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Surya
Moderator: Dr Shailaja
Definition
Epidemiology
Risks
Ovarian Reserve Tests
Etiology
Investigations
Female Infertility
Definition
Infertility
1 year of unprotected intercourse without conception.
Subfertility
not sterile but exhibit decreased reproductive efficiency
Female Infertility
Female Infertility
Female Infertility
Epidemiology
Female Infertility
% pregnant
3 months
57%
6 months
72%
1 year
85%
2 years
93%
Female Infertility
Female Infertility
Female Infertility
Causes of infertility %
Male factor
25-40%
Unusual problems; 5%
10%
Unexplained infertility
10%
10
Female Infertility
30-40%
Unexplained infertility
10-15%
Miscellaneous causes
10-15%
Unusual problems; 10
Unexplained; 10
Tubal and Pelvic Pathology; 40
Tubal & peritoneal factor
30-40%
Ovulatory dysfunction; 40
11
Female Infertility
Age
Stress
Poor diet
Smoking
Alcohol
STDs
Overweight
Underweight
Caffeine intake
Too much exercise
12
Female Infertility
Age
Conception rate
26 to 30
25 years
73%
Conception rate
74%
73%
26-30years
31 to 35
31-35years
>35
> 35years
74%
62%
62%
27%
27%
& lower
Age
<25 yrs
13
Female Infertility
Likelihood
of success declines by
5% for each additional year of the female
15-25% for each added year of infertility
40-45yrs
Female Infertility
14
Oocyte
15
16
Female Infertility
17
Female Infertility
naturally
starts to
decline after late
20's.
After 35 decreases
rapidly.
with time, the supply
diminishes, the EGG.
The remaining eggs
also age along with
the rest of the body.
18
Female Infertility
19
Female Infertility
Treating
Female Infertility
21
Female Infertility
Female Infertility
Assays
Predicts
Sensitivity
Serum estradiol
By
24
Female Infertility
Elevated
27
Female Infertility
CCCT
In
2006
Female Infertility
Inhibin B
Secreted
Female Infertility
low
31
Female Infertility
Antimullerian Hormone
Produced
by
Female Infertility
In
40-97%; sensitivity,
78-92%; specificity,
22-88%; PPV and
97-100%; NPV for predicting poor response to stimulation
(<3 follicles, or <2-4 oocytes),
but have proven neither sensitive nor specific for
predicting pregnancy
Very
Female Infertility
Female Infertility
Histology- proportional
Female Infertility
In
Female Infertility
Ovarian Volume
Decreases with follicular depletion.
High inter-cycle and inter-observer
variability,
ovarian pathology such as endometriomas
and polycystic ovary syndrome, results
have limited generalizability.
Ovarian volume (length width depth
0.52) generally correlates with the number
of oocytes retrieved, but poorly with
pregnancy.
37
Female Infertility
Female Infertility
Ovarian factors
ANOVULATION AND OLIGOOVULATION
Hypothalamic
anovulation
Psychological factors
Low BMI and obesity
-disrupts hypothalamic pituitary ovarian axis
39
Congenital hypothalamic
failure( Kallmann syndrome)
Psychotropic drugs
Tranquilizers
40
Female Infertility
Pituitary
Sheehans syndrome
41
Female Infertility
Tumor: Prolactinomas
- Prolactin level inhibitory effect on
pulsatile GnRH release hypogonadotropic
effect
-granulosa cell number and FSH binding
-granulosa cell estradiol production
-causes inadequate
luteinization and
Female Infertility
42
Hypothalamic-pituitary axis
dysfunction
Anovulation due to hypogonadotropic-hypogonadism
- Presence of serum LH, FSH and estradiol
- Causes :
Craniopharyngioma
Pituitary adenomas
Arteriovenous malformation
Central space occupying lesion
chronic
43
Female Infertility
Thyroid
Anovulatory infertility
Unexplained infertility
Tubal infertility
Male infertility
Female Infertility
- No ovulation
cyst formation
45
Female Infertility
Activate receptor
Female Infertility
47
Female Infertility
During follicular
endometrium exhibit proliferative
During luteal
secretory transformation
