INTERCOURSE

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TYPES OF SUBFERTILITY

• PRIMARY SUBFERTILITYNO PREVIOUS PREGNANCY
• SECONDARY SUBFERTILITYPREVIOUS PREGNANCY

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THE EPIDEMIOLOGY OF INFERTILITY

• FERTILITY RATESIN THE VERY FIRST MONTH OF
  EXPOSURE THE OBSERVED CONCEPTION RATES ARE ONLY
  30-33 AND THESE ARE THE HIGHEST RATES
• THE FREQUENCY OF INTERCOURSE PLAY VERY IMPORTANT
  ROLE IN DETERMINING THE RATE OF FERTILITY .

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The highest conception rates reported in normal
couples of ultimately proven fertilty
MONTHS
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INTERCOURSE EVERYDAY GIVES A FIVE TIMES HIGHER
CHANCE OF CONCEIVING THAN INTERCOURSE ONCE A WEEK
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FREQUENCY OF SEX AND CHANCE OF PREGNANCY
chance of pregnancy
daily once a week
frequency of sex
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INFERTILITY IN THE POPULATION

• INCIDENCE ONE IN SIX
• DISTRIBUTION OF CAUSES
• 1. OVULATORY FAILURE 21
• 2. TUBAL DAMAGE 14 .
• 3. ENDOMETRIOSIS 6 .
• 4.MUCUS DYSFUCTION 3 .
• 5.SPERM DYSFUNCTION 24 .
• 6.COITAL FAILURE 6 .
• 7.UNEXPLAINED INFERTILITY 28 .
• 8.OTHERS 11 .

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HOW TO MANAGE A CASE OF INFERTILITY ?

• HISTORYNAME,AGE,DURATION OF MARRIAGE,PRIMARY OR
  SECONDARY INFERTILITY.
• PAST HISTORYCONCEPTION,I U C D,
• AND OTHER PREGNANCIES.
• MEDICAL PROBLEMS,SURGICAL PROBLEMS,GYN.PROBLEMS,
• VENEREAL DISEASES.

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PRESENT HEALTH

• SPECIFIC ILLNESSOR OTHER COMPLAINT ,DRUGS
• WT. STEADY/ VARIABLE PRES. WT
• APPETITE, H/O DIETING,SMOKING
• BOWELS,MICTURATION,SLEEP,ALCOHOL
• HOT FLUSHES,GALACTORRHOEA,
• HIRSUTISM TEMP.INTOLERANCE.

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MENSTRUAL HISTORY

• MENARCHE,PRESENT CYCLE/LMP.
• PREVIOUS CYCLE ABNORMAL?
• PV.LOSS SCANTY,NORMAL,HEAVY
• PAIN? PRE,INTRA ANDPOST MENST.

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COITAL HISTORY

• PCB,MUCUS RECOGNITION,PV DISCHARES
• COITAL FREQENCY,TIMING IN CYCLE
• COITAL DIFFICULTIES AND PAIN

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WIFE PHYSICAL EXAMINATION

• GENERAL FEATURES/BUILD ,B/P
• THYROID,HAIR DISTRIBUTION
• BREAST,ABDOMEN
• VULVA,VAGINA,CERVIX,UTERUS
• SWELLING AND TENDERNESS

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HISTORYPHY FOR HUSBAND

• AGE,DURATION OF MARRIAGE,H/O P.MARRAIGE
• PRIMARY OR SECONDARY INFERTILITY
• AGE OF PUBERTY,H/O MUMPS
• SURGICAL ORCHIDUPEXY,HERNIA
• H/O VENEREAL DISEASE
• SMOKING,ALCOHOL AND DRUGS.
• ERECTION,PENETRATION,EJACULATION
• PHYSICAL EXAM. USUALLY CARRIED OUT BY UOROLOGIST.

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INVESTIGATION OUTLINE

• 1- IF DURATION OF INFERTILITY LESS THAN 1 YEAR
  AND H/P WERE -VE REASURE
• 2- IF INFERTILITY LESS THAN 1 YEAR BUT H/P WERE
  VE OR FEMALE AGE MORE THAN 30 YEARS OR
  INFERTILITY MORE THAN 1 YEAR , THEN ASK FOR
  HSG,SEMEN ANALYSIS AND SER.PROG. AT D.21 OF
  M.CYCLE

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progesterone nmole/L
DAY
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PROGESTERONE LEVELS IN TYPICAL CYCLE

• PLASMA PROGESTERONE LEVELS MAY BE BELOW OVULATORY
  VALUES APPROX 30 NMOL/L IF BLOOD IS TAKEN
  OUTSIDE THE LUTEAL PHASE.
• CONSEQUENTLY THE BLOOD SAMPLING MUST BE
  ACCURATELY TIMED DURING THE MENSTRUAL CYCLE.

