Transcript cystic acne medication

‫بسم هللا الرحمن الرحيم‬
infertility management
mini osce
Done By :
Maram Mohammad AL-Atiyat
Before u start reading the slides read about infertility causes from the lecture
(male , female and idiopathic causes )
Female infertility Hx
Age
Regularity of the cycle
Hx of glactorrhea ,hypothyroidism ,hirsutism
Previous pregnancies ectopics , abortions
Hx of contraception use
Hx of pelvic inflammatory disease and STDs
Past medical and surgical Hx
Family Hx especially of infertility cases
Habits such as smoking , alcohol and drug use
male Hx:
Hx of mumps
Exposure to chemical . Irradiation , drugs
Previous operations (varicocele or hernias)
STDs
Past medical and surgical Hx
Family Hx especially of infertility cases
Habits such as smoking , alcohol and drug use
Case 1 :
A 25 YO aerobics teacher , she has irrigular periods snd has low BMI = 17 ,
she exercises for 4-5 hrs a day she is otherwise well and has no
significant past medical or surgical Hx , her husband works as a
computer programmer , he is well and has no significant past medical or
surgical Hx both of them are non smokers she r complaining from
infertility
What investigations would u do for he and her husband?
To asses her ovulation :
-Hormonal assay mid luteal progesteron level 7 days prior to the subsequent
menses normally 20-30 nmol/L (the most accurate , ((morning session note ))
-LH and FSH (gonadotrophins) day 2-5 of menstrual cycle ( asses the ovarian
reserve of oocyte ) normally <10
-Prolactin level must be < 20 ng/ml
- TSH
-LH peak and surge : this is one of the best method in determine the time of
ovulation which approximately occure 36 hrs after LH surge and 12 hrs after
peak
-US folliculometry and pelvic US
Semen analysis for her husband
Normal WHO criteria for semen analysis :
Volume : >2ml
Density : >20 million / ml
Motility: >50% forward motile within 2 h
Morphology > 30 %normal form
Note :
If azospermia (lack of sperm cells in the semen )
or oligospermia (very low number of viable
sperms) is there we do hormonal assay for (FSG
,LH ,Prolactine )and we may do chromosomal
analysis
In men with low progressive motility antisperm
antibodies should be determined
Results : R normal
Pelvic US scan is normal , FSH 4.3 u/l ,
LH 3.0 u/l prolactine and thyroid function
normal
Sperm count 53 million/ml ,45%motile with
good progressive motility , morphology
65% abnormality
What ur advice ?
Reduce duration and frequency of exercise
and to gain weight to a a BMI of 19-20
When to do ovulation induction in general?
-If the cause of infertility due to ovulatory
disorders
-and after adressing the underlying cause
ovulation induction should be
considered only if regular menstruation
does not resume
What r the possible causes of male
subfertility ?
Disorders of spermatogenesis
Impaired sperm transport
Ejaculatory dysfunction
Immunological and infective causes
Ovulation induction
ovulation induction : medical or surgical
(medical : oral ( clomiphene ) or injectable
(I will mention them later )) , surgical in
case of PCOS ovarian drilling
Case 2 :
A 30 yo female para 1 plus 3 ( miscarriages) came to you
with history of amenorrhea and infertility
What other important thing to ask about in the history?
D&C after miscarrages
-What the type of infertility and amenorrhea here?
Secondary
-What is the possible cause of infertility in this case?
Asherman's syndrome
-What is the gold standard investigation to confirm your
diagnosis?
Hysteroscopy
-What other possible investigations?
hysterosalpingography or Sonohysterography (US)
How to treat ?
Adhenolysis
How to prevent recurrence?
-the use of mechanical barriers IUCD , and gel
)barriers ) to maintain opposing walls apart
-Antibiotic prophylaxis is necessary in the
presence of mechanical barriers to reduce the
risk of possible infections
-followed by a estrogen hormonal therapy with
progestin to stimulate endometrial growth and
.prevent opposing walls from fusing together
HSG view
Case 3 :
A 22 yo female married for 4 yrs came to u with
history of infertility , did not use any type of
contraception , she have dyspareunia
,lower abdominal pain and abnormal vaginal
discharge
What is the possible cause for her infertility ?
PIDs
What is the definite conformation of ur diagnosis
(infertility due to PIDs ) ?
Laparoscopy
what are the possible laparoscopic findings ?
-Adhesion of the tubes to adjecent structures( causing obstruction)
-Multiple adhesions forming masses and abscesses(
adnexal
mass , tuboovarian abscess )
-Retroverted uterus due to adhesion to the pelvis
-Hydrosalpinx because of the terminal occlusion of the tube
How to overcome this problem ?