Inadequate corpus luteum progesterone regarded as cause
of infertility and early pregnancy loss
48
Female Infertility
Causes
Disturbances in pituitary gonadotropin secretion pattern
- GnRH pulse
FSH level
Ass. With poor luteal function
- Rapid GnRH pulse frequency and LH frequency during mid
cycle surge and reduced LH bioactivity
49
Female Infertility
Endocrinopathies:
affect hypothalamo-pituitary-ovarian axis
Hyperthyroidism and hypothyroidism
Changes SHBG level Feedback inhibition in
gonadotropin secretion
- Primary hypothyroidism
TRH
Stimulates lactotrophs directly
prolactin gene transcription
activates
Hyperprolactinemia
Inhibit GnRH secretion
No luteal function
Progesterone level
50
Female Infertility
Other causes
- Endometriosis
- Dysfunctional uterine bleeding
51
Female Infertility
Tubal factors
52
Female Infertility
INFECTION
-
Organisms:
STI: Gonococcus, Chlamydia, Mycoplasma
Pyogenic: Streptococcus, E.coli,Staphylococcus, Gp
B streptococcus, Bacteroide fragilis, actinomycoses
Tubercular: M. tuberculosis
53
Female Infertility
Mode of spread:
Ascending infection
- Gonococcal infection may affect the tubes during initial
exposure or from Bartholins gland and cervix
- Pyogenic infection follow: Delivery, induced abortion,
minor procedure like D & C, hysterosalphingography,
IUCD, infected polyp
- Recently, chlamydia is regarded as common cause,
ascends up from the cervix
Female Infertility
Pathogenesis
Pyogenic: Infection from uterine cavity & cervix
Pelvic cellulitis Perisalphingitis
Endosalphingitis
55
Pathology
Pyogenic: Outer coat is involved, adhesion are
more and dense
Gonococcal : - Mainly endosalphingitis, adhesions
are less and filmsy
- Fimbriae gets phymotic, edematous and
indrawn by cicatricle contraction closure of
abdominal ostium
defective ovum pick up
- Loss of cilia
infertility
56
Female Infertility
Site of obstruction
Proximal :
- Prevents sperm to reach distal portion ..hinders
fertilization
- Causes: tubal spasm, temporary mucous
plugging,salpingitis isthmica nodosa(23-60%)
- Risk of perforation with cannulation ranges from 3%11%
Distal:
- Prevents ovum capture
- Exhibits a spectrum: mild( tubal obstruction),
moderate( fimbrial phimosis) to severe
( complete obstruction)
- Causes: Pelvic infection, Endometriosis, prior
abdominal and pelvic surgery
57
Female Infertility
nodes
58
Female Infertility
Pathology
Female Infertility
ENDOMETRIOSIS
-
Mechanism of infertility:
Distorted adenexal anatomy
Blockage of tubo-ovarian motility due to adhesion
Interference with oocyte development or early
embryogenesis
Reduced endometrial receptibility
60
Female Infertility
PELVIC SURGERY
Appendicectomy
Divurticulectomy
61
Female Infertility
Peritoneal factors
Causes:
Pelvic inflammatory disease
Endometriosis
Previous surgeries
62
Female Infertility
Polymicrobial:
STI: N. Gonorrhea 30%
Chlamydia trachomatis 30%
Mycoplasma 10%
Female Infertility
Pathology
Initiated in endosalphinx
Destruction of
epithelial cells, cilia and microvilli
All three layers gets involved
hyperemic
Edematous and
64
Female Infertility
Female Infertility
Risk
of infertility
Episodes of
Episode of PID
PID
1
1st 2
2nd3
3rd
st
nd
rd
Female Infertility
% of
% of infertility
infertility
10-12%
10
12
23-35%
23- 35
54-75%
54- 75
66
Uterine Factors
Causes:
CONGENITAL : - Absence of uterus
Uterine hypoplasia
CONGENITAL MALFORMATION:- Uterine
didelphus(25%), Unicornuate(38%), Septate(25-47%)
- Pregnancy outcome depends upon site of blastocyst
implantation
67
Female Infertility
68
Female Infertility
UTERINE LEIOMYOMA
-
Female Infertility
A meta-analysis showed:
Pregnancy rate increased to 57-67% after
abdominal myomectomy for infertiltiy
70
Female Infertility
ENDOMETRIAL POLYP
-
71
Female Infertility
72
Female Infertility
Intrauterine infection
