Infertility Problem

Gunawan Dwi Prayitno

Introduction
Definition :
Infertility is Failure to conceive after
regular unprotected sexual intercourse for
2 years in the absence of known
reproductive pathology

Infertility Causes
In RSPAD-Gatot Soebroto Jakarta
FAKTOR PENYEBAB INFERTILITAS

FAKTOR ISTRI

49

51

FAKTOR SUAMI

Female Factor
Di RSPAD Gatot Soebroto

PENYEBAB FAKTOR ISTRI

TUBA

OVARIUM

10
11
46

15
15
3

UTERUS &
SERVIKS
HORMONAL
ENDOMETRIO
SIS
IMUNOL/INFE
KSI

Requisite for Succesful

pregnancy

Oosit : ovulation ?
Sperm : Concentration, motility,
morphology
Sperm & oosit transport, fertilization,
and implantation. : Psychology,
organic, and immunologic compatible.

Menstrual Cycle
Eumenorrhea

25 31 days

Polymenorrhea

: < 25 days

Oligomenorrhea

: > 31 days

Amenorrhea

> 3 months

Method for ovulation detection

Not rutine
O,2-0,5 oC

Which
Investigations?!

Diagnostic tests for infertility are

categorized into 3 categories.
ESHRE Capri workshop 2000
1-Testes which have an established correlation with
pregnancy.
2- Testes which are not consistently correlated with
pregnancy.
3-Testes which seem not to correlate with pregnancy.

Tabel 1.1 Hierarchy of evidence

Level Evidence
1a
Systematic review and meta-analysis of randomised
controlled trials
1b
At least one randomised controlled
study without
randomisation
2a
At least one well-designed controlled
study without
randomisation
2b
At least one other type of well-designed quasi- experimental
study
3
Well-designed non-experimental descriptive studies,
such
as comparative studies, correlation studies or
case studies
4
Expert committee report or opinions and/ or clinical
experienceof respected authoritis

Tabel 1.2 Stength of evidence corresponding to

each level of recommendation
Grade
A
B

C
D

Strenght of evidence
Directly based on level 1
evidence
Directly based on level 2
evidence or extrapolated
recommendation from level 1
evidence
Directly based on level 3 evidence or extrapolated
recommendation from either level 1 or 2 evidence
Directly based on level 4 evidence or extrapolated
recommendation from either level 1, 2 or 3 evidence
The view of the Guideline Development Group

Good practice
Poin (GPP)
NICE Technology Recommendation taken from a NICE Technology Appraisal
Appraisal

The First Category

The Basic Routine Infertility Investigation

Tests which have an established correlation

with pregnancy are:

1- Semen analysis
2-Tubal patency by HSG or laparoscopy
3-Mid luteal progesterone for the diagnosis of
ovulation

RCOG Guidelines : Grade B Recommendation 1999

ESHRE Capri workshop 2000

National Guideline Clearinghouse 2000

The Second Category

Testes which are not consistently correlated with
pregnancy as.

Zona-free hamster egg penetration tests.

Post coital test.

Antisperm antibodies assays.

RCOG Guidelines : Grade B Recommendation 1999

ESHRE Capri workshop 2000

The Third Category

Includes tests which seem not to correlate

with pregnancy as:
Endometrial dating.
Varicocele assessment.
Chlamydial testing.

May have a role in special situations

ESHRE Capri workshop 2000

Hysteroscopy & U/S

Hysteroscopy.
U/S scan of the endomerium.
Are not recommended in the routine.
Investigation of the infertile couple.

RCOG Guidelines : Grade C Recommendation

T3, T4, TSH & PL??

There is no value in measuring thyroid
function or prolactin in women with a
regular menstrual cycle, in the absence
of galactorrhoea or symptoms of thyroid
disease.

RCOG Guidelines : Grade B Recommendation 2001

Day 3 (FSH) And Estradiol

D3 (FSH) and (E2)estradiol for
patients >35 years.
because of their reduced
window of fertility potential.

Bloomington: Institute for Clinical Systems Improvement (ICSI);

2000 The National Guideline Clearinghouse .Modified 2002

Semen Analysis
Serial semen samples (at least two) should be
assessed in the same laboratory
The lower limit of the normal semen testing is
> 20 million/mL.
>50% progressive motility
>30% normal forms
WHO,1999

Semen Analysis
In a RCT, the determination of motility characteristics
as obtained by computer-assisted sperm analysis
(CASA ) systems is of limited value . (Krause ,1995 ).

CASA is not superior to

conventional semen analysis.
RCT= Randomized control trial

Azoospermia:Testicular biopsy
Testicular biopsy should be
performed only in the context of
a tertiary service where there
are facilities for sperm recovery
and cryostorage

RCOG Guidelines :Grade C Recommendation

General Advice
Weight loss if BMI > 30,
Women should give up smoking (B).
Men should give up smoking (C)
Regular intercourse throughout the
cycle,rather than the use of temperature
charts and LH detection (C)
RCOG Guidelines

Azoospermia:Testicular biopsy
Testicular biopsy should be
performed only in the context of
a tertiary service where there
are facilities for sperm recovery
and cryostorage

RCOG Guidelines :Grade C Recommendation

Treatment
&

Male Subfertility

Oligo/asthenospermia
Gonadotrophin is effective for
treatment for male
hypogonadotrophic hypogonadism.
However, drug treatments are
ineffective in the treatment of
idiopathic male infertility.

RCOG Guidelines : Grade B Recommendation

Male Subfertility
Oligo/asthenospermia
IUI offers couples with male subfertility benefit
over timed intercourse, both in natural cycles
and in cycles with COH.
Mild ovarian hyperstimulation with
gonadotrophins is advised in cases with less
severe semen defects (motile sperm
concentration > 10 million).
Cohlen et al., January 1999 (Cochrane Review). In: The
Cochrane Library, Issue 2 2002. Oxford: Update Software.

