Fertility Disorder and Infertility Assessment on Female

Silvia W Lestari Medical Biology Department FMUI

INTRODUCTION
Infertility : (Chuang et al, 2007) - Conception (-) - Regular sexual activity (intercourse) - Contraceptioion (-) - 1 year (12 ovulation cycles) Indonesia : 200 million citizen (2010) age 10% infertility cases. Etiology of infertility : (Moeloek, 2001) 40% in fertile

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15% 40% 45%

DEFINITION
Primary Couple has never conceived No conception during first year without contraception Secondary Couple has had at least one prior conception

ETIOLOGY
Peritoneal factors 40%, - Endometriosis. Tubal blockage 20%. Ovulatory dysfunction 15-20% - Hypothalamichypogonadotrophic hypogonadism - Hypothalamic pituitary dysfunction (PCOS) - Ovarian failure Uterine cavity abnormalities - Asherman's syndrome - Uterine fibroids. Cervical hostility 5-10%, - Infection - Female sperm antibodies

HISTORY TAKING (FEMALE)

Symptoms (past or present) - P I D / STD,
- dysparenuria - galactorrhoea, - thyroid symptoms

Obstetric history Menstrual history - irregularities Surgical history - D & C, abdominal/pelvic surgery Contraception
- IUCDs

Cervical smear

EXAMINATION
General health and nutritional status BMI <19 (F) > 29.(M/F) Secondary sex character Hirsuitism, galactorrhoea Bimanual examination - adnexal masses (tubo/ovarian, ovarian cyst) - tenderness (PID/ endometriosis) - uterine fibroids

BIMANUAL EXAMINATION

OVARIAN CYST

PELVIC INFLAMMATORY DISEASE (PID)

Pelvic inflammatory disease (or disorder) (PID) is a term for inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This can lead to infertility. Although an STI is often the cause, many other routes are possible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or intrauterine device (IUD) related, and hematogenous spread. Symptoms in PID range from subclinical (asymptomatic) to severe. If there are symptoms, then fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, or irregular menstrual bleeding may be noted. Laparoscopic identification is helpful in diagnosing tubal disease, 6590% positive predictive value in patients with presumed PID. Treatment is usually started empirically because of the serious complications that may result from delayed treatment

ENDOMETRIOSIS

Endometriosis is a gynecological medical condition in which cells from the lining of the uterus (endometrium) appear and flourish outside the uterine cavity, most commonly on the peritoneum which lines the abdominal cavity. The uterine cavity is lined with endometrial cells, which are under the influence of female hormones. Endometrial-like cells in areas outside the uterus (endometriosis) are influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. Symptoms often worsen with the menstrual cycle. Endometriosis is typically seen during the reproductive years; it has been estimated that endometriosis occurs in roughly 610% of women. Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is pelvic pain in various manifestations. Endometriosis is a common finding in women with infertility.

In principle the various stages show these findings: Stage I (Minimal) Findings restricted to only superficial lesions and possibly a few filmy adhesions Stage II (Mild) In addition, some deep lesions are present in the cul-de-sac Stage III (Moderate) As above, plus presence of endometriomas on the ovary and more adhesions. Stage IV (Severe) As above, plus large endometriomas, extensive adhesions. Endometrioma on the ovary of any significant size (Approx. 2 cm +) must be removed surgically because hormonal treatment alone will not remove the full endometrioma cyst, which can progress to acute pain from the rupturing of the cyst and internal bleeding. Endometrioma is sometimes misdiagnosed as ovarian cysts.

POLYCYSTIC OVARY SYNDROM (PCO)

Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders. PCOS is a complex, heterogeneous disorder of uncertain etiology, but there is strong evidence that it can to a large degree be classified as a genetic disease. PCOS produces symptoms in approximately 5% to 10% of women of reproductive age (1245 years old). It is thought to be one of the leading causes of female subfertility and the most frequent endocrine problem in women of reproductive age. The principal features are anovulation, resulting in irregular menstruation, amenorrhea, ovulation-related infertility, and polycystic ovaries; excessive amounts or effects of androgenic hormones, resulting in acne and hirsutism; and insulin resistance, often associated with obesity, Type 2 diabetes, and high cholesterol levels. The symptoms and severity of the syndrome vary greatly among affected women.

