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Kadında İnfertilite

İngilizce Tıp 4.sınıf öğrencilerine anlattığım ders slaytı. www.sahmay.com www.jinekolojik.org

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Kadında İnfertilite

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  1. FemaleInfertility Prof.Dr.Sezai ŞAHMAY İ.Ü.Cerrahpaşa Tıp Fakültesi Kadın hastalıkları ve Doğum ABDReprodüktif Endokrinoloji Bilim Dalı www.sahmay.com

  2. INFERTILITY: Definitions Infertility: failure to achieve conception over a 12-month period of unprotected intercourse Primary infertility: never having had a live birth Secondary infertility: failure to achieve a live birth after having had a live birth previously

  3. Age andFertility % Klein NA et al.:Clin Obstet Gynecol 41:912, 1998

  4. Infertility: facts Number of infertile couples globally - >100 million. Associated with : • - Female factor * 40% • - Male factor * 30-40% • - Common to both partners * 15-20% • - Unexplained 5-10%

  5. Risk factors • Age • Tobacco smoking • Alcohol use • Being overweight( BMI>35 ) • Too much exercise • Caffeine intake

  6. Başlıca infertilite nedenleri 1.Spermin ulaşamaması 2.Yumurtlama olmaması 3.Uterus faktörü 4.Tüplerin kapalı olması

  7. Causes of Female Infertility • vaginal • cervical • uterine • pelvic • ovarian • other causes • unexplained

  8. Causes of female infertility • Fallopian tube damage or blockage • Endometriosis • Ovulation disorders • Hyperprolactinemia • Polycystic ovary syndrome (PCOS) • Early menopause • Uterine fibroids • Pelvic adhesions

  9. Vaginal causes coital difficulty • vaginismus • vaginal obstruction • imperforate hymen • absence of the vagina • vaginal septum • gynetresia • poor erection • impotence • premature ejaculation

  10. cervical infertility It involves inability of the sperm to pass through the mouth of the uterus due to damage of the cervix. Causes include the following: a) Inadequate or inhospitable cervical mucous b) Cervical narrowing or "stenosis" c) Infections of the cervix with common sexually transmitted diseases (Chlamydia, gonorrhoea, or trichomonas, as well as mycoplasma hominis and ureaplasma urealyticum) d)Immune attack of sperm or "sperm allergy" (Antisperm antibodies) Cervicalcauses

  11. by Leonardo da Vinci of uterus with fetus,circa 1510.

  12. Anatomicproblems (polyps, uterine fibroids, abnormal shape of the uterus, septum or "dividing wall" within the uterus) Thinor abnormal uterine lining Asherman’s syndrome Uterinecauses

  13. Tubal Disease •PelvicInfections •Endometriosis •PelvicSurgery

  14. Pelvic causes Includeany disruption of the normal pelvic anatomy: Scar tissue or "adhesions" Endometriosis Blocked, scarred, or distorted fallopian tubes, dysfunctional FT. Pelvic causes

  15. Pelvic inflammatory disease (PID) and infertility Infection of the pelvic organs that cause severe illness and may lead to tubal blockage and pelvic adhesions leading to infertility A common sequel to STDs, post-partum and post-abortal infections and some systematic infections e.g. tuberculosis, schistosomiasis The risk of tubal factor infertility increases with each successive episode of PID

  16. Endometriosis

  17. Ovarian Causes of Infertility • Ovarian Failure • PCOS • Anovulation • Poor ovarian reserve • Premature Menopause • Luteal dysfunction • Gonadal dysgenesis • Ovarian Cancer

  18. Cultural and social factors • Female genital Mutilation • Early age at marriage or sexual intercourse • Multiple sexual partners (Risk of genital infection)

  19. Preventable causes • Infections–STI: • Gonorrhoea, • Syphilis Etc. • Chlamydia, • Infectious And Parasitic Diseases: • Tuberculosis, • Schistosomiasis, • Sickle Cell Disease.

  20. Preventable causes • Health care practices and policies • Unhygienic obstetric practices • Septic abortion and their complications • Postpartum and postabortal complications • Exposure to potentially toxic substances in: • Environment: arsenic, aflatoxins, pesticides • Diet: caffeine, tobacco, alcohol • Electro-magnetic radiation • Gamma, x-rays etc

  21. Male: Avoid alcohol, tobacco and street drugs Avoid hot tubs and steam baths Female: Avoid alcohol, tobacco and street drugs Exercise moderately Avoid weight extremes Limit caffeine Limit medications Prevention

  22. TimeRequiredForConception Fertility: One year of unprotected coitus without conception Affects 10-15% of couples in reproductive age group

  23. When should a work-up begin? • Most people need no treatment • 3 year rule • 5% decrease per year in age • 15-25% per year of infertile • >35yrs don’t wait • Obvious reasons

  24. HistoryandPhysical • SexualHistory– coitalfrequency • Gynecologic History • menstrual history, pelvic pain, pelvic infections, endometriosis • ObstetricHistory • MedicalHistory • Thyroid abnormalities, hair growth and acne, nipple discharge • Childhoodillnesses,chickenpox,German measles • Medications • SurgicalHistory • Abdominal and pelvic surgeries • SocialHistory/FamilyHistory

  25. Investigations of InfertileCouple • Semen qualitative analysis (sqa) • BasalBody Temp. charts • Tubal patency tests (HSG) • Hormonal tests • Ultrasonography • Laparoscopy • Hysteroscopy

