Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
infertile couple
Dr. Salma Kafeel Qureshi
Consultant obstetrician & Gynecologist
MBBS (Pb), FRCOG (UK),
Sonologist, Epidural specialist (UK)
IVF specialist (Sydney Australia)
HOD Quaid-e-Azam International Hospital
Infertility
Defining infertility
A woman of reproductive age who has
not
conceived
after
1
year
of
unprotected vaginal sexual intercourse,
in the absence of any known cause of
infertility, should be offered further
clinical assessment and investigation
along with her partner.
[ NICE;new 2013]
Incidence of infertility
Infertility
is a common clinical
problem. It affects 13% to 15% of
couples worldwide
Prevalence
of infertility in Pakistan is
approximately 22%
04% primary Infertility
18% secondary infertility
Neelofar S, Tazeen S:The cultural politics of gender for infertile
women in Karachi, Pakistan.InGender Studies Conference. South
Africa; 2006
Centers for Disease Control and Prevention. 2006 Assisted Reproductive Technology Success Rates: National Summary and
Fertility Clinic Reports. 2008. http://www.cdc.gov/ART/ART2006/508PDF/2006ART.pdf. Accessed April 20, 2009.
Causes of Infertility-Pakistan
Multiple factors
(male + female)
Minimal Investigation
Tests established correlation with
infertility
Semen Analysis
Mid Luteal progesterone
ovulation
diagnosis
Tubal Patency test (HSG or
Laproscopy)
History-taking
Focused
couple.
Good history is Gold standard to
investigate underlying problem
Female Partner:
Present history, menstrual history, obstetric,
contraceptive,
surgeries or serious illness, sexual history, Family history
Male Partner:
Present history, contraceptive, surgeries or serious illness,
Family history, sexual history
Focused clinical
examination
Female Partner:
Basic Investigation:
General Examination,
Abdominal Examination,
Breast Examination,
Genital Examination,
Hormonal assay,
Advanced Investigations
Transvaginal ultrasonography,
Hysterosalpingography or
Hysterosalpingocontrast-sonography
Laparoscopy
Hysteroscopy
Ultrasound of
endometrium
early follicular
triple line
luteal
Lap / Dye
A/Prof R Gyaneshwar
11
Laparoscopy
Ectopic
A/Prof R Gyaneshwar
13
A/Prof R Gyaneshwar
14
A/Prof R Gyaneshwar
15
Endometriosis
A/Prof R Gyaneshwar
16
Hysteroscopy
Hysterosalpingo-contrast-ultrasonography
Focused clinical
examination
Male
Partner:
General Examination,
Semen analysis,
Anti-sperm antibodies,
Advanced Investigations
Hormonal assay,
Testicular biopsy
Male Infertility
Volume: 2-5ml
pH: 7.2-7.8
Liquefaction time: within 40 mins.
Sperm Count: -20-120 million/ml
(WHO Criteria)
Sperm motility: >50% after hour.
Sperm Morphology: >50% normal.
Abnormal Semen
Parameters.
Oligospermia:
million/ml
Mild: -10-20 million/ml
Moderate: -5-10million/ml
Severe: -<5 million/ml.
Azoospermia: - Absence of single
sperm in ejaculate.
Asthenospermia: -Sperm motility
<50%
Teratospermia: - <4% normal
sperms associated with poor fertility
Building burdeninfertility
Quacks
Hakeems
Dayaa
Inexperienced
practitioners
Ovarian Stimulation
Young
Patient
Minimal Stimulation
CC or letrozole
Poor responder or poor ovarian
reserve/Age >35 years
(melatonin, DHEA EXCEL)
Inj. LH/ FSH 75IU
PolyCysticOvaries (PCO)
Diane-35/androgen
Lezra
Inj. rFSH 75IU
OVULATION DISORDERS
WHO Classification
Clomiphene Citrate
Dose:
50-100 mg./day.
starting day 2,3,4 or 5 for 5 days.
Monitoring confirm ovulation:
ultrasound
LH kits, LH serum levels
day 21 progesterone.
CC Pathways
normoovulatory LH monitoring is
preferred
If
Anovulatory cycles
Clomiphene
If
effective
in
anovulatory infertility.
It has the following
advantages:
1- It reduce E2 level.
2- It avoids the
unfavorable effects
on the endometrium
frequently seen with
CC
Metformin
The
Prolactin Reducing
Medications
- For Hyperprolactinaemia associated
infertility.
Causes:
Dopamine agonist:
- Bromocriptine.
- Quinagolide.
- Cabergoline
Gonadotropins :
Indications
Indications:
-Failure to respond to antiestrogen
therapy
At least 3 cycles of C.C. and no ovulation
Dose: 0-200mg/day for 7 days.
At least 6 Ovulatory cycles and not conceived.
CC /Letrozole
+Gonadotropins
_________________________________
D2_____________D6__________D10
Clomiphene Citrate
Inj. hMG
(HMG Massone)
_________________________________
D2_____________D6__________D10
Letrozole (LEZRA)
Inj. hMG
(HMG Massone)
Hypothalamus
Hypothalamus
GnRH
Travels via
portal blood
Positive
feedback exerted
4
by large in
estrogen
output.
Anterior pituitary
LH surge
FSH
LH
Ruptured
follicle
3Slightly
elevated
estrogen
and rising
inhibin
levels.
Progesterone
Estrogen
Inhibin
8
Thecal
cells
Granulosa
cells
Inhibin
Androgens
Convert
androgens to 2
estrogens
Early and midfollicular phases
Mature follicle
Corpus luteum
Ovulated
secondary
oocyte
Late follicular and
luteal phases
Thank you