Female infertility Causes diagnosis management

1. Sharon Treesa Antony
First Year M.Sc Nursing
Govt College Of Nursing
Kottaym
FEMALE INFERTILITY

2. Infertility is a failure to conceive
within one or more years of
regular unprotected coitus.

3. Review of physiology of reproductive
system
 GnRH ( hypothalamas)
 FSH/LH(pituitary)
 Estradiol (ovary)

4. Ovarian cycle
 Recruitment of groups of follicles (FSH)
 Selection of dominant follicle and its
maturation(FSH, highest estrogen containing
follicle)
 Ovulation (LH surge, FSH surge)
 Corpus luteum formation(maintained by LH,
produces progesterone, life: 12-14 days)
 Demise of the corpus luteum ( due to
withdrawal of tonic LH support)

5. Endometrial cycle
 Stage of regeneration (2-3 daays after
menstruation)
 Stage of proliferation(D5/6 –D14, due to rising
ovarian estrogen)
 Stage of secretion( due to estrogen&
progesterone from corpus luteum.D15 to 5-6 days
before menstruation)
 Menstruation ( fall in estrogen& progesterone)

6. TYPES
 PRIMARY
 SECONDARY

7. CAUSES

9. OVARIAN FACTORS

10. Anovulation or oligoovulation
 Turner’s syndrome
 Hypothyroidism
 Ovarian tumors
 X ray/ radioactive exposure
 General ill health
 Poor diet

11. Cont...
• BMI <20/>24
 Use of easily digested carbohydrates (white
bread)
 PCOS
 Stress
 High insulin or glucose levels

12. TUBAL FACTORS

13.  Chronic salpingitis
 History of tubal ligation
 PID
 STDs
 IUCD
 Multiple sexual partners

14. UTERINE FACTORS

15.  Fibroids
 Congenital deformation
 Low estrogen /progesterone from ovary
 Endometriosis in ovaries/ fallopian tubes

16. CERVICAL FACTORS

17.  Coitus after 12 – 72 hours after ovulation
 Infection
 Stenotic cervical os
 Obstruction of os
 Repeated cervical surgeries
 Anti sperm antibodies

18. VAGINAL FACTORS

19.  Infections
 Sperm immobilizing or agglutinating antibodies

20. DIAGNOSTIC TESTS

21. History
 Age
 Duration of marriage
 History of previous child bearing

22. General Medical History
 TB
 STDs
 Diabetes mellitus
 Pelvic Inflammation

23. The surgical history
 Abdominal / pelvic surgery

24. Menstrual history
 Hypo/ oligo/amenorrhea

25. Previous Obstetric History
 No. of pregnancies, interval between them
 Pregnancy related complications
 Premature rupture of membranes
 Puerperal sepsis

26. Contraceptive Practice
 IUCD may lead to PID

27. Sexual problems
 Dyspareunia
 Loss of libido

28. General examination
 Obesity
 Marked reduction in weight
 Abnormal distribution of hairs
 Underdeveloped secondary sexual characters

29. Systemic Examination
 Hypertension
 Organic heart disease
 Chronic renal lesion
 Endocrinopathies

30. Gynaecologic Examination
 Adequacy of hymenal opening
 Adnexal masses
 Evidence of vaginal infections
 Cervical tear or chronic infections
 Undue elongation of cervix
 Uterine size, position

31. Speculum examination
 Abnormal cervical discharge

32. DIAGNOSIS OF OVULTION

33. Indirect methods
 Menstrual history
Features of ovulation
 Regular normal menstrual loss
 Mittelschmerz syndrome
 PMS/ Primary dysmenorrhoea

34. Evaluation of peripheral/ end organ
changes
 Basal body temperature : biphasic pattern
 Cervical mucus study:
 disappearance of fern pattern after 22nd day
suggests ovulation
 Loss of stretchablity which was present in
midcycle

35.  Vaginal cytology:
 Vagina contains: parabasal/intermediate/
Superficial
Maturation index
Preovulatory period: 0/40/60
Mid secretory : 0/70/30

36. Hormone Estimation
 Serum progesterone: on D8 and D21
Increase from <1ng/ml to 6ng/ml indicates
ovulation
• Serum LH: daily in midcycle
Ovulation occurs 34-36 hours after beginning of LH
surge/ 10-12 hours after LH peak

37.  Serum oestradiol: peak rise 24 hours prior to LH
surge and about 24-36 hours prior to ovulation
 Urinary LH: ovulation occurs within 14-26 hours of
urinary LH surge