Genital tuberculosis( tubercular endometritis)
Schistosomiasis
73
Female Infertility
CHRONIC ENDOMETRITIS
-
74
Female Infertility
Cervical factors
ANATOMIC
- Congenital elongation of cervix
- Cervical stenosis( pinhole Cx os)
PHYSIOLOGICAL
- Fault in compositon of cervical mucous
- Antisperm antibodies
75
Female Infertility
76
Female Infertility
Anti
sperm antibodies
77
Female Infertility
Effect
- Interference with
- Capacitaton
- Acrosomal reaction
- Sperm egg recognition & fusion
- Cleavage of early embryo
78
Female Infertility
Vaginal factors
Septate vagina
Narrow introitus
Vaginitis
Vaginismus
Vulvodynia
79
Female Infertility
Unexplained infertility
-
80
Female Infertility
81
Female Infertility
Im healthy
strong
person I
would not
have any
problem
producing
a baby
OBESITY
AN EMERGING MENACE
An Obese Woman is
about Thrice as likely
to be Infertile as a
normal woman
Yes
Obesity can be
Main
Secondary or
Accompanying
infertility factor
Obesity is strongly
associated with
PCOS
CENTRAL PLAYER
Insulin
resistance
Hyperandroge
nism
Elevated leptin
Leptin
resistance
both
regular or irregular cycle
UNDERLYING MECHANISM
anovulation
release of oocytes with
reduced fertilization potential
endometrial abnormalities
Both seed and soil defective
Infertility
treatment should
be deferred until
BMI<35 kg/m2
preferably
BMI<30 kg/m2 in
young women
with good
ovarian reserve
Treatment Modalities
For Infertility in Obesity
Diet
Exercise
Psychologic
al
Counseling
ART
IUI
IVF
ICSI
Surgical
Intervention
Bariatric
surgery
Pharmacological intervention
Pregnancy after
Bariatric Surgery
Pre-Pregnancy
Counselling
Smoking
-13% of female infertility relate to smoking
-
Mechanism:
- Accelerated follicular depletion
- Loss of ciliary function
- Menstrual cycle abnormalities
- Gamete or embryo mutagenesis
100
Female Infertility
Substance abuse
-
ALCOHOL
- Heavy alcohol consumption: fertility
- Moderate alcohol consumption: fecundability
- Associated with lower pregnancy rate achieved with
ART
101
Female Infertility
CAFFINE
-
Female Infertility
General factors
Coital errors
Dyspareunia
Frequency and timing coitus
Use of spermicide
Anxiety / apprehension
Family disposition, genetic and constitutional
factors
103
Female Infertility
Evaluation
Objective:
To identify and correct specific causes of infertility
To provide accurate information
To provide emotional support
To guide for alternatives ART, use of donar gamete
and adoption
Counseling must be the ongoing process
104
Female Infertility
Principle
Couple-centered management
Access to evidence-based information
(verbal and written)
Counseling from someone not directly involved in
management of the couples fertility problems
Contact with fertility support groups
Specialist teams
105
Female Infertility
Indication
106
Female Infertility
HISTORY
- Age , duration of marriage, previous marriage
- Occupation
- Duration of infertility/ previous evaluation and
treatment
- Coital frequency/time of cycle/ sexual dysfunction
- Vaginal discharge/ chronic pelvic pain
107
Female Infertility
MENSTRUAL HISTORY
-
OBSTETRIC HISTORY
- Parity, pregnancy outcomes/losses & complications
- Pregnancy termination, septic abortion, ectopic
pregnancy
108
Female Infertility
PAST HISTORY
-
Female Infertility
FAMILY HISTORY
- Early menopause, reproductive failure
PERSONAL HISTORY
- Use of tobacco, alcohol, smoking, drug abuse
- Eating habit, exercise
PHYSICAL EXAMINATION
- Weight/ BMI/ Secondary sexual characteristic
- Signs of androgen excess
- Thyroid enlagement, nodules, tenderness
- Breast secretion, character
110
Female Infertility
SYSTEMIC EXAMINATION
-
111
Female Infertility
112
Female Infertility
Lifestyle advice:
Sexual intercourse every 23 days
12 units alcohol/week for women; 34
units/week for men