Fertility may be restored in women affected by PID. Traditionally
tuboplastic surgery was the main approach to correct tubal
obstruction or adhesion formation, however success rates tended to
be very limited. In vitro fertilization (IVF) has been used to bypass
tubal problems and has become the main treatment for patients who
want to become pregnant.
A tuboplasty is a surgical operation to correct a fallopian tube obstruction or adhesion, to
achieve a pregnancy in women with tubal infertility. Thus, it is a form of assisted
reproductive technology….wikipedia
Case 4 :
A 25 yo woman came to u with history of
infertility in the history she had acne ,
hairsutism , amenorrhea
U did for her US and she found to have the
following :
-What is your diagnosis?
PCOS ( polycystic ovary syndrome )
-what r the US findings ?
Eight or more subcapsular follicular cysts less than or
equal to 10 mm in diameter and increased ovarian
stroma
-What other investigations u can do to confirm ur
diagnosis ?
Serum androgen levels ( increased )
Serum Sex hormone binding globulin (reduced )
Blood test for gonadotrophins which may show
elevated LH:FSH ratio
-What is the cause of subfertility in case of PCOS?
Anovulation ( PCOS is the commonest cause of anovulatory infertility )
Mention other causes of ovulation problems ?
Stress , psychological disturbances , weight change (by disrupting the
normal pulsatile release of GnRH ) , hyper and hypothyroidism (may
result in ovulatory failure )
-How to manage this patient ?
Give her Clomiphene ( ovulation induction )
Also u can use metformin either alone or in combination with
clomiphene if this is not successful
Gonadotrophin therapy if not successful Laparoscopic ovarian drilling
or IVF
Notes :
Clomiphine citrate :
is untiestrogen medication used to stimulate the
development of one or more mature follicles
Clomiphene is administerd during the follicular
phase of the cycle it is thought to act by
increasing gonadotrophin release from the
pituitary leading to enhance follicular recruitment
and growth
Mention other examples of medical ovulation
induction?
-Exogenous gonadotrophins given by daily injection from
the beginning of the cycle the dose is monitored by an
US assesment of follicular number and size
-HMG ( Human Menopausal Gonadotropin ) =
FSH mainly+ LH small doses (induces follicular
maturation)
-hCG given after inducing follicular maturation ( follicular
maturation on US = 1-3 follicles 18 mm in diameter ))
- LHRH analogue-continous : given before administration
of HCG and HMG so that exogenous and endogenous
hormones do not interfere with each other
- LHRH analogue-pulsatile : infusion every 90 minute to
induce ovulation directly by mimicing the effect of
endogenous hormones
What R the complications of
ovarian induction?
-Ovarian cysts
-Multiple pregnancies
-ovarian stimulation
syndrome ( in severe
case can lead to
ascitis , large ovarian
cyst , hydrothorax and
thromboembolic disease
)
- early menopause and
ovarian cancer (not
confirmed yet )
Case 5 :
A 30 yo lady came to u with un explained
galactorrhea , visual disturbance, irregular
menses and infertility ?
-What other things to ask about in the history ?
- Signs of hypothyroidism ( because there is
increase of TSH in hypothyroidism which can
cause hyperprolactenemia)
- ask about renal failure and hepatic dysfuntion
(cause hyperprolactinemia )hyperprolactinemia
impair the pulsatile release of GnRH leading to
anovulation)
-drugs :
drugs r the most common cause of
hyperprolactinaemia
-phenothiazine (antipsychotic) ,
-metoclopramide ( antiemetic and gastroprokinetic
agent. Thus it is
primarily used to treat
nausea and vomiting, and to facilitate gastric
emptying in patients with gastroparesis
-antipsychotic medications in general
-If she did not have hypothyroidism , renal or hepatic
dysfunction symptoms, and not take any medications
what is the possible cause of her hyperprolctinemia ?
Prolactinoma a type of pituitary adenoma
How to confirm ur diagnosis ?
full investigations r needed including TFT , KFT , LFT
test for prolactin blood levels >30 IU / L
And do Plain skull x-ray or MRI ( more sensitive )
How to treat prolactinoma ?
-medical therapy : Bromocriptine ( by this u tt
hyperprolactinemia and decrease the size of the tumor )
-If medical therapy is only partially successful, this therapy
should continue, possibly combined with surgery or
radiation treatment.
-Surgery should be considered if medical therapy
cannot be tolerated or if it fails to reduce prolactin levels,
restore normal reproduction and pituitary function, and
reduce tumor size
Case 6 : Premature Ovarian Failure
(POF)
Sometimes, women in their 20s, 30s or early
40s may start having irregular periods or
miss them altogether for a few months.
This may be a symptom of premature
ovarian failure, a term used to describe the
dysfunction of the ovaries or the depletion
of follicles in a woman’s body before the
age of 40.
