Infertility


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Vinay    on Aug 03, 2012 Says :

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1 : Infertility Dr. B.Surakshith
2 : Facts Older civilizations blamed women Greeks first to demonstrate male infertility Women feel more burdened ?+?= Fertility state
3 : Definitions Infertility – 1 year of unprotected intercourse without pregnancy Important terms Secondary infertility Fecundability – pregnancy Fecundity – live birth
4 : Workup ! Workup ! Workup ! Both couples should be assessed together first visit Complete medical/surgical/gynecologic history Menstrual cycle/pelvic pain/PID/pelvic surgery/medications Pituitary/thyroid evaluation Developmental defects/infections/trauma/ Occupation/coital frequency/family history
5 : Male Infertility Pretesticular Hypogonadropic hypogonadism Coital disorders Erectile dysfunction/vascular/drugs Post testicular obstructive- congenital/infective Testicular Genetic- Klinefelter’s/Y chromosome deletion,etc. Congenetal- cryptorchidism Infective Drugs- antidepressants,etc. Idiopathic
6 : Male Infertility Important Terminology Oligozoospermia Asthenozoospermia Teratozoospermia Azoospermia
7 : Male Infertility WHO (Normal Values) Volume > 2ml Number of spermatozoa >20 million/mL Sperm Motility > 50% forward progression Morphology >15% normal
8 : Male Infertility Treatment Pre testicular Azoospermia – GnRH or hCG Testiculat Azoospermia – surgical retrival of sperm from testes+ ICSI Post testicular Azoospermia – Surgical retrival of sperm from epididymis + ICSI (or) Vasoepididymostomy (microsurgery) Donor Insemination
9 : Female Infertility Decreased ovarian reserves Ovulatory Disorders Tubal Factors Uterine Factors Underlying Systemic Diseases Cervical factors Unexplained Factors (endometriosis)
10 : Decreased Ovarian Reserves Age strongest determinant of success of fertility Fertility rates drop after 30 years Assesment : Serum Inhibin B levels/CCCT/TVS/day 3 FSH Treatment COH Oocyte donation program
11 : Ovulation Signs of ovulation LH monitoring (LH Surge) 40mIU/mL BBT(Progesterone) .58 F Mid luteal serum progesterone 3ng/mL USG monitoring-fluid cul-d-sac
12 : Poly Cystic Ovarian Syndrome Anovulation Polycystic ovaries Hirsutism Hyperandrogenism
13 : PCOS treatment Weight Loss Metformin 500mg(hyperinsulinemia) Gonadotropin therapy Surgical
14 : Other Anovulation Causes Hyperprolactinemia Assess prolactin levels Treatment – bromocriptine (or/and) cabergoline Hypogonadotropic Hypogonadism Assess LH/FSH/Estrogen levels Treatment-pulsatile GnRH Hypothyroidism Assess T3/T4/TSH levels Treatment- thyroxin supplement
15 : Anovulation
16 : Tubal Factors Damage or obstruction of fallopian tubes Assessment HSG Sonohysterography Falloposcopy Laparoscopy Treatment Proximal tube – salphingography/hysteroscopic tubal cannulation Distal tube – fimbrioplasty/salphingostomy Bypass - IUI
17 : Uterine Factors Malformations of the uterus Assessment USG/Sonohysterography(90%) Hysteroscopy Treatment Congenital anomolies(septate,didelphic,unicornuate) Hysteroscopic septoplasty Metroplasty unproven Leiomyomas(fibroid) Myomectomy Endometrial polyp Polypectomy Ahserman’s Syndrome(Intra uterine adhesions) Hysteroscopic resection of adhesions
18 : Cervical factors To a much lesser extent Assesment PCT - cervical mucous/no. of mot sperm/ASA Treatment Antisperm antibody –IgG, M, A – Corticosteroids in men ? Bypass - IUI
19 : Unexplained Infertility Part 1 :Endometriosis Normal HSG/Normal FSH/LH/Normal Thyroid/pituitary Assesment Diagnostic laparoscopy(endometiosis) Treatment – harmonal suppression Combined OCPs GnRH agonists Danazol Laparoscopic Ablation/resection After clearance COH+IUI
20 : Unexplained Infertility Part 2 : no endometriosis Normal HSG/Normal FSH/LH/Normal Thyroid/pituitary Empirical Management 2 Superovulation- Clomiphone Citrate/letrozole Gonadotropins hMG/FSH/LH hCG 10,000 IU when follicle 18-20 mm(stop premature surge) Sperm washing IUI Monitoring TVS Serum estradiol – detect OHSS
21 : Types of ART Involve interventions to retrieve oocytes IVF ICSI Lesser used GIFT ZIFT
22 : ART Steps COH (with CC or Gonadotropins) Prevention of premature LH Surge(using Gnrh-agonists) Oocyte maturation(using hCG 10,000 IU) TV US guided oocyte retrieval (35 hrs after hCG) Fertilization with IVF/ICSI (100,000 washed sperm+ 1 retrieved oocyte in culture for 20hrs) (micromanipulation of stabilized egg + sperm under magnification) Luteal support (with progesterone) Transfer of embryo (after 5 days ,embryo transfer into uterine cavity with Tefcat catheter) First trimester monitoring(hCG monitoring , TVS)
23 : Thank You “Don’t wait.The time will never be just right” – Napoleon Hill

 

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