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3-IF SHE IS NOT OVULATING WITH H/O AMENORRHEA OR
GALACTO. THEN ASK FOR PROLACTIN,FSH,LH,ANDROGENS
AND E2.IF PROLACTIN RAISED PREGNANCY HAS TO BE
R/OPREGNANCY VE WITH RAISED PROL THEN ASK FOR
SKULL X-RAY,TSH LEVEL EXCLUDE PCO.
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4-IF ABNORMAL HSG GO FOR HYSTROSCOPYLAPAROSCOPY
THEN PROCEED ACCORDING5-IF ABNORMAL SEMEN
ANALYSIS THEN REPEAT 2-3 TIMES AT 3- 6 WEEKS
INTERVALSIF SEMEN ANALYSIS AGAIN NORMAL AND PREG
VE THEN ASSESS SPERM FUNCTION PCT,SMI
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SPERM FUNCTION ASSESSMENT

• 1-NO. OF SPERM MORE THAN 50,000 IN SWIM UP THEN
  GO FOR IUI,IVF,GIFT
• 2-IF NO.OF SPERM LESS THAN 50,000 THEN GO FOR
  SPERM OOCYTE INJECTION

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HORMONAL RESULTS PLAN

• 1-IF PROLACTIN LEVEL IS NORMAL THEN GIVE
  PROGESTERONE TO CAUSE WITHDRAWAL BLEEDING.
• 2-IF THERE IS WITHDRAWAL BLEEDING THEN ASK FOR
  T.V SCAN TO EXCLUDE PCO , IF ITS PCO THEN TREAT.
• 3-IF NO WITHDRAWAL BLEEDING THEN ASK FOR LHFSH.
• 4-IF LHFSH NORMAL THEN TREAT WITH CLOMIPHINE OR
  GONADOTROPHINE.

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5-IF LHFSH RAISED THINK ABOUT MENOPAUSE OR
PREMATURE OVARIAN FAILURE.6-IF LHFSH LOW THINK
ABOUT HYPOTHALAMIC CAUSE KALMAN , ASK FOR
KARYOTYPE.7- IF AN OVULATION ASSOCIATED WITH
HIRSUTISM THINK ABOUT PCO ASK FOR T.V
SCAN,LHFSH,ANDROGENS , IF PCO TREAT.
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SEMEN ANALYSIS (World Health Organization
reference values)

• Volume 2-5mL
• Liquification time within 30 minutes
• Sperm concentration 20 million/mL
• Sperm motility gt50 progressive motility
• Sperm morphology gt30 normal forms
• White blood cells lt1 million/mL

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SEMEN ANALYSIS PLAN

• 1-IF SEMEN ANALYSIS AFTER THE 3RD TIME IS
  ABNORMAL ASK FOR FSH,LHANDROGENS
• 2-IF LH,FSHANDROGENS ARE LOW YOU HAVE TO EXCLUDE
  HYPOTHALAMIC-PITUTARY CAUSE
• 3-IF LH,FSHANDROGENS ARE NORMAL WITH AZOOSPERMIA
  THEN THINK ABOUT OBSTRUCTION
• 4-PUS CELLS C/S TREAT WITH ANTIBIOTICS

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5-IF SPERM ANTIBODIES TREAT WITH STEROID6-IF
ALL MEASURES ANTIBIOTICS,STEROIDSVARICOCELE
REPAIR NOT HELPFUL THEN GO FOR IUI,GIFT,IVF.
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CUMULATIVE CONCEPTION RATES INDIFFERENT TYPES OF
INFERTILITY TREATED AS APPROPRIATE

• 1-WOMEN WITH AMENORRHOEA DO SO WELL LIKE THE
  NORMAL GROUP .
• 2-WOMEN WITH OLIGOMENORRHEA ON OTHER HAND DO NOT
  DO SO WELL ,BECAUSE OF THEIR DISORDER ARE MORE
  SUBTLEPCO
• 3-WOMEN WITH MODERATE OR SEVERE TUBAL DAMAGE DO
  VERY BADLY BECAUSE EVEN THE BEST SURGERY
  AVAILABLE CAN NOT DEAL WITH IRREVERSIBLE
  ENDOTUBAL DISEASE. THE ONLY REAL HOPE IS IVF

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percent of couples
months cycle
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percent of couples
months cycle
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percent of couples
months cycle
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percent of couples
months cycle
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percent of couples
months cycle
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percent of couples
months cycle
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4-THE GROUP OF OLIGOSPERMIA WHO ARE DEFINED NOT
ONLY BY LOW SPERM COUNTS BUT BY FAILURE OF MUCUS
PENETRATION HAD POOR PROGNOSIS.5-THE MEN WITH
COMPLETELY NORMAL SEMINAL ANALYSIS BUT FAILURE OF
MUCUS PENETRATION HAD ALSO POOR PROGNOSIS.
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UNEXPLAINED INFERTILITY

• AFTER MORE THAN 3 YEARS UNEXPLAINED INFERTILITY
  THE CHANCE OF NATURAL COCEPTION FAILS TO
  UNHELPFUL LEVEL 1-2 EACH MONTH AND TREATMENT
  IS NEEDED.
• TRIAL OF CLOMID , RATE CYCLE PREGNANCY 3-5 .BUT
  GONADOTROPIN OR IUI GIVE 10 .

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percent of couples
months
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ENDOMETRIOSIS TREATMENT

• 1-TREATMENT FOR MINOR ENDOMEMETRIOSIS SHOW THAT
  THERE IS NO EFFECTIVE METHOD TO IMPROVE THE
  CHANCE OF NATURAL CONCEPTION
• 2- CONTROLLED TRILS OF PROGESTOGENS OR DONAZOL
  HAVE SHOWS NO BENEFIT ON THE CONTRARY, THE CHANCE
  OF PREGNANCY IS DELAYED BY THE DURATION OF
  TREATMENT

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3- UNCONTROLLED REPORTS OF PITUITARY
DESENSITAZATION TREATMENT OR LAPAROSCOPIC LASER
ABLATION THERAPY HAVE NOT IMPROVED AN
OBSERVED PREGNANCY RATE WITHOUT TREATMENT
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percent of couples
months
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percent of couples
months
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percent of couples
months
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