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INFERTILITY

INFERTILITY. OBJECTIVES. To present a case of a patient with infertility To know the different causes of infertility To know the management for infertility. CLINICAL CASE. General Data. B.C. 41 y/o Single G0 Filipino Roman Catholic. Chief complaint.

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INFERTILITY

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  1. INFERTILITY

  2. OBJECTIVES • To present a case of a patient with infertility • To know the different causes of infertility • To know the management for infertility

  3. CLINICAL CASE

  4. General Data • B.C. • 41 y/o • Single • G0 • Filipino • Roman Catholic

  5. Chief complaint • Failure to conceive after one year

  6. Review of Systems • unremarkable

  7. Past Medical History • (-) HPN, DM, Asthma • (-) Allergies • (+) Nodular Hyperplasia w/ Lymphatic Thyroiditis s/p L lobectomy w/ isthmusectomy (2007) • (+) Fibrocystic change; ductal hyperplasia; intraductal papilloma w/ apocrine metaplasia s/p excision of breast masses, biateral (2007)

  8. Family History • (-) HPN, DM, BA • (+) Cancer – brain, sister

  9. Personal And Social History • (-) smoker • (-) Alcoholic beverage non-drinker

  10. Menstrual History • Menarche – 16 y/o • Interval – regular • Duration – 3-5 days • Amount – 3-4 ppd, moderately soaked • Pain – (+) dysmenorrhea on first day • LMP : Jan 2010 • PMP : Dec 2009

  11. OB History • G0P0

  12. Gynecologic History • Age of first sexual contact: 29 y/o • One sexual partner • (-) Vaginal bleeding or discharge • (-) dyspareunia or post-coital bleeding • Last pap smear: January 2009, normal • Sexually active: intercourse every 2-3 months

  13. History of Present Illness • 1 yr PTA: infertility • No pain, intermenstrual bleeding, vaginal discharge • Hysterosalpingogram: possible uterine fundal myoma, patent fallopian tubes • FSH: 4.97 mIU/mL • TVUSG: 2 echogenic structures • 1.2 x 0.9 cm and 0.7 x 0.6 cm • Observe for 1 year w/ regular ff-up at REI • Admitted for hysteroscopy

  14. PHYSICAL EXAMINATION General Survey Conscious, coherent, not in cardio-respiratory distress, ambulatory Vital Signs Blood Pressure: 120/80 mmHg Cardiac Rate: 68 bpm, regular Pulse Rate: 68 bpm, regular Respiratory Rate: 18 cpm Temperature: 36.9°C Weight: 46 Kg Height: 155 cm

  15. PHYSICAL EXAMINATION • Pink palpebral conjunctiva, anicteric sclera, pupils briskly and equally reactive to light (2-3 mm) • Supple neck, with no palpable neck mass • No palpaple breast mass, no abnormal nipple discharges • Symmetrical chest expansion, no rib retractions, no crackles.

  16. PHYSICAL EXAMINATION • Adynamic precordium, normal rate, regular rhythm, no murmurs • Flabby abdomen, NABS, soft, non-tender, uterus not enlarged

  17. PHYSICAL EXAMINATION • IE: cervix short, firm, close uterus not enlarged no adnexal masses or tenderness • Speculum exam: not done • Full and equal pulses, (-) bipedal edema

  18. Impression • 41 y/o SNG • Primary infertility

  19. DISCUSSION

  20. INFERTILITY • Inability of a couple of reproductive age to achieve conception after 1 year of sexual intercourse without contraception compared with the mean capacity of the general population.

  21. INFERTILITY • Primary infertiliy: no previous pregnancies have occurred • Secondary infertiliy: in which a prior pregnancy, although not necessarily a live birth, has occurred.

  22. INFERTILITY • Fecundability: is the probability of achieving pregnancy within a single menstrual cycle • Fecundity: is the probability of achieving a live birth within a single cycle

  23. INCIDENCE • Female factors: 32% • Male factors: 18.8% • Male and female factors: 18.5% • Unknown: 11.1%

  24. CAUSES OF INFERTILITY • Male factor • Decreased ovarian reserve • Ovulatory disorders (ovulatory factor) • Tubal injury, blockage, or paratubal adhesions (including endometriosis with evidence of tubal or peritoneal adhesions)

  25. CAUSES OF INFERTILITY • Cervical and immunologic factors • Uterine factors • Conditions such as immunologic aberrations, infections, and serious systemic illnesses • Unexplained factors (including endometriosis with no evidence of tubal or peritoneal adhesions)

  26. INITIAL VISIT • The male partner should be present at this first visit because his history is a key component in the selection of diagnostic and therapeutic plans. It cannot be overemphasized that infertility is a problem of the couple.

  27. INITIAL VISIT • Complete medical, surgical, and gynecologic history from the woman. - menstrual cyclicity, pelvic pain, and obstetric history. - History of pelvic inflammatory disease (PID), intrauterine device use, or pelvic surgery, should be reviewed. - History of intrauterine exposure to diethylstilbestrol (DES)

  28. INITIAL VISIT • Complete medical, surgical, and gynecologic history from the woman. - pituitary, adrenal, and thyroid function. - History of occupational exposures that might affect the reproductive function of either partner is also important. - The interviewer should obtain information about coital frequency, dyspareunia, and sexual dysfunction.

