logging in or signing up Infertility 11 june 2010 NEW mjkz Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Copy Does not support media & animations WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 2856 Category: Science & Tech.. License: All Rights Reserved Like it (5) Dislike it (0) Added: June 19, 2010 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: sirishareddy3344 (3 week(s) ago) pls m in need of ds presentation....its an awesom 1 Saving..... Post Reply Close Saving..... Edit Comment Close By: sirishareddy3344 (3 week(s) ago) can u pls mail me ds presentation nw 2 firstname.lastname@example.org Saving..... Post Reply Close Saving..... Edit Comment Close By: talalnukari (31 month(s) ago) thaks for your kind presentation which is very rich, and provided me a very good information Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript INFERTILITY : INFERTILITY Presented by Dr. Musarrat Jabeen Kazi MBBS MCPS Definition : Definition Medical experts have defined infertility as: Any woman not being able to get pregnant after at least one year of trying without contraception. Slide 4: 80% to 90% couples conceive within one year of their marriage. Incidence : 10% to 15% of all couple are infertile. Incidence varies among different communities but generally about 15% of couples need some help to achieve pregnancy. Slide 5: Infertility is a common condition affecting one in six couples. About 80 million couples are affected world wide. It is of two types: Primary Infertility Secondary Infertility Etiological Factors : Etiological Factors Pregnancy is a result of complex chain of events which includes ovulation that is release of mature egg from the ovary. Its transport through the fallopian tubes. Availability of healthy sperms that fertilize the egg. The fertilized egg must attaches itself to uterus. Slide 7: So infertility can result from problems that interfere with any of these steps. Infertility is not always women’s problem. Causes of infertility may lie either in male or female or in both. Major Causes : Major Causes Causes in male (Responsible for 35-40% of cases) : Causes in male (Responsible for 35-40% of cases) Abnormal spermatogenesis Impaired sperm transport Immunological and infective factor VaricoceoleNormal spermatogenesis depends upon adequate gonadotrophic stimulation of testes, proper testicular function and patent seminal duct. Conti: : Conti: Orchitis Undescended testes Past history of mumps Chronic renal failure. Chronic liver diseases Malignancies Un control diabetes mellitus Multiple scleroses Exposure to radiations or Chemotherapy received for Rx of malignant conditions. Excessive exposure to heat. Investigation in male : Investigation in male First step in male investigation is Semen analyses If this is normal then no other test is needed. If oligospermia or azoospermia is found then patients are referred to specialist fertility clinic for further investigation. WHO Criteria For Normal fertile Semen : WHO Criteria For Normal fertile Semen Volume 2-6 m/ml Liquefaction 30 min Count: >20m/ml Motility >60% Morphology >70%N.Sperm Mixed anti body -ve reaction test (MARS). This is done to detect ASA in semen. Conti: : Conti: Hormonal analysis serum testosteron S F S H S L H To rule out : Hypogonadotrophic Hypogonadism Trans rectal U/S to rule out ductel obstruction Conti: : Conti: 3. Testicular biopsy Done to retrieve sperm used in assisted reproductive technique Indicated in Selective causes of azoospermia where the cause is ductel blockage and patient is willing for treatment through ART. Treatment for Male Infertility: : Treatment for Male Infertility: At least one-half of male problems can be treated. Treatment in collaboration with urologists and endocrinologist is essential. Treatment options are: Drug Therapy Surgery IUI ART Slide 16: Drug Therapy includes medication to improve sperm production to treat hormonal dysfunction and cure infections. Drugs used are: Testosterone Tamoxifen Clomephene Slide 17: Testosterone is a hormonal preparation available in tablet and injection forms. It can be given for 3 to 6 months. Tamoxifen, Clomephene are anti-estrogen preparations. They trigger pituetary gland to cause release of FSH & LH which stimulate testes for production of testosterone. Hence improves sperm count. Slide 18: Antibiotics like Levofloxacine, Doxycyclene are used to treat infections of urinary tract, infections of prostrate STD’s which impair fertility. Slide 19: Surgery for male infertility is performed to treat reproductive tract obstruction. Vasoepididymostomy is microsurgical procedure which corrects obstructions in semineferous tubules. Varicocoel can be corrected by Embolization technique. Causes in female: : Causes in female: Disorder of ovulation Hypogonadotrophic Hypogonadism