Transcript Basic Infertility Investigation

Basic Infertility Investigation
“Hope and Despair”
SUPERVISOR: PROF. DR. DR. T. Z. JACOEB,
SPOG (K)
PRESENTERS: MARGARETHA GUNAWAN,
MONA JAMTANI, NURUL LARASATI
Topics
 Definition
 Prevalence
 Factors Causing Infertility
 Female factor
 Male factor
 Other factors
 Classification
 Basic Infertility Investigation
 Management
Definition
 Infertility is defined as failure to conceive after 1 year of
unprotected intercourse.
(Case, 2003)
 Infertilitas adalah kegagalan sepasang suami istri untuk
hamil selama 12 bulan atau lebih dengan koitus yang
teratur dan tanpa menggunakan alat kontrasepsi.
(Wiknjosastro, 2005)
 Infertilitas atau ketidaksuburan adalah kesulitan untuk
memperoleh keturunan pada pasangan yang tidak
menggunakan kontrasepsi dan melakukan sanggama
secara teratur.
(Depkes RI, 2008)
Prevalence
 In developed country: 5-8% are infertile.
 In developing country: 30% are infertile.
 WHO estimated approx. 8-10% or 50-80 millions
couples around the world are infertile.
 In Indonesia: 12% or approx. 3 millions couples with
infertility problems.
(Wiknjosastro, 2005)
Factors Causing Infertility
 Infertility can be caused by the female (60-70%%), male
(30-40%), or both (20-30%), as well as other factors
(10%).
(Scott, 2004)
Female:
Vagina (3-5%)
Cervix (1-10%)
Uterus (4-5%)
Fallopian tube (6580%)
Ovaries (5-10%)
Anovulation (35%)
Male:
Sperm evacuation
problem
Stricture of the semen
channel due to infection,
immunologic/anti-body,
anti-sperm, or nutrition.
Combination
Other factors
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Age
Length of infertility
Life style
Obesity
Being too skinny
Environment
Alcohol consumption
Medication or recreational drugs
Excessive exercise
Ovulation disorder
Infection
Sexual intercourse (too frequent, positioning, ovulation period)
Classification
 Infertility can be classified into two:
 Primary female infertility: where a woman had never been
conceived at all despite having intercourse, and faced with the
possibility of pregnancy for 12 months.
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Secondary female infertility: is where a woman has previously
conceived, but then can not conceived again despite having
intercourse and faced with the possibility of pregnancy for 12
months
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(Wiknjosastro, 2005)
Basic Infertility Investigation
 Basic infertility investigations aim to assess three
main areas:
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Ovulation
Tubal damage or dysfunction
Male factors
(Case, 2003)
Anamnesis
 Ovulatory dysfunction:
 age of menarche, cycle length, history of increased or decreased
intervals between cycles, and physical symptoms of ovulation and
hormone production.
 Ovulatory dysfunction is identified  an endocrine review of systems
 etiology of the irregular menses.
 Thyroid symptoms, androgen excess, marked weight
changes, and galactorrhea.
 Signs of decreased ovarian function: shortened menstrual
cycle length, new onset of irregular cycles, or hot flashes
 Worsening dysmenorrhea, intermenstrual bleeding, and
menorrhagia  diseases in the pelvic peritoneum or uterus.
Scott JR, Gibbs RS, Karlan BY, Haney AF. Danforth's Obstetrics and Gynecology: Lippincott Williams & Wilkins
Publishers; 9th edition. August 2003
Phhysical Examination
 Breast formation
 Galactorrhea
 Genitalia (e.g., patency, development, masses,
tenderness, discharge, mucus quality)
 Rectovaginal exam: lumps behnd the uterus
(ligament sakrouterina)
 Signs of hyperandrogenism (e.g., hirsutism, acne,
clitoromegaly)
 Thyroid gland
Diagnostic Tests for Infertility based on EBM
 Three categories:
1.
Tests with established correlation with pregnancy :
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Semen analysis
Tubal patency by hysterography (HSG)
Mid luteal progesterone for the diagnosis of ovulation
Tests that are not always correlated with pregnancy:
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Zona-free hamster egg penetration tests
Post coital test
Antisperm antibody assays
Tests that seem to not correlate with pregnancy:
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Endometrial dating
Varicocele assessment
Chlamydial testing
Mid-luteal Progresterone (Ovulation)
 Serum progesterone on day 22-26 (>3 ng/ml 
ovulation)
 Transvaginal sonography is the method of choice.
 Endometrial biopsy is not a routine procedure.
Basal body temperature chart (ovulation)
 Low cost, reliable, informs
patient of ovulation time
 Take temperature in the
morning, right after waking
up (keep thermometer by
the bed) after at least 5
hours of sleep at the same
time everyday.
