DEFINITION OF INFERTILITY

THE INVOLUNTARY FAILURE TO CONCEIVE WITHIN EIGHTEEN MONTHES OF COMMENCING UNPROTECTED INTERCOURSE

TYPES OF SUBFERTILITY
PRIMARY SUBFERTILITY:NO PREVIOUS PREGNANCY
SECONDARY SUBFERTILITY:PREVIOUS PREGNANCY

THE EPIDEMIOLOGY OF INFERTILITY

FERTILITY RATES:IN THE VERY FIRST MONTH OF EXPOSURE THE OBSERVED CONCEPTION RATES ARE ONLY 30-33% AND THESE ARE THE HIGHEST RATES THE FREQUENCY OF INTERCOURSE PLAY VERY IMPORTANT ROLE IN DETERMINING THE RATE OF FERTILITY .

The highest conception rates reported in normal couples of ultimately proven fertilty
100 90 80 70 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 percent couples

INTERCOURSE EVERYDAY GIVES A FIVE TIMES HIGHER CHANCE OF CONCEIVING THAN INTERCOURSE ONCE A WEEK

FREQUENCY OF SEX AND CHANCE OF PREGNANCY

70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 barrea & marshall schwartz

INFERTILITY IN THE POPULATION

INCIDENCE: ONE IN SIX DISTRIBUTION OF CAUSES 1. OVULATORY FAILURE 21% 2. TUBAL DAMAGE 14% . 3. ENDOMETRIOSIS 6% . 4.MUCUS DYSFUCTION 3% . 5.SPERM DYSFUNCTION 24% . 6.COITAL FAILURE 6% . 7.UNEXPLAINED INFERTILITY 28% . 8.OTHERS 11% .

HOW TO MANAGE A CASE OF INFERTILITY ?

HISTORY:NAME,AGE,DURATION OF MARRIAGE,PRIMARY OR SECONDARY INFERTILITY. PAST HISTORY:CONCEPTION,I U C D, AND OTHER PREGNANCIES. MEDICAL PROBLEMS,SURGICAL PROBLEMS,GYN.PROBLEMS, VENEREAL DISEASES.

PRESENT HEALTH
SPECIFIC ILLNESSOR OTHER COMPLAINT ,DRUGS WT. STEADY/ VARIABLE &PRES. WT APPETITE, H/O DIETING,SMOKING BOWELS,MICTURATION,SLEEP,ALCOHOL HOT FLUSHES,GALACTORRHOEA, HIRSUTISM &TEMP.INTOLERANCE.

MENSTRUAL HISTORY
MENARCHE,PRESENT CYCLE/LMP.
PREVIOUS CYCLE ABNORMAL? PV.LOSS {SCANTY,NORMAL,HEAVY} PAIN? PRE,INTRA ANDPOST MENST.

COITAL HISTORY
PCB,MUCUS RECOGNITION,PV DISCHARES
COITAL FREQENCY,TIMING IN CYCLE COITAL DIFFICULTIES AND PAIN

WIFE PHYSICAL EXAMINATION

GENERAL FEATURES/BUILD ,B/P
THYROID,HAIR DISTRIBUTION BREAST,ABDOMEN VULVA,VAGINA,CERVIX,UTERUS

SWELLING AND TENDERNESS

HISTORY&PHY FOR HUSBAND

AGE,DURATION OF MARRIAGE,H/O P.MARRAIGE PRIMARY OR SECONDARY INFERTILITY AGE OF PUBERTY,H/O MUMPS SURGICAL ORCHIDUPEXY,HERNIA H/O VENEREAL DISEASE SMOKING,ALCOHOL AND DRUGS. ERECTION,PENETRATION,EJACULATION PHYSICAL EXAM. USUALLY CARRIED OUT BY UOROLOGIST.

INVESTIGATION OUTLINE
1- IF DURATION OF INFERTILITY LESS THAN 1 YEAR AND H/P WERE [-VE] REASURE 2- IF INFERTILITY LESS THAN 1 YEAR BUT H/P WERE [+VE] OR FEMALE AGE MORE THAN 30 YEARS OR INFERTILITY MORE THAN 1 YEAR , THEN ASK FOR HSG,SEMEN ANALYSIS AND SER.PROG. AT D.21 OF M.CYCLE

45 40 35 30 25 20 15 10 5 0 1 4 7 10 13 16 19 22 25 28 progesterone level

PROGESTERONE LEVELS IN TYPICAL CYCLE

PLASMA PROGESTERONE LEVELS MAY BE BELOW OVULATORY VALUES [APPROX 30 NMOL/L] IF BLOOD IS TAKEN OUTSIDE THE LUTEAL PHASE.
CONSEQUENTLY THE BLOOD SAMPLING MUST BE ACCURATELY TIMED DURING THE MENSTRUAL CYCLE.

3-IF SHE IS NOT OVULATING WITH H/O AMENORRHEA OR GALACTO. THEN ASK FOR PROLACTIN,FSH,LH,ANDROGENS AND E2. IF PROLACTIN RAISED PREGNANCY HAS TO BE R/O PREGNANCY VE WITH RAISED PROL THEN ASK FOR SKULL X-RAY,TSH LEVEL &EXCLUDE PCO.