Polycystic ovarian disease Hyperprolactenemia Tubal factors Salpeingitis --- due to PID or Genital tract T/B Endometrioses causes peri tubal adhesions. PCO : PCO It is a metabolic and endocrine disorder associated with an ovulation menstrual irregularities hirsuitism and wt gain. Insuline levels are high which cause androgen secretions by ovarian stroma causing hormonal imbalance. Rx is wt reduction with metformin and clomiphene citrate. Cyclical estrogen pregestrone pill for irregular cycle Endometriosis : Endometriosis Occurs when the uterine tissue implants and grows outside of the uterus, affecting the function of the ovaries, uterus and fallopian tubes. Scar tissue can block the fallopian tubes and prevent the egg from entering the uterus. There is a 25-35% rate of infertility in moderate to severe cases of Endometriosis Cervical causes : Cervical causes These include Unfavorable cervical mucus Anti sperm anti body. Cervical stenosis Anti-sperm antibodies : Anti-sperm antibodies Due to some autoimmune phenomenon, anti-sperm antibodies maybe present in cervical mucus which neutralize sperms by clumping them together and destroying their membrane. About 12-15% of unexplained infertility in women is linked to ASA. Disorder of implantation : Disorder of implantation These include Large fibroids distorting uterine cavity Congenital abnormalities in shape of uterus. Leuteal phase insufficiency, due to progestrone deficiency which causes preparation of endometrium for reception of fertilized ovum. Uterine Fibroids and Pelvic Adhesions : Uterine Fibroids and Pelvic Adhesions Fibroids are benign tumors in the wall of the uterus May cause infertility by blocking the fallopian tubes Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery This scar tissue formation may impair fertility. Other causes : Other causes Adrenal dysfunction Hyper and hypo thyroidism Un controlled diabetes Patients with diabetes are more likely to have miscarriages and SB. Sec. infertility may arise due to infections which patient might get due to repeated D & E’s and manipulation during delivery. Slide 28: What Increases the Risks? Age Stress Poor diet Smoking Alcohol STDs Overweight Underweight Caffeine intake Too much exercise Investigations for Female: : Investigations for Female: Tests for Female: Blood C.P – Urine D.R – Blood Sugar Levels Pelvic ultra sound Hysterosalpingogram Pelvic Ultrasound : Pelvic Ultrasound A detailed ultrasound is important diagnostic tool. It reveals uterine abnormalities, uterine masses, ovarian size, presence or absence of follicles, diagnosing PCO. Slide 31: In selective cases FSH LH day 21 serum progesterone, serum prolactin level and thyroid function test if clinically indicated. Slide 32: Laproscopy: It is considered as investigation of choice It has advantage of diagnosing tubal blockage and simultaneously treating the pathology. e.g. ( Breaking adhesions, Opening the lumen of fallopian tube, Removing any T O mass, Small fibroids). Sub-serosal fibroids can be removed if are less than 5cm size. Treatment : Treatment Treatment should be based on documentation of abnormality leading to infertility. The first thing to offer a couple is counseling and reassurance. Because infertility treatment can be physically uncomfortable, time consuming, costly and without guarantee of success. General Measures : General Measures Improve general health Stop cigarette smoking Limiting alcohol consumption Obtaining standard Wt. Both over weight and underweight can cause sub fertility Infections are treated with appropriate antibiotics Treatment for an Ovulation : Treatment for an Ovulation A delicate balance of Estrogen, Progesterone, FSH, LH is needed for timely growth and release of egg from the ovary. Even slight irregularity in these hormones can cause an ovulation. Drugs used for induction of ovulation are: Clomed HMGS Dopamine Agonists Clomid : Clomid Clomid is a synthetic weak estrogen. It competes with endogenous estrogen for estrogen binding sites in the hyprthalamus giving a negative feedback to pitutiary gland which starts producing large amounts of FSH which causes growth and maturity of folical hence ensuring ovulation. HMGS are GlycoProtein Hormones directly stimulates ovary : HMGS are GlycoProtein Hormones directly stimulates ovary These drugs are prepared from urine of menopausal women. The trade name is pergonal and humegon. They are used to produce super ovulation in ART and in certain cases where clomephen citrate fails to produce ovulation. Progesteron support is given from 15 to 25th day. Dopamine Agonists used when cause of an ovulation is hyperprolactenemia : Dopamine Agonists used when cause of an ovulation is hyperprolactenemia Bromocripten is used to treat hyperprolactenemia Tablet palodel and dopergin are used with successful results. Dose Treatment for Antisperm antibodies : Treatment for Antisperm antibodies Anti sperm anti bodies are treated with low dose coticosteroids. Predinsolone 40 – 60 mg is used from day 1 to 10 and than 20 mg for next 2 days. This therapy is given for 6 to 9 months. IUI : IUI In this procedure semen is centrifuged and washed to get healthy and motile sperms and injected with the help of small catheter directly into the uterine cavity on the day of ovulation. Hence cervical factors are bypassed. Success rate is 25 to 30 %. Assisted Reproductive Technologies : Assisted Reproductive Technologies The pioneer of IVF is prof: Ian Craft, a British Gynaecologist. 