The World Health Organization criteria for classification of anovulation include the determination of oligomenorrea (menstrual cycle >35 days) or amenorrea (menstrual cycle > 6 months) in combination with concentration of prolactin, follicle stimulating hormone (FSH) and estradiol (E2). The patients are classified as -WHO1 (15%) - hypo-gonadotropic, hypo-estrogenic, -WHO2 (80%) - normo-gonadotropic, normo-estrogenic -WHO3 (5%) - hypper-gonadotropic, hypo-estrogenic. The vast majority of anovulation patients belong to the WHO2 group and demonstrate very heterogeneous symptoms ranging from anovulation, obesity, biochemical or clinical hyperandrogenism and insulin resistance. The patients of PCOS form a large subgroup of the WHO2 group.

Some common symptoms of PCOS include: Menstrual disorders: PCOS mostly produces oligomenorrhea (few menstrual periods) or amenorrhea (no menstrual periods), but other types of menstrual disorders may also occur. Infertility: This generally results directly from chronic anovulation (lack of ovulation). Hyperandrogenism: The most common signs are acne and hirsutism (male pattern of hair growth), but it may produce hypermenorrhea (very frequent menstrual periods) or other symptoms.[12][7] Approximately three-quarters of patients with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia. Metabolic syndrome:[11] This appears as a tendency towards central obesity and other symptoms associated with insulin resistance.[7] Serum insulin, insulin resistance and homocysteine levels are higher in women with PCOS.

UTERINE FIBROID

INVESTIGATIONS
Primary care Secondary care

Assess ovulation. Other hormonal tests Tests for PID

Tubal patency Uterine abnormality

ASSESSING OVULATION
Do if regular cycles with > 1 year of infertility irregular cycles 1) Serum progesterone (mid luteal phase ie day 21 of 28 week cycle) -Regular cycles - 7 days before next MP -Irregular cycles - day 28/35 wk then weekly till menstruation occurs 2) LH/FSH levels High levels poor ovarian function High LH compared to FSH -PCOS

3) E2, Testosterone levels PCOS 4) Prolactin ONLY if - ovulation problems - galactorrhoea, - pituitary problem. 5) Thyroid tests - only with symptoms/ signs 6) Other androgen profile (DHEAS, Androstenedione, SBHG) as per etiology

ASSESSING OVULATION

TESTS FOR PID

HVS Chlamydia screening

CERVICAL HOSTILITY
Post coital test - no longer recommended Mucus invasion test - doubtful significance

POST COITAL TEST

Sample of cervical mucus on the vagina, endocervix and exocervix, taken between 9-24 hours postcoitus. Progressive concentration and motility of spermatozoa is observed. It is considered normal in the presence of progressive motile sperm in the endocervix.

CERVICAL MUCUS TEST

The womans cervix usually produces a barrier of tick mucus that prevents the invasion of bacteria and other organisms from entering the uterus. As you all know, the mucus becomes thinner and more elastic to enable sperm to move freely into the uterus during the time of ovulation. Then, your doctor can determine the quality and consistency of the cervical mucus by taking a sample at the time of suspected ovulation.

TESTS FOR UTERINE/TUBAL PROBLEMS

HSG/hystero salpingo-contrast USG

Laparoscopy + dye test Done only when ovulation tests/Sperm tests normal.Choice of tests depends upon co morbidities

MANAGEMENT IN PRIMARY CARE

Lifestyle changes - Weight reduction, BMI 19-29 - Smoking cessation- offer support groups - Alcohol reduction <1-2 units/week for women <3-4 units/week for men - S I every 2-3 days - Information about OTC/ recreational drugs Pre conceptual advice - Folic acid supplementation - Rubella status - Cervical screening

MANAGEMENT IN SECONDARY CARE

Depends upon the etiology.. Ovarian dysfunction : - antiestrogen ( ) - metformin - laparoscopic ovarian drilling Peritoneal problems : - laparoscopic surgical resection - if ovarian endometriomas laparoscopic cystetomy

LAPAROSCOPIC

MANAGEMENT IN SECONDARY CARE

Tubal factors:
- Laparoscopic tubal surgery/ tubal microsurgery - Salpingography + tubal catheteristion - Hysteroscopic tubal cannulation

Uterine factors : - hysteroscopic adhesiolysis

- myomectomy

IUI IVF-ICSI

IUI

Sperm is washed and collected into vagyna, cervical canal or in the uterus. Sperm could be from spouse or anonymous donor.

IVF
is a process by which egg cells are fertilized by sperm outside the body, in vitro. The process involves hormonally controlling the ovulatory process, removing ova (eggs) from the woman's ovaries and letting sperm fertilise them in a fluid medium. The fertilized egg (zygote) is then transferred to the patient's uterus with the intent to establish a successful pregnancy.

Have a nice study