4-IF ABNORMAL HSG GO FOR HYSTROSCOPY&LAPAROSCOPY THEN PROCEED ACCORDING 5-IF ABNORMAL SEMEN ANALYSIS THEN REPEAT 2-3 TIMES AT 3- 6 WEEKS INTERVALS IF SEMEN ANALYSIS AGAIN NORMAL AND PREG VE THEN ASSESS SPERM FUNCTION [PCT,SMI]

SPERM FUNCTION ASSESSMENT

1-NO. OF SPERM MORE THAN 50,000 IN SWIM UP THEN GO FOR [IUI,IVF,GIFT] 2-IF NO.OF SPERM LESS THAN 50,000 THEN GO FOR SPERM OOCYTE INJECTION

HORMONAL RESULTS PLAN

1-IF PROLACTIN LEVEL IS NORMAL THEN GIVE PROGESTERONE TO CAUSE WITHDRAWAL BLEEDING. 2-IF THERE IS WITHDRAWAL BLEEDING THEN ASK FOR T.V SCAN TO EXCLUDE PCO , IF ITS PCO THEN TREAT. 3-IF NO WITHDRAWAL BLEEDING THEN ASK FOR LH&FSH. 4-IF LH&FSH NORMAL THEN TREAT WITH CLOMIPHINE OR GONADOTROPHINE.

5-IF LH&FSH RAISED THINK ABOUT MENOPAUSE OR PREMATURE OVARIAN FAILURE. 6-IF LH&FSH LOW THINK ABOUT HYPOTHALAMIC CAUSE [KALMAN] , ASK FOR KARYOTYPE.

7- IF AN OVULATION ASSOCIATED WITH HIRSUTISM THINK ABOUT PCO ASK FOR T.V SCAN,LH&FSH,ANDROGENS , IF PCO TREAT.

SEMEN ANALYSIS (World Health

Organization reference values) Volume: 2-5mL

Liquification time: within 30 minutes Sperm concentration: 20 million/mL Sperm motility: >50% progressive motility Sperm morphology: >30% normal forms White blood cells: <1 million/mL

SEMEN ANALYSIS PLAN

1-IF SEMEN ANALYSIS AFTER THE 3RD TIME IS ABNORMAL ASK FOR FSH,LH&ANDROGENS 2-IF LH,FSH&ANDROGENS ARE LOW YOU HAVE TO EXCLUDE HYPOTHALAMICPITUTARY CAUSE 3-IF LH,FSH&ANDROGENS ARE NORMAL WITH AZOOSPERMIA THEN THINK ABOUT OBSTRUCTION 4-PUS CELLS C/S TREAT WITH ANTIBIOTICS

5-IF SPERM ANTIBODIES TREAT WITH STEROID 6-IF ALL MEASURES [ANTIBIOTICS,STEROIDS&VARI COCELE REPAIR] NOT HELPFUL THEN GO FOR IUI,GIFT,IVF.

CUMULATIVE CONCEPTION RATES INDIFFERENT TYPES OF INFERTILITY TREATED AS APPROPRIATE

1-WOMEN WITH AMENORRHOEA DO SO WELL LIKE THE NORMAL GROUP . 2-WOMEN WITH OLIGOMENORRHEA ON OTHER HAND DO NOT DO SO WELL ,BECAUSE OF THEIR DISORDER ARE MORE SUBTLE[PCO] 3-WOMEN WITH MODERATE OR SEVERE TUBAL DAMAGE DO VERY BADLY BECAUSE EVEN THE BEST SURGERY AVAILABLE CAN NOT DEAL WITH IRREVERSIBLE ENDOTUBAL DISEASE. THE ONLY REAL HOPE IS IVF

100 90 80 70 60 50 40 30

normal
20 10 0 1 3 5 7 9 11 13 15 17 19 21 23

amenorrhea

100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 normal oligo

100 90 80 70 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 normal unexplained

100 90 80 70 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 normal tubal damage

100 90 80 70 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 normal oligosperm

100 90 80 70 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 normal s.m.p.f

4-THE GROUP OF OLIGOSPERMIA WHO ARE DEFINED NOT ONLY BY LOW SPERM COUNTS BUT BY FAILURE OF MUCUS PENETRATION HAD POOR PROGNOSIS. 5-THE MEN WITH COMPLETELY NORMAL SEMINAL ANALYSIS BUT FAILURE OF MUCUS PENETRATION HAD ALSO POOR PROGNOSIS.

UNEXPLAINED INFERTILITY
AFTER MORE THAN 3 YEARS UNEXPLAINED INFERTILITY THE CHANCE OF NATURAL COCEPTION FAILS TO UNHELPFUL LEVEL [1-2% EACH MONTH] AND TREATMENT IS NEEDED. TRIAL OF CLOMID , RATE CYCLE PREGNANCY 3-5% .BUT GONADOTROPIN OR IUI GIVE 10% .

70 60 50 40 unex 1-3 y 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 unex more than 3y

ENDOMETRIOSIS TREATMENT
1-TREATMENT FOR MINOR ENDOMEMETRIOSIS SHOW THAT THERE IS NO EFFECTIVE METHOD TO IMPROVE THE CHANCE OF NATURAL CONCEPTION
2- CONTROLLED TRILS OF PROGESTOGENS OR DONAZOL HAVE SHOWS NO BENEFIT ON THE CONTRARY, THE CHANCE OF PREGNANCY IS DELAYED BY THE DURATION OF TREATMENT

3- UNCONTROLLED REPORTS OF PITUITARY DESENSITAZATION TREATMENT OR LAPAROSCOPIC LASER ABLATION THERAPY HAVE NOT IMPROVED AN OBSERVED PREGNANCY RATE WITHOUT TREATMENT

100 90 80 70 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 normal minor endo

100 90 80 70 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 normal moderate endo

100 90 80 70 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 normal severe endo