1st IVF Baby was born in 1978 in UK Prof: IAN CRAFT ART has revolutionized Rx for infertility and enables many couples to have their own biological child. Slide 44: In natural conception, fertilization occurs in ampullary region of F.P tube and then fertilized ovum migrates toward uterine cavity. In IVF technique of assisted reproduction, process of conception instead of occurring in fellopian tube is carried out in laboratory and fertilized ovum is then placed in uterine cavity. What is IVF : What is IVF As the term ‘in vitro fertilization’ or ‘test tube baby’ explains itself, It is the procedure to fertilize eggs with sperm outside the human body IVF involves invasive procedures, more hospital visits and higher costs. It is also associated with certain complications. The most important aspect is counseling of the couple regarding success rates, side effects, complications and cost of different techniques. Who needs IVF? : Who needs IVF? There are different reasons why IVF is recommended which include: blocked or damaged fallopian tubes, abnormal sperm, endometriosis or immunologic problems, failed attempts of artificial insemination or other infertility treatment, advanced maternal age. Procedures of IVF & ET : Procedures of IVF & ET 1. Controlled Superovulation (COH) (Clomiphene, hMG, uFSH, rFSH ) 2. Monitoring (Ultrasound, E2) 3. Egg retrieval & IVF (or ICSI) 4. Embryo culture 5. Embryo Transfer (ET) 6. Luteal phase support (progesterone) 7. Pregnancy test 1.Controlled Ovarian Hyperstimulationwith Exogenous Gonadotropins : 1.Controlled Ovarian Hyperstimulationwith Exogenous Gonadotropins 2. Monitoring: E2, Ultrasound 2. Ultrasound monitoring of follicles : 2. Ultrasound monitoring of follicles 3. Ultrasound Guided Oocyte Retrieval : 3. Ultrasound Guided Oocyte Retrieval 4. Embryo Culture : 4. Embryo Culture 5. Embryo Transfer : 5. Embryo Transfer Intracytoplasmic sperm injection (ICSI) : Intracytoplasmic sperm injection (ICSI) ICSI is a highly technical procedure designed to insert a sperm into the cytoplasm of egg using a thin glass tube under the special microscope with a manipulator. Indications: •Severe male factor infertility •Poor quality eggs with thickened shell (zona) •Prior or repeated fertilization failure with standard IVF •Anti-sperm antibodies •Use of surgically retrieved sperm directly from the epididymis or testis Intracytoplasmic sperm injection (ICSI) : Intracytoplasmic sperm injection (ICSI) Factors affecting IVF results : Factors affecting IVF results • Age !!!!!!!!!!!! • Sperm quality • Responsiveness to ovulation induction • IVF lab quality • Embryo transfer technique Complications of IVF : Complications of IVF Multiple pregnancy Ovarian hyperstimulation syndrome (OHSS) Ovaries may enlarge and cause pain and bloating Higher risk in PCOS women Bleeding or infection Low birth weight Birth defects OHSS is iatrogenic condition occurs in few patients who receive HMG for ovulation induction in ART. Risk is more common in women with PCO : OHSS is iatrogenic condition occurs in few patients who receive HMG for ovulation induction in ART. Risk is more common in women with PCO It is characterized by increase in vascular permeability causing fluid shift from intravascular to extra vascular space leading to reduced circulating volume depletion of albumin manifest by ovarian enlargement ascites hydrothorax. If this condition arises treatment cycle should be canceled. Slide 58: Patient should be monitored. Hypovolaemia corrected with amino acids. Ascites should be drained. Prophylactic heparin should be given. Condition is usually self limiting. Laparotomy is needed in severe cases. Conclusion : Conclusion Infertility should be evaluated after one year of trying without contraception. History and Physical examination usually will help to identify the etiology. If patients fail the initial therapies then the proper referral should be made to a reproductive specialist. Adoption : Adoption Option of adoption is also offered to infertile couples when all the treatments are failed Slide 64: thank you You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.