  29. ETIOLOGY

  30. OVULATORY FACTOR • Disorders of ovulation account for 30-40% of all cases of female infertility • Most easily diagnosed and most treatable causes of infertility

  31. OVULATORY FACTOR • Ovulation is an obligatory prerequisite to conception, ovulation must be documented as part of the basic assessment of the infertile couple. • Initial diagnoses among women with ovulatory factor infertility may include anovulation (complete absence of ovulation) or oligoovulation (infrequent ovulation).

  32. OVULATORY FACTOR • Luteinizing Hormone Monitoring - Documentation of the LH surge represents a remarkably reproducible method of predicting ovulation. - Ovulation occurs 34 to 36 hours after the onset of the LH surge and about 10 to 12 hours after the LH peak

  33. OVULATORY FACTOR • Basal Body Temperature - least expensive method of confirming ovulation - Significant progesterone secretion by the ovary generally occurs only after ovulation. - Progesterone is a thermogenic hormone, causes an increase of 0.58°F

  34. OVULATORY FACTOR • Basal Body Temperature - Charting of daily BBTs produces a characteristic biphasic pattern in women with ovulatory cycles. - A normal luteal phase is characterized by a documented temperature elevation lasting at least 10 days.

  35. OVULATORY FACTOR • Midluteal Serum Progesterone - constitute indirect evidence of ovulation. - serum progesterone measurement should coincide with peak progesterone secretion in the midluteal phase (21 to 23 of an ideal 28-day cycle). - level above 3 ng/mL (10 nmol/L) confirms ovulation.

  36. OVULATORY FACTOR • Ultrasound Monitoring - Ovulation is characterized both by a decrease in the size of a monitored ovarian follicle and by the appearance of fluid in the cul-de-sac. - most often occurs when follicular size reaches about 21 to 23 mm

  37. TUBAL, PARATUBAL, AND PERITONEAL FACTORS • Accounts for 30% to 40% of cases of female infertility. • Tubal factors: damage or obstruction of the fallopian tubes and are usually associated with previous PID or previous pelvic or tubal surgery. • Peritoneal factors: peritubal and periovarian adhesions, which generally result from PID, surgery, or endometriosis. • Incidence of tubal infertility: 12% (1x), 23% (2x), and 54% (3x) episodes of PID.

  38. Hysterosalpingography HSG is the initial diagnostic test used to assess tubal patency because it has a sensitivity of 85% to 100% in identifying tubal occlusion.

  39. HSG is usually performed between cycle days 6 and 11. • To reduce the chance of iatrogenic infection, HSG should ideally follow the cessation of menstrual flow • To avoid possible fetal irradiation and interference with conception, HSG should precede ovulation.

  40. It is estimated that infection follows 1% to 3% of HSG procedures and occurs almost exclusively in women with hydrosalpinges or with current or prior pelvic infection. • One typical regimen uses doxycycline, 100 mg twice daily, beginning the day before HSG and continuing for 3 to 5 days.

  41. Laparoscopy The best technique for diagnosing tubal and peritoneal disease is laparoscopy. • Allows visualization of all pelvic organs and permits detection of intramural and subserosal uterine fibroids, peritubal and periovarian adhesions, and endometriosis.

  42. CERVICAL AND IMMUNOLOGIC FACTORS • Cervical factor is a cause of infertility in no more than 5% of infertile couples. • The classic test for evaluation of the potential role of cervical factor in infertility is the post-coital test (PCT).

  43. CERVICAL AND IMMUNOLOGIC FACTORS • Designed to assess the quality of cervical mucus, the presence and number of motile sperm in the female reproductive tract after coitus, and the interaction between cervical mucus and sperm.

  44. CERVICAL AND IMMUNOLOGIC FACTORS • The PCT should be performed just before ovulation because its proper interpretation requires the examination of cervical mucus at a time of sufficient estrogen exposure. The PCT should be performed 1 or 2 days before the anticipated time of ovulation.

  45. UTERINE FACTORS • Uterine anatomy and function are both critical determinants governing implantation of the embryo and subsequent fetal growth and development.

  46. Congenital Anomalies of the Uterus • Associated with infertility, spontaneous pregnancy loss in the first or second trimester, or late-trimester pregnancy complications. • In women with didelphic, unicornuate, and septate uteri, the rates of spontaneous abortion and preterm delivery are highly increased at 25% to 38% and 25% to 47%, respectively.

  47. In Utero Exposure to Diethylstilbestrol • Increases a woman's risk for congenital reproductive tract malformations and obstetric complications, including preterm labor and cervical incompetence. • In one study, almost 70% of women exposed to DES in utero were noted to have uterine malformations on HSG. The most common malformation was the T-shaped uterus.

  48. Acquired Abnormalities of the Uterus Leiomyomas - Never been shown to be a direct cause of infertility. - Alter uterine contractility and thereby disrupt normal sperm migration. - Adversely affect vascular and molecular profiles of sites of implantation.

  49. Acquired Abnormalities of the Uterus Leiomyomas -No prospective, randomized trial comparing expectant management with myomectomy in infertile patients with uterine leiomyomas has yet been conducted.

  50. Acquired Abnormalities of the Uterus Leiomyomas - The presence of other causes of infertility and duration of infertility were associated with worse prognosis, whereas the size, number, or site of fibroids did not affect pregnancy outcomes.

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