POF and Infertility
Premature Ovarian failure can affect a woman at
any age in her life. This may be after the birth of
a baby, or even before she starts getting her
menstrual cycles. Thus, the most overwhelming
or infertility part of this issue is the factor of
getting pregnant. Because POF causes the
cessation of your periods, getting pregnant can
be nearly impossible without treatment. Luckily,
there are a variety of treatment options
nowadays for women with POF hoping to get
.pregnant
symptoms
Age of onset can be as early as the teenage years
but varies widely. If a girl never begins
menstruation, it is called primary ovarian failure
If she have it later in her life (before the age of 40)
the symptoms will be :
having irregular or missed periods for a
considerable time and infertility (major symptom
of POF)
Others : symptoms of menopause remember here
it is an early menopause
-Laboratory findings :
Raised serum FSH and low estradiol
concentrations
- causes :
-genetic causes : Turner syndrome or XY gonadal
dysgenesis mainly the cause of ovulation failure
before puberty
-acquired : Damage by viruses or toxins
- Iatrogenic : pelvic surgery , irradiation and
cytotoxic treatment
-autoimmune problems ; may be detected with
serum autoantibodies to steroid-producing cells
including the ovary , adrenal gland and thyroid
resulting in degenerative changes within the
ovaries
Between 5 and 10 percent of women with
POF may spontaneously become
pregnant. Currently no fertility treatment
has officially been found to effectively
increase fertility in women with POF, and
the use of donor eggs with IVF ( NOT
applicable here ) and adoption
Case 7 :
Patient came to u with history of infertility from the history
she found to have dysmenorrhea , dyspareunia ,
cyclical hamaturea ,dyschezia (painful bowel movement
) no abnormal vaginal discharge .
What is the possible cause of her infertility ?
Endometriosis ( 30-40% of patient with endometriosis
complain of difficulty in conceiving )
How can it cause infertility ? By mechanical damage
-Endometrioma (ovarian endometriosis) interfere with
ovulation
-Endometriosis in the abdominal cavity causing
inflammation and adhesions which can block the
fallopian tubes
What is the gold standard investigation ?
Laparoscopy
What r the laparoscopic features ?
-Powder burn lesion = puckered blue-black lesion
with surrounding white fibrous plaque
-Extensive hemorrhagic lesions indicative of
active symptomatic disease
-Adhesions for ex in the ovarin fossa
What other investigations can be used ?
-CA 125 level but not used alone for the
diagnosis
-US in case of endometrioma
-MRI but of little benefits because some lesions r
very small to appear in the MRI
Active endometriosis with red and powder-burn lesions and
.adhesions from old scarring
Endometriosis on the ovary
Endometrioma in ovary seen with ultrasound
Note :
The charactarestic feature of endometrioma in US is
a homogenous hypoechoiec collection of low-level
echoes within ovarian cyst
How to tt her infertility?
Laparoscopic ablation of endometriosis ,adhesions
and resection of endometriomas as medical
treatment fail to improve conception rate ( this what
I understood from the TEN TEACHERS page 115 116 ) Dr at the lecture said medical and surgical tt
(u can read them from endometriosis lecture)
So treat it expectantly after surgery, with fertility
medication, or with IVF…..wikipedia
Case 8 :
An obese , nulliparus , african lady came to
u with hx of infertility complaining from
menorrhagea , dysmenorrhea , urinary
frequency , urgency and constipation
What is the possible cause of her infertility ?
fibroids
How can u confirm this ?
By US and in some patients MRI can
provides additional informations
How can fibroids cause infertility ?
-The fibroid may be positioned in a way that
it pushes on the fallopian tubes, creating
a block that keeps the sperm from
reaching the egg or that doesn't allow the
egg to be released
-fibroids keep the egg from implanting
correctly or keep the embryo from
growing and developing properly. Many of
these difficulties can also create
miscarriages in women with fibroids
How to tt her ?
Surgical removal (myomectomy) because it
is symtomatic and interfere with pregnancy
Complication of this procedure ?
Carry some risk of uterine rupture during
pregnancy and labour
Note :
In a case of of infertility,.
- what is the key lab investigation?
Progesterone level 7 days prior to the
subsequent menses .
-If hormonal profile &ovarian fxn were normal
in a subfertile female, what is your next step?
Hysterosalpingogram to check uterus and
tubes.
-Always don’t forget ask about male Hx when a
female came to ur clinic complaining from
infertility
U can read about Assested Reproductive
Techniques from the lecture
In the previous slides I did not talk about
physical examination in case of infertility
I did not mention every thing about
investigations u can go back to the lecture
to read about them
Sorry for any mistake