38.  Endometrial biopsy: sharman curette /pipelle
endometrial sampler. Done D21- D23.
Evidence of secretory activity in 2nd half of cycle.
 Sonography
 Graffian follicle prior to ovulation(18-20mm)
 Recent ovulation (collapsed follicle and fluid in
POD)

39. Direct methods
 Laparoscopy
 Recent corpus luteum
 Detection ovum in aspirated peritoneal fluid from
the POD

40. CONCLUSIVE
 Pregnancy

41. LUTEAL PHASE DEFECT ( poor
function of corpus luteum)
 BBT chart
 Slow rise of temperature taking 4-5 days following
the fall in midcycle
 Rise of temperature sustains < 10 days
• Endometrial biopsy (D25 –D27)
Lagging at least 2 days
 Serum progesterone
D8: <10ng/ml

42. Luteinised Unruptured Follicle
 Sonography: persistence of echo free dominant
follicle beyond 36 hours after LH peak
 Laparoscopy
 Ovarian biopsy: ovum in the middle of corpus
luteum

43. DIAGNOSIS OF TUBAL FACTORS

44. Dialatation and insufflation test
 Done in post menstrual phase at least 2 days
after stoppage of bleeding.
 Air/ CO2
 Fall in pressure when raised> 120 mmHg
 Hissing sound in illiac fossa
 Shoulder pain

45. Hysterosalpingography
 Dye injection
 Reveals site of block, uterine abnormalities

46. Laparoscopy and chemopertubation
 Done in secretory phase
 can see recent corpus luteum and take
endometrial biopsy
 Laparoscopic visualisation of pelvis, tubes and
ovaries
 Inject methylene blue to check tubal patency

47. Sonosalpingography
 Under USG
 Inject saline / air through a foley’s catheter
 Detects tubal patency, peritubal adhesions,
unsuspected endometriosis

48. Hysteroscopy and falloposcopy
 To study interstitial part of tube
 A soft pliable cannula can be used to brake small
synechiae

49. Ampullary and fimbrial salpingoscopy
 To study the mucosa of fallopian tube
 Inject starch into pouch of Douglas; presence of
starch in cervical mucous 24 hours after injection
indicates tubal patency

50. Salpingoscopy
 Rigid endoscope is inserted through the fimbrial
end of tube through a laparoscope

51. DIAGNOSIS OF UTERINE FACTORS

52.  USG
 HSG
 Hysterscopy
 Laparoscopy

53. DIAGNOSIS OF CERVICAL FACTORS

54. Post coital test
 Done D12- D13
 Report to clinic within 8-12 hours of intercurse
 Aspirate endocervical mucus
 Visualise under high power microscope
 10 progressively motile sperm/HPF : normal
 Immotile sperm with normal sperm count:
immunological factors

55. Sperm cervical mucous contact test
 In vitro cross over test
 Midcycle endocervical mucous & semen
Vs
Donor’s mucus and semen

56. TREATMENT

57. Couple instructions
 Assurance
 Obtain optimum BMI
 No alcoholism and smoking
 Have intercourse during midcycle
 Detect urine LH surge

58. OVULATORY DYSFUNCTION

59. ANOVULATION
 Ovulation Induction
 Psychotherapy
 Reduce weight

60. Drugs
 Stimulation of ovulation
 Clomiphene citrate
 Letrozole
 hMG
 FSH
 hCG
 GnRH
 GnRH analogues

61.  Correction of biochemical abnormality
 Metformin
 Dexamethasone
 Bromocriptine
 Substitution Therapy
 Thyroxin
 Anti diabetic drugs

62. Clomiphene Citrate
 INDICATIONS
 Normo gonadotrophic normo prolactinemic with
normal cycles& absent/ infrequent ovulation
 PCOS with oligomenorrhea/ amenorrhea
 Hypothalamic amenorrhea

63.  ACTION
 Blocks estrogen receptors in hypothalamas
 Increased GnRH pulse amplitude
 Increased gonadotrophin secretion

64.  DOSE
 Initial 50mg daily; max: 250mg daily
 Start between D2-D5, for 5 days
 Ovulation expected to occur about 5-7 days after
last day of therapy
 Usually 6 cycles

65. Letrozole
 Inhibits aromatase in granulosa cells
 Suppress estrogen synthesis
 25mg from D3 – D7
 Stimulates development of ovarian follicle

