Transcript بسم الله الرحمن الرحيم

‫بسم هللا الرحمن الرحيم‬
Problem Based Learning
‫الرحيم‬
‫بسم هللا الرحمن‬
Infertility
CASE
A 33 YEARS OLD WOMAN ATTENDS TO INFERTILITY
CLINIC HAVING BEEN TRYING TO CONCEIVE FOR 24
MONTHS. SHE HAS HAD TWO PREGNANCIES, WHICH
RESULTED IN THE BIRTH OF HER SON 3 YEARS
PREVIOUSLY BY EMERGENCY CESAREAN SECTION
FOR FETAL DISTRESS AND A MISCARRIAGE AT 10
WEEKS GESTATON, FOLLOWING WHICH SHE
REQUIRED UTERINE EVACUATION.
What are the basic
requirements for
conception?
Basic Requirements of Conception
Conception requires the juxtaposition of
male and female gametes at the optimal
stage of maturation followed by
transportation of the conceptus to the
uterine cavity at a time when the
endometrium is supportive of its continued
development and implantation.
Basic Requirements of Conception
For these events to occur the male and
female reproductive system must be
anatomically and physiologically intact and
coitus must occur with sufficient frequency
for the semen to be deposited in close
temporal relationship to release of the
oocyte from the follicles.
When would infertility be
considered?
When a couple of
reproductive age fail to
achieve conception after 1
year of regular sexual
intercourse without
contraception.
What do you want to know
and do about this case ?
History
Examination
Investigation
Classification
Infertility
Primary
Secondary
Without previous
pregnancy
When it follows a
previous
conception
In general infertility could be due to:
•
•
•
•
•
•
Male fertility factors (35%)
Ovulatory factors (25%)
Peritoneal factors (25%)
Cervical factors (5%)
Uterine factors (5%)
Idiopathic (5%)
This is a case of secondary infertility, the
male factor is considered normal here.
The possible causes of infertility here are:
• Ovulatory causes
• Peritoneal causes
• Cervical causes
• Uterine causes
History
• Age
• Duration of trying to achieve pregnancy
• Any previous pregnancies
History
• Menstrual history:
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•
•
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Secondary amenorrhea-LMP
Regularity (irregularity seen in anovulation)
Cycle length (if <25 or >35→irregular ovulation)
Variation between cycles ( if >7→irregular
ovulation)
• Dysmenorrhea
• Premenstrual symptoms
History
• Endocrine system:
– Headache, galactorrhea, Visual changes.
“pituitary adenoma-hyperprolactenemia”
– Excessive exercise, extreme emotional stress,
excess hair growth.
“hypothalamic – pituitary failure”
– Symptoms of hypo- and hyperthyroidism.
– Hot flashes, vaginal dryness
“premature ovarian failure-menopause”
History
• Reproductive system:
• Pelvic pain
• dysuria, fever >> PID or STD
• Premenstrual spotting, dysmenorrhea,
>> endometriosis
• Previous ectopic pregnancy
• Previous D & C
• Contraception:
type, duration, complications
Especially previous IUD  pelvic adhesion
dyspareunia
History
• Marital history
husband's age
intercourse frequency
history of impotence
usage of lubricants
• Past history
systemic disease
previous pelvic surgery
previous STD or PID
History
• Drug history
Name - Dose - Duration - Side effect
• Social history
smoking, alcohol
diet ( e.g. caffeine)
expose to chemical or radiation (e.g. DES)
stress and emotion
lifestyle
Examination
•
•
•
•
•
•
•
•
Vital sign
BMI (obesity)
Signs of androgen excess
Signs of Thyroid disease
Galactorrhea
Pelvic scar
Pelvic tenderness
Vaginal discharge
Investigations
• Hormonal level
–
–
–
–
Serum progesterone
FSH level
LH level
inhibin B level
• Basal body temprature
measure temperature before arising in the morning and
record in chart
Investigations
• Endometrial biopsy
biopsy is taken in the luteal phase
• Hystrosalpingography
Oil or water-soluble contrast injected through
cervix and fallopian tube for fluoroscopic x-ray
• Postcoital test
For cervical mucus analysis
Investigations
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•
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Laparoscopy
Ultrasound
MRI
Genetic Testing
Test for Autoimmune Disease
INFERTILITY MANAGEMENT
Basic work-up to evaluate infertility
1- Documentation of ovulation;
2-Semen analysis;
3- Postcoital test;
4- Evaluation of tubal patency;
5-Diagnostic laproscopy
Cervical factors
1- Infection……………Doxycycline
2-Poor mucus quality ……….estrogen from
day 7 until ovulation
3-IUI
Ovulatory factors
1-Luteal phase defect……vaginal
progestrone
2-Hypothalmic aminorrhea….GNRH in small
doses
3-PCOS……………..….clomiphine citrate
4-Hyperprolactinaemea…….Dopamine
agonists ‘bromocriptine’
5-surgical excision of androgen producing
ovarian stroma (wedge resection)
In this case, the male factor is
normal, but the female factor is
abnormal
So, what could be the cause of
infertility in this female?????
1-Cervical factor
In Hx: ask about previous cervical surgery
(cautery), infection and in utero
diethylstilbestrol expousre (DES).
In Exam.: cervical abnormalities or lesions.
In screening test: postcoital test that
evaluate sperm cervical mucus interaction.
Treatment is: Intrauterine insemination (IUI)
2-Tubal and pertonial factor
In Hx: prior pelvic infection or ectopic
pregnancy
In Exam.: stigmata of endometrosis.
In screening test: hystrosalpingogram,
laproscopy with tubal lavage(gold std.)
Treatment : surgery or in vitro fertilization
3- Ovarian factor
In Hx: Secondary amenorrhea, irregular
menses
In Exam.: obesity, hirutism and galactorrhea
In screening test: Measurement of daily
basal body temperature
Treatment : ovulation induction
Prognosis
• 50% of couples will successfully achieve
pregnancy among the couples with an
identifiable cause.
• 60% of couples with unexplained infertility
who receive no treatment will conceive
within 3-5 years
THANK YOU