Download INFERTILITY

‫‪INFERTILITY‬‬
‫د‪.‬الق سعيد العارضي‬
INFERTILITY
• Infertility is the inability to conceive a child. A couple may
be considered infertile if, after two years of regular sexual
intercourse, without contraception, the woman has not
become pregnant (and there is no other reason, such as
breastfeeding or postpartum amenorrhoea). Primary
infertility is infertility in a couple who have never had a
child. Secondary infertility is failure to conceive following a
previous pregnancy.
PREVALANCE
• 15% of married couples complaining of inability to
conceive .
• By simple advise within 6 month , 60% will conceive ,
within 1 year .
PATHOPHISIOLOGY
INFERTILITY
• The fertility depends on several factors :
1. Mother age > 35 year , sever decline in the ability to
conceive .
2. FSH level in male and female .
3. If there is no previous pregnancy is worser .
4. BMI .
5. Smoking .
6. Drugs .
7. Male factors .
PATHOPHISIOLOGY
PATHOPHISIOLOGY
General factors affecting both sex :
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Diabetes mellitus, thyroid disorders, adrenal disease.
• Hypothalamic-pituitary factors
• Hyperprolactinemia
• Hypopituitarism
• The presence of anti-thyroid antibodies is associated with
an increased risk of unexplained subfertility.
• Environmental factors Toxins such as glues, volatile
organic solvents or silicones, physical agents, chemical
dusts, and pesticides, Tobacco smokers are 60% more
likely to be infertile than non-smokers.
PATHOPHISIOLOGY
FEMALE FACTORS :
Ovarian factors
• Polycystic ovary syndrome.
• Anovulation : Female infertility caused by anovulation is
called "anovulatory infertility", as opposed to "ovulatory
infertility" in which ovulation is present.
• Diminished ovarian reserve.
• Premature menopause
• Menopause
• Luteal dysfunction
• Gonadal dysgenesis (Turner syndrome)
• Ovarian cancer
PATHOPHISIOLOGY
PATHOPHISIOLOGY
FEMALE FACTORS :
Tubal (ectopic)/peritoneal factors
• Endometriosis can lead to anatomical distortions and
adhesions( has been suggested that endometriotic lesions
release factors which are detrimental to gametes or
embryos, or, alternatively, endometriosis may more likely
develop in women who fail to conceive for other reasons
and thus be a secondary phenomenon).
• Pelvic adhesions
• Pelvic inflammatory disease
(PID, usually due to chlamydia)
• Tubal occlusion
• Tubal dysfunction
PATHOPHISIOLOGY
FEMALE FACTORS :
Uterine factors
1.Uterine malformations
2.Uterine fibroids (leiomyoma)
3.Asherman's Syndrome]
Cervical factors
1.Cervical stenosis
2.Antisperm antibodies
3.Non-receptive cervical mucus
Vaginal factors
1.Vaginismus
2.Vaginal obstruction
PATHOPHISIOLOGY
Male factors :
• Disorder of spermatogenesis
• impaired sperm transport
• Ejaculatory dysfunction
• Immune factors
• infections
PATHOPHISIOLOGY
MANAGEMENT
Diagnosis of infertility begins with a medical history and
physical exam :
History about :
• Duration of infertility
• Age of female
• Life style
• Regularity of sexual intercourse
• Any medical illness
• Hx of pelvic surgery
• Drug history of both male and female
• Nutritional history
• Menstrual history
MANAGEMENT
Examination :
Examination of female :
• Secondary sexual charecterstics
• Abnormal fusion of labia majora and minora
• Hypertrophy of clitoris
Examination of male :
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Hypogonadism
Abscent testis , undescended testis
Abnormality of shape of external genitalia
Abscense of pubic hair , axillary hair or gynaecomastia
MANAGEMENT
INVESTIGATION :
• Lab tests
• hormone testing, to measure levels of female hormones at certain
times during a menstrual cycle
• day 2 or 3 measure of FSH and estrogen, to assess ovarian
reserve
• measurements of thyroid function (a thyroid stimulating hormone
(TSH) level of between 1 and 2 is considered optimal for
conception)
• measurement of progesterone in the second half of the cycle to
help confirm ovulation
MANAGEMENT
Examination and imaging :
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an endometrial biopsy, to verify ovulation and inspect the lining of the
uterus
laparoscopy, which allows the provider to inspect the pelvic organs
fertiloscopy, a relatively new surgical technique used for early
diagnosis (and immediate treatment)
Pap smear, to check for signs of infection
pelvic exam, to look for abnormalities or infection
a postcoital test, which is done soon after
intercourse to check for problems with sperm
surviving in cervical mucous
(not commonly used now because of test
unreliability)
special X-ray tests
MANAGEMENT
Investigations for male :
• Seminal fluid analysis
• Hormonal analysis ( FSH , LH , prolactine and
testesterone )
• Check for liver function
• Check for renal function
• Bloob sugar in case of DM
MANAGEMENT
TREATMENT :
Medical treatments
• Medical treatment of infertility generally involves the use of
fertility medication, medical device, surgery, or a
combination of the following.
• If the sperm are of good quality and the mechanics of the
woman's reproductive structures
are good (patent fallopian tubes,
no adhesions or scarring),
physicians may start by
prescribing a course of ovarian
stimulating medication.
MANAGEMENT
• The physician may also suggest using a conception cap
cervical cap, which the patient uses at home by placing the
sperm inside the cap and putting the conception device on
the cervix, or intrauterine insemination (IUI), in which the
doctor introduces sperm into the uterus during ovulation,
via a catheter. In these methods, fertilization occurs inside
the body.
• If conservative medical treatments fail to achieve a full
term pregnancy, the physician may suggest the patient
undergo in vitro fertilization (IVF). IVF and related
technique (ICSI) are called assisted reproductive
technology (ART) techniques.
MANAGEMENT
• ART techniques generally start with stimulating the ovaries
to increase egg production. After stimulation, the physician
surgically extracts one or more eggs from the ovary, and
unites them with sperm in a laboratory setting, with the
intent of producing one or more embryos. Fertilization
takes place outside the body, and the fertilized egg is
reinserted into the woman's reproductive tract, in a
procedure called embryo transfer.
• Other medical techniques are e.g. tuboplasty, assisted
hatching, and Preimplantation genetic diagnosis.