66. Gonadotrophins
 Ovarian reserve must be present(FSH<10 IU/L 0n
D3)
 INDICATIONS
 Hypogonadotrophic hypogonadism
 Clomiphene failed/ resistant
 Unexplained infertilty

67.  DOSE SCHEDULE
 hMG stimulates follicular growth (75IU IM/day)
 Start on D2-D5
 Continue for 7-10 days
 monitor follicular growth &s. Estradiol
 Optimum levels
 S.estradiol-500-1500pg/ml
 Max follicular diameter:18-20mm

68.  At opt.levels,hCG 5000-10000IU IM to induce
ovulation ( favourable if endometrial thickness is
8-10mm)
 Ovulation occurs 36 hours after hCG
administration

69. Gonadotrophin releasing
hormone
 Stimulates physiolgic levels of pituitary
gonadotrophin secretion
 INDICATIONS
 Hypothalamic amenorrhea
 Hypogonadotrophic hypogonadism
 Women with hyperprolactinemia

70.  DOSAGE
 IV/SQ infusion pump
 5 microgram IV every 90 minutes
 Follicular growth is similar to a normal menstrual
cycle

71. GnRH Analogues
 INDICATIONS
 Refractory to gonadotrophins
 Elevated LH
 Premature follicular luteinisation
 Premature ovulation due to premature LH surge

72.  ACTION
For down regulation of pituitary gland by
desensitisation of pituitary GnRH receptors
 hCG is administered as in hMG therapy

73. GnRH antagonists
 Blocks pituitary GnRH receptors
 Luteal phase support by hCG/ progesterone

74. Luteal Phase Defect
 Natural progesterone PV 100mg TDS from day of
ovulation until menstruation/ 10th week of
pregnancy.
 hCG
 Clomiphene citrate
 IVF

75. Luteinised unruptured follicle
 hCG
 Ovulation inducing drugs with hCG
 Bromocriptine in hyperprlactinemia

76. SURGERY
 Laparoscopic ovarian drilling or laser vaporisation
( multiple puncture of cysts in PCOS)
 Wedge resection of ovaries bilateral
 For pituitary prolactinomas
 For removal of ovarian or adrenal tumor

77. Tumour and peritoneal factors
 Salpingo ovariolysis: peritubal adhesions
 Proximal tubal block
 salpingography
 tubal cannulation under hysteroscopic guidance
 Distal tubal block:
 fimbrioplasty
 Neosalpingostomy
 Midtubal block : reversal tubal ligation

78. Adjuvant therapy
 Antibiotics
 Adhesion prevention devices
 hydrotubation

79. CERVICAL FACTORS

80.  Conjugated estrogen 1.25 mg daily from D8 for 5
days
 Chlamydia/M.Hominis: Doxycycline 100 mg BD

81. IMMUNOLOGICAL FACTOR

82.  Antisperm antibodies: dexona o.5 mg at bedtime
in the follicular phase

83. UTEROVAGINAL SURGERY
 Myomectomy
 Metroplasty
 Adhesiolysis
 Enlargement of vaginal introitus
 Removal of vaginal septum
 Amputation of cervix
 Gilliam type operation

84. Attempt for pregnancy after infertility
surgery
 Microsurgical tubal anastamosis:6 weeks
 Uterotubal implantation: 6 months
 Salpingostomy:6-12 mon
 Surgery for endometriosis: soon following surgery
 Myomectomy/metroplasty: 3-6 months
 Adhesiolysis: soon after surgery

85. Unexplained infertiliy
 Induction of ovulation
 IUI
 Superovulation+IUI
 ART

86. ARTIFICIAL INSEMINATION
INTRAUTERINE
INSEMINATION
FALLOPIAN TUBE
SPERM
PERFUSION

87. Intra Uterine Insemination

88. INDICATIONS
 Hostile cervical mucus
 Cervical stenosis
 Oligospermia/asthenozoospermia
 Immune factors
 Male : impotency/anatomical defect
 Unexplained infertility

89. Procedure
 Washing
 Swimming up
 Centrifugation
 injection

90. Timing
 Spotnaneous cycles:IUI*2 on D12 and D14
 Clomiphene citrate induced cycles: 5& 7 days after
completion of CC
 Urinary LH detection: 24 hours after detection
 Use hCG & sonography: hCG at 18 mm of follicle
IUI *2 following 34-40 hours of hCG administration

91. THANK YOU