Download 10_Infertility

Infertility
By as. Stelmakh O.
Objectives
• Define primary and secondary infertility
• Describe the causes of infertility
• Diagnosis and management of infertility
Infertility - Statistics
• causes are identified in 90 % of patients
• pregnancy results in 40 % of those
• 30 % of couples have male AND female
factors
• Of 100 subfertile couples the break down is
as follows:
• 40 % male factor etiology
• 20 % female hormonal imbalance
• 30 % female peritoneal factor
• 5 % ‘hostile’ cervical environment
• 5 % unexplained
• psychological impact can be significant
Infertility
• Primary infertility
– a couple that has never conceived
• Secondary infertility
– infertility that occurs after previous pregnancy regardless of
outcome
Causes for infertility
• Male
–
–
–
–
–
–
Drugs
Tobacco
Health problems
Radiation/Chemotherapy
Age
Enviromental factors
• Pesticides
• Lead
• Female
– Age
– Stress
– Poor diet
– Athletic training
– Over/underweight
– Tobacco
– STD’s
– Health problems
Causes of Infertility
• Anovulation (1020%)
• Anatomic defects of
the female genital
tract (30%)
• Abnormal
spermatogenesis
(40%)
• Unexplained (10%20%)
Evaluation of the
Infertile couple
•
•
•
•
History and Physical exam
Semen analysis
Thyroid and prolactin evaluation
Determination of ovulation
– Basal body temperature record
– Serum progesterone
– Ovarian reserve testing
• Hysterosalpingogram
Abnormalities of
Spermatogenesis
Normal
• Sperm made in
seminiferous
tubules
• Travel to
epididymis to
mature
Normal
• Sperm exit through
vas deferens
• Semen produced
in prostate gland,
seminal glands,
cowpers glands
• Sperm only 5% of
ejaculation
• Sperm can live 5-7
days
Semen Analysis (SA)
• Obtained by masturbation
• Provides immediate information
–
–
–
–
–
•
•
•
•
Quantity
Quality
Density of the sperm
Morphology
Motility
Abstain from coitus 2 to 3 days
Collect all the ejaculate
Analyze within 1 hour
A normal semen analysis excludes male factor
90% of the time
Normal Values for SA
Volume
Sperm Concentration
Motility
Viscosity
Morphology
pH
WBC
– 2.0 ml or more
– 20 million/ml or more
– 50% forward progression
25% rapid progression
– Liquification in 30-60 min
– 30% or more normal
forms
– 7.2-7.8
– Fewer than 1 million/ml
Causes for male
infertility
• 42% varicocele
– repair if there is a low count or decreased
motility
• 22% idiopathic
• 14% obstruction
• 20% other (genetic
abnormalities)
Abnormal Semen
Analysis
• Azoospermia
– Klinefelter’s (1 in 500)
– Hypogonadotropichypogonadism
– Ductal obstruction
(absence of the Vas
deferens)
• Oligospermia
–
–
–
–
Anatomic defects
Endocrinopathies
Genetic factors
Exogenous (e.g.
heat)
• Abnormal volume
– Retrograde
ejaculation
– Infection
– Ejaculatory failure
Evaluation of Ovulation
Female Reproductive System
• Ovaries
– Two organs that
produce eggs
– Size of almond
– 30,000-40,000 eggs
– Eggs can live for
12-24 hours
Menstruation
• Ovulation occurs 13-14 times per year
• Menstrual cycles on average are Q 28 days
with ovulation around day 14
• Luteal phase
– dominated by the secretion of progesterone
– released by the corpus luteum
• Progesterone causes
– Thickening of the endocervical mucus
– Increases the basal body temperature (0.6° F)
• Involution of the corpus luteum causes a fall
in progesterone and the onset of menses
Menstrual cycle
Serum Progesterone
• Progesterone starts rising with the LH
surge
– drawn between day 21-24
• Mid-luteal phase
– >10 ng/ml suggests ovulation
Salivary Estrogen:
Ovulation Tester- 92%
accurate
Add Saliva Sample
Non-Ovulatory Saliva
Pattern
High Estrogen/ Ovulatory
Saliva Pattern
Anovulation
Anovulation Symptoms
Evaluation*
• Irregular menstrual
cycles
• Amenorrhea
• Hirsuitism
• Acne
• Galactorrhea
• Increased vaginal
secretions
• Follicle stimulating
hormone
• Lutenizing hormone
• Thyroid stimulating
hormone
• Prolactin
• Androstenedione
• Total testosterone
*Order the appropriate tests based on the clinical indications
Fertilization
Implantation
Anatomic Disorders of
the Female Genital
Tract
Congenital Anatomic
Abnormalities
Hysterosalpingogram
• An X-ray that
evaluates the
internal female
genital tract
– architecture and
integrity of the
system
• Performed between
the 7th and 11th day
of the cycle
• Diagnostic accuracy
of 70%
Hysterosalpingogram
• The endometrial
cavity
– Smooth
– Symmetrical
• Fallopian tubes
– Proximal 2/3 slender
– Ampulla is dilated
• Dye should spill
promptly
HSG: Tubal Infertility
Some women have trouble getting pregnant because scar tissue
prevents eggs from traveling down the fallopian tubes. This scarring
can be caused by endometriosis, the overgrowth of tissue that lines
the uterus, a history of pelvic infections, or previous surgeries
Treatment of the
Infertile Couple
Inadequate
Spermatogenesis
• Laparoscopy surgery
• Eliminate alterations of thermoregulation
• Clomiphene citrate is occasionally used for
induction of spermatogenesis
– 20% success
• In vitro fertilization may facilitate fertilization
• Artificial insemination with donor sperm is
often successful
Intrauterine insemination
(artificial insemination)
Artificial Insemination
• Sperm donation or
sperm aspiration
In Vitro Fertilization
IVF Protocol
• GnRH agonist (e.g. Lupron) for 7 days
• FSH agonist (follistim, Gonal-F,
Repronex) until follicles measure 17-20
mm in diameter
• hCG given to induce egg maturation
• Egg retrieval (transvaginally) 34-35 h
later
IVF Protocol, cont’d.
• 3 to 5 embryos are injected to increase
chances of pregnancy
• woman given progestagen to prevent
miscarriage
Surrogate mother
– Woman unable to have children may
have IVF in another woman who has
the child
IVF With Donor Eggs
Women who are over 40, have poor egg quality, or have not
had success with previous IVF cycles may consider IVF with
donor eggs
Primary Diagnosis of Women Undergoing ART- 1998
12%
15%
9%
2%
27%
9%
26%
Tubal factor
Male factor
Ovulation dysfxn
Endometriosis
Unexplained
Uterine factor
Other
Conclusion
• Infertility should be evaluated after one
year of unprotected intercourse.
• History and Physical examination
usually will help to identify the etiology.
• If patients fail the initial therapies then
the proper referral should be made to a
reproductive specialist.