 Can be oral, rectal, or
vaginal  keep the method
everyday
 Plot for a few months to see
the pattern
LH or Ovulation Predictor Kit
 Tests for LH peak before
ovulation
 Test can be started on
day 11 of 28 day cycle
(varies with cycle)
 Best used at around 2 pm
(12pm – 8pm), LH peaks
in the morning but is
detected in urine after 4
hours
Evaluation of Ovulation: Others
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Ultrasound, cervical mucus examination, and
endometrial biopsy can also suggest or confirm
ovulation  less frequently used because of
consideration of reliability and cost.
For women over the age of 30, testing for decreased
ovarian function should be added to the
assessment of ovulation: a day 3 folliclestimulating hormone (FSH) level.
Scott JR, Gibbs RS, Karlan BY, Haney AF. Danforth's Obstetrics and Gynecology: Lippincott Williams & Wilkins Publishers;
9th edition. August 2003
Tubal Patency through Hysterosalpingography
(HSG)
 x-ray examination of a
woman's uterus and
fallopian tubes using
fluoroscopy and a
contrast material.
 Low sensitivity, high
specificity  good for
screening tubal
obstruction.
Semen Analysis
 “Gold standard” for investigating the male.
 At least two serial semen samples.
 WHO criteria (1999) of normal semen:
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Volume: >2.0 mL
pH: 7.2-7.8
Concentration: >20 millions/mL
Motility: >50% with forward
progression
Morphology: >30% normal
WBC: <1 million/ml
Total motile count
(concentration x vol x motility): >20 millions
 Best performed after 72 hours of
abstinence. (Case, 2003)
More Advanced Tests
 TORCH evaluation
 Endometrial biopsy – endometrial hyperplasia, TB
 Hysteroscopy – evaluate endometrium
 Laparoscopy – evaluate whole uterus, possible
perforation, endometriosis
 Post-coital test – to see if sperm reaches the cervix
Referring a Patient
 Woman’s age:
 <35 with >18 months infertility
 >35 with >12 months infertility
 Female:
 History of endometriosis
 Pelvic inflammatory disease or STI or pelvic/abdominal surgery
 Amenorrhea/oligomenorrhea
 Pelvic pain
 Pelvic exam result abnormality
 Male:
 Abnormal semen analysis result
 History of STI, urogenital surgery or pathology
 Varicocele or abnormal results from genital exam
 Patient’s request or anxiety.
Infertility Evaluation in Men (JoseMiller, 2007)
 History
 Coital practices
 Developmental history
 Medical history (e.g., genetic disorders, chronic illness, genital trauma,
 orchitis)
 Medications (e.g., sulfasalazine [Azulfidine], methotrexate, colchicine,
 cimetidine [Tagamet], spironolactone [Aldactone])
 Potential sexually transmitted disease exposure, symptoms of genital
 inflammation (e.g., urethral discharge, dysuria)
 Previous fertility
 Recent high fever
 Substance use
 Surgical history (e.g., previous genitourinary surgery)
 Toxin exposure
Infertility Evaluation in Men (JoseMiller, 2007)
 Physical examination
 Genital infection (e.g., discharge, prostate
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tenderness)
Hernia
Presence of vas deferens
Signs of androgen deficiency (e.g., increased body
fat, decreased muscle mass, decreased facial and
body hair, small testes, Tanner stage < 5)
Testicular mass
Varicocele
Infertility Evaluation in Men (JoseMiller, 2007)
 Laboratory evaluation/specialized tests
 Complete blood cell count (if infection suspected)
 Follicle-stimulating hormone, testosterone levels (if hypogonadism
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suspected)
Gonorrhea and chlamydia cultures, urinalysis (if genital infection
suspected)
Other laboratory studies based on history and physical examination
findings
Postejaculatory urinalysis (if retrograde ejaculation suspected)
Renal and liver function studies
Scrotal ultrasonography
Semen analysis (two or more samples)
Specialized sperm studies (if initial evaluation of both partners
unrevealing)
Transrectal ultrasonography (if ejaculatory duct obstruction suspected)
References
 Winkjosastro.2005. Ilmu Kandungan.Jakarta: Yayasan Bina Pustaka
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Sarwono Prawirohadjo.
Depkes RI.2008. Pedoman Pelaksanan Kegiatan KIE Kesehatan
Reproduksi. Jakarta:Depkes.
Scott Naylor. 2004. Obtetri Ginekologi. Jakarta : EGC.
Case AM. Infertility evaluation and management. Can Fam Physician
2003;49:1465-1472.
Scott JR, Gibbs RS, Karlan BY, Haney AF. Danforth's Obstetrics and
Gynecology: Lippincott Williams & Wilkins Publishers; 9th edition.
August 2003
Jose-Miller AB. Infertility. Am Fam Physician 2007;75:6:849-856.
www.fertilityplus.com