Smoking cessation programme for smokers
Body mass index of 1929
Information about prescribed, over-the-counter
and recreational drugs
Information about occupational hazards
113
Female Infertility
114
Female Infertility
Investigation
Any investigation for infertility couple should begin
with:
- Semen analysis
- Confirmation of ovulation
- Documentation of tubal pathology
115
Female Infertility
Initial assesment
TLC/ DC/ Bl group/ RBS/ Hb/ ESR
Chest x ray/sputum AFB/ RFT/ LFT/HVS c/s
Assessment of ovulation
Frequency and regularity of menses
Endometrial biopsy (+ AFB culture)
Follicular study
Progesterone level/ FSH,LH level
Urinary LH excretion
BBT, Cx mucous study
116
Female Infertility
Laparoscopy
117
Female Infertility
MENSTUAL HISTORY
119
Female Infertility
120
Female Infertility
PROGESTERONE CONCENTRATION
122
Female Infertility
Female Infertility
URINARY LH EXCRETION
124
Female Infertility
125
Female Infertility
ENDOMETRIAL BIOPSY
-
126
Female Infertility
FOLLICULAR STUDY
127
Female Infertility
Female Infertility
Laparoscopy
- Detailed information of
Female Infertility
HYSTEROSALPHINGOGRAPHY (HSG)
130
Female Infertility
Procedure
-
Vaginal cleansing
An acorn (Jascho) cannula or via ballon catheter
introduced
Contrast material is then injected
- Water soluble contrast media ( Meglumine
diatrizoate, Renografin 60)
- Oil-based (Ethiodol)
Volume of contrast
- Initial 3-4ml: outline of uterine cavity
- Further 5-10ml: demonstrate B/L tubal patency
131
Female Infertility
Rapid absorption
Less risk
Low
132
Female Infertility
Female Infertility
Contraindication
-
Hydrosalphinx
Current PID
Cervicitis
Palpable adenexal mass
Tenderness on bimanual examination
134
Female Infertility
Complication
-
Infection(0.3%-1.3%)
Cx laceration
Uterine perforation
Haemorhage
Vasovagal reaction
Allergic response to dye
Radiation exposure
135
Female Infertility
Instruments of Hysterosalpingography:
Volsellum
Speculum
Higar dilator
Screw cannula
Contrast media
Uterus Unicornis
1 tube
1 uterus
Diagnosis: Hydrosalpinx.
Description: take different size and shape of dilatation
(sacculation).
Diagnosis: adenomyosis.
Description: irregular outline, multiple diverticulum..
Case 34
LAPAROSCOPY
Gold standard
Indication
- Abnormal HSG
- Failure to conceive of normal HSG
- Unexplained infertility
- Age > 35years
154
Female Infertility
Procedure
-
155
Female Infertility
Female Infertility
SALINE
HYSTEROSALPHINGOGRAPHY
-
Timing
- Proliferative phase : Endometrial polyp
- Secretory phase: Submucous fibroid
- Pregnancy to be ruled out
157
Female Infertility
Preparation
-
Interpretation
- Detection of saline in POD indicated tubal patency
- Hysterosalphingo contrast sonography( HyCoSy)
Contrast media consisting of surfactan
158
Female Infertility
159
Female Infertility
TRANSVAGINAL USG
Modern transducers produce high resolution images
Endovaginal probes yield details of
- Uterus, ovaries or adenexal pathology
- Fallopian tubes cannot be visualised
Saline sonohysterosalphingography performed
160
Female Infertility
Indication
-
Timing
- In all phases of the cycle
Diagnostic accuracy can be compared with
hysteroscopy
161
Female Infertility
HYSTEROSCOPY
-
Indication
-
162
Female Infertility
Procedure
-
163
Female Infertility
Therapeutic
-
164
Female Infertility
Objective
- To assess quality of cervical mucous
- To assess presence of number or motile sperm
- To see interaction between Cx mucous and sperm
Prerequisite
- Absteinence for 48hrs, no lubricants, douching, medications
- Performed shortly before ovulation, examined within 212hours of coitus
- The post coital test for diagnosis of cervical factor is no longer
recommended
165
Female Infertility
166
Female Infertility
167
Female Infertility
168
Female Infertility
Thank you