Male Subfertility
Oligo/asthenospermia
Intrauterine insemination with or without ovarian
stimulation is an effective treatment where the
man has abnormalities of semen quality, but it
has to be remembered that the pregnancy
rates even after treatment remain very low (A)

Cohlen et al., January 1999 (Cochrane Review). In: The Cochrane Library,
Issue 2 2002. Oxford: Update Software.

Varicocele
Varicocele treatment should be offered
when all of the following are present:
1.
A varicocele is palpable.
2.
The couple has documented infertility.
3.
The female has normal fertility or potentially
correctable infertility.
4.
The male partner has one or more abnormal
semen parameters .
Baltimore (MD): American Urological Association, Inc.; 2001 Apr. 9 p. [15 :National
Guideline Clearinghouse modified 2002

Obstructive Azoospermia
Vasectomy reversal and surgical
correction of epididymal blockage
(microsurgical)can be considered in
cases of obstructive azoospermia .
It needs Expert hands.

RCOG Guidelines : Grade B Recommendation

ICSI
Intracytoplasmic sperm injection (ICSI) is
indicated in
Severe deficits in semen quality
Obstructive azoospermia .
Non-obstructive azoospermia .
Previous IVF cycle with failed or
very poor fertilisation.
RCOG Guidelines : Grade A Recommendation

Ovulation Disorders
Clomiphene C. is an effective treatment
for anovulation in appropriately
selected women.(A)
(Mild to moderate WHO type 1
T type 2 dysfunction)

Up to 12 cycles of treatment should be

considered (B).
RCOG Guidelines

Ovulation Disorders
FSH and hMG are both effective
for ovulation induction in women
with clomiphene resistant
polycystic ovarian syndrome.

RCOG Guidelines : Grade A Recommendation

Ovulation Disorders
There is no advantage in routinely
using GRh analogues in
conjunction with gonadotrophins
for ovulation induction in women
with clomiphene-resistant PCOS

RCOG Guidelines : Grade A Recommendation

Hyperprolactinaemia
Dopamine agonists are
effective treatment for
women with anovulation due
to hyperprolactinaemia

RCOG Guidelines : Grade A Recommendation

PCO:Laparoscopic Drilling"

Laparoscopic ovarian drilling

with either diathermy or laser is
an effective treatment for
anovulation in women with
clomiphene-resistant PCOS
RCOG Guidelines : Grade A

PCO:Laparoscopic
Drilling"
There is insufficient evidence of a difference
in pregnancy rates between :
Laparoscopic ovarian drilling after 6-12 m follow
up & Gonadotrophins 3-6 cycles .
Multiple pregnancy are considerably reduced
after laparoscopic drilling.
.

Farquhar et al., August 2001 (Cochrane Review). In: The Cochrane

Library, Issue 2 2002. Oxford: Update Software.

Endometriosis :Minimal
&Mild
Surgical ablation of minimal
And mild endometriosis improves fertility
in subfertile women

RCOG Guidelines : Grade A Recommendation

Endometriosis : Mild
. Also , ovarian stimulation with
IUI is more effective for them
than either no treatment or IUI
alone.

RCOG Guidelines : Grade A Recommendation

Endometriosis :
Moderate to Severe

Endometriosis :Moderate to Severe

Surgical treatment may improve

fertility but controlled studies and
comparisons with assisted
reproduction techniques are
required (B).
RCOG Guidelines : Grade B Recommendation

Endometriosis-associated infertility
Hormonal therapy for ovulation
suppression cannot be recommended as
a standard therapy for endometriosisassociated infertility.
So drug treatments dont improve conception rate.
Hughes

et al., 1996 (Cochrane Review). In: The Cochrane Library,

Issue 2 2002. Oxford: Update Software.

RCOG Guidelines : Grade A Recommendation

Microsurgical Tubal
Surgery
Microsurgical tubal surgery may be
appropriate for :
Mild distal tubal disease ( Laparoscopy).
Proximal tubal obstruction, or
Reanastomosis to reverse sterilization .
If pregnancy has not occurred within 12 m of
surgery, IVF should be discussed.
RCOG Guidelines : Grade B Recommendation

Microsurgical Tubal
Surgery

Mild distal tubal disease

Micro scissor
Cutting fimbrial
band

Dissection of
fimbriae
adherent to the
uterus

Cutting fimbrioomental band

Tubal Catheterization
Where proximal tubal
obstruction is suspected, and
there are no other tubal
abnormalities, a tubal
catheterisation procedure may
be attempted
RCOG Guidelines : Grade B Recommendation

Tubal Catheterization
R. Ovary
Bilateral Cornual Block

R. fimbria

Cornual catheterization

Moderate to Severe Distal tubal Disease

. IVF should be considered

as the first line treatment
for moderate to severe
distal tubal disease

RCOG Guidelines : Grade B Recommendation

Hydrosalpinges & IVF,

Laparoscopic
salpingectomy should be
considered for all women
with hydrosalpinges
prior to IVF treatment

Johnson et al., March 2002(Cochrane Review). In: The Cochrane

Library, Issue 2 2002. Oxford: Update Software.

Unexplained Infertility
Expectant management (no
treatment) for up to three
years of trying should be
considered, taking into
consideration the woman's
age.
RCOG Guidelines : GradeC Recommendation

Unexplained Infertility
The effective treatment for
unexplained infertility is
ovarian stimulation in
conjunction with IUI . If failed
IVF is recommended.
RCOG Guidelines : Grade A Recommendation

TERIMA KASIH