  26. Polyp Bicornate Mid secr Late Prolif Early Prolif

  27. Ovulatory dysfunction Hypothalamicamenorrhea 10% Hyperprolactinemia 10% PolycysticOvary Syndrome (PCOS) 70% Premature ovarian failure 10%

  28. LÜTEİNİZASYON OVÜLASYON FOLİKÜLER MATÜRASYON

  29. Infertility: Ovarian Factor • Menstrual History: 97.7% predictor • BBT • Thermogenic potential of progesterone (.4-.8) • Ovulation when see rise (1-5 days after) • 12 or more days to menses • Progesterone 3-4 ng/mL • 7-8 days post ovulation • Luteal phase function

  30. BasalBodyTemperature • Temperatureincreasesasaresultofprogesteroneproductioninthe luteal phaseofthecycle • Coincides with an increase intheprogesteronelevelabove4ng/ml • A biphasic pattern signifies ovulation • Temperaturetakenuponawakening • PredictstheLHsurgeonlywithin2-3days First day ofthe period Fertile period Peak lutealP4level

  31. DocumentOvulatoryFunction • Basal BodyTemperature • OvulationPredictorKits • Day22-24Progesterone • Midlutealphase > 3ng/ml • Preferably >10 ng/ml

  32. The Declining Follicle Pool VeldeER,etal., Maturitas30(1998)119-125

  33. Over reservinin değerlendirilmesi • Basal hormonlar FSH Östradiol İnhibin-B Antimüllerien hormon (AMH) • Ultrasonik parametreler Antral Folikül sayısı Over Volümü • Dinamik testler CCCT (Clomiphene challenge test) EFORT (Exogenous FSH ovarian reserve test) GAST (GnRH agonist stimulation test) • Johnson NP et al.:BJOG; 113:1472, 2006

  34. AMH düzeyi, gebelik oranları ile pozitif ilişkilidir Sahmay S, Demirayak G, Guralp O, Ocal P, Senturk LM, Oral E, Irez T J Assist Reprod Genet. 29:589–595, 2012

  35. Over cevabı-AFS ve AMH Nelson SM.:Fertil Steril, 2013

  36. Luteal phase defect -infertility -short menstrual cycle -infertility -polimenorrhea -oligomenorrhea Anovulation PRL levels and Clinical findings Hyperprolactinemia Hypoestrogenism osteoporosis Amenorrhea Şahmay, S: Temel Kadın Hastalıkları ve doğum Bilgisi, 1996

  37. Cervical Factor • Postcotial test (Sims-Huhner) Intercourse (2-12 hrs) for test Look at: pH, Sperm, Spinnbarkeit, Ferning Cellularity, Sperm Shaking, sperm Agglutanation Has seen better days

  38. Tubal Factor • Risk factors • PID; 12%,24%,75%, Ectopic 6 fold • HSG • 2-5 days after menses • 1-3 % infection rate high risk • Increase preg rate • False positive obstruction rate (15-30%)

  39. Anatomic Evaluation Hysterosalpingogram (HSG) Myoma Hydrosalpinges Normal HSG

  40. Laparoscopy

  41. Hysteroscopy

  42. İnfertilitede Tedavi • Doğru tanı • Uygun tedavi seçimi • Yeterli süre tedavi • Tedavi maliyetinin düşünülmesi • Çiftin bilgilendirilmesi

  43. Gebeliği etkileyen Faktörler • Yaş • İnfertilite süresi • İnfertilite nedeni • Biyolojik belirteçler (AFS, AMH, FSH) • Diğer

  44. İnfertilitede Tedavi Seçenekleri • Bekle gör • Ovülasyon belirlenmesi ve ilişki • Ovülasyon uyarılması • İntrauterin inseminasyon • Cerrahi tedavi • Yardımla üreme teknikleri

  45. Ovülasyon İndüksiyonu - Tarif Ovülasyon İndüksiyonu (Anovülatuar infertil kadınların tedavisi) Anovülatuar hastalarda, folikül matürasyonu,rüptürü ve fertilize olabilecek nitelikte oosit oluşumu amacıyla farmakolojik ajanların kullanımı. Kontrollü Ovarian Hiperstimülasyon (Ovülatuar kadınlarda süperovülasyon) Ovülatuar veya Anovülatuar hastalarda, Çok sayıda folikül matürasyonu,rüptürü ve fertilize olabilecek nitelikte oosit oluşumu amacıyla farmakolojik ajanların yoğun olarak kullanımı.

  46. İntrauterin İnseminasyon (İUİ)

  47. Yardımla Üreme Teknolojileri AH (Asisted Hatching) IVF (In Vitro Fertilization) GIFT (GameteIntrafallopianTransfer) PROST(PronuclearStageTubal Transfer) TET (TubalEmbryoTransfer ) ZIFT (ZygoteIntrafallopian Transfer ) ICSI (Intracytoplasmic sperm injection) MESA (Microepididymal sperm aspiration) PESA (Percutaneousepididymal sperm aspiration) PGD (Preimplantation genetic diagnosis) TESE (TesticularSperm Extraction) TET (Tubal embryo transfer) ZIFT (Zygote intrafallopian transfer)

  48. IVF-ET (Tüp Bebek) Yumurtalık uyarılması COH Yumurta toplanması OPU Vücut dışında Döllenme IVF Embriyo Transferi ET

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