INFERTILITY

Presentation prepared by

Dr. Rashida Shahid

Post Graduate Trainee Gynaecoloy & Obstetrics Department. Allied Hospital, Faisalabad.

DEFINITION
Failure to conceive after regular unprotected intercourse for one to two years in the absence of known reproductive pathology

TYPES
PRIMARY INFERTILITY No previous pregnancies have occurred SECONDARY INFERTILITY A prior pregnancy has occurred

DIAGNOSTIC CLASSIFICATION
Primary
Male factor Disorders of ovulation Tubal factor Endometriosis Un explained 25 % 20 % 15 % 10 % 30 %

Secondary
20 % 15 % 40 % 5% 20 %

FERTILITY STATISTICS
 Per cycle  3 months  6 months  9 months  12 months  2 years
20 % 42 % 75 % 88 % 98 % 92 %

FERTILITY DECREASES WITH AGE AND MORE SO AFTER 35 YEARS.

INFERTILITY PREVALANCE
Life time . 6.6% - 32.6% PAKISTAN UK ... 10 - 15% Conceive without treatment . 8 % Other . 8 % Primary infertility .. 50 % Secondary infertility .. 50 %

EVALUAION OF INFERTILITY
 Detailed history and examination of couple  Exclusion of obvious medical disorders  Explanation about normal pattern of conception  Advice about life style measures

INITIAL ADVICE
 Natural conception  Frequency and Timing of sexual intercourse  Alcohol consumption  Smoking  Caffeinated beverages  Tight underwear for men  Body weight  Occupation  Prescribed, over-the-counter and recreational drug use  Folic acid supplementation  Susceptibility to rubella  Cervical cancer screening

WHEN TO INVESTIGATE
In the absence of known reproductive pathology, couples who have been trying for 1 to 2 years, should be investigated

ASSESSMENT AND REFERRAL

FIRST CONSULTATION CAN BE IN PRIMARY CARE AND DOES NOT NECESSARILY REQUIRE REFERRAL TO A SPECIALIST CLINIC Referral depends upon  Age of the female partner (>35 y)  Duration of infertility (>3 y)  History of predisposing factors  Presence of chronic viral infections

HISTORY

GENERAL HISTORY
FEMALE MALE  Age  Same as female  Duration of marriage  1st or 2nd marriage

FERTILITY HISTORY
Female  Duration of infertility  Nature of infertility / s)  Evidence of previous fertility with past partners  Previous investigations and record  Previous treatment and record  Time to previous conception and outcome Male  Same as female

MENSTRUAL HISTORY
      
Age at menarche LMP Present cycle Previous cycle abnormalities Blood loss (scanty, normal, heavy) IMB, PCB Pain (pre, intra and post menst.)

OBSTETRIC HISTORY
 Number and outcome of previous pregnancies  Ante partum complications  Postpartum complications  H/O Miscarriages

GYNAECOLOGICAL HISTORY
 Contraception history.  History of papsmear

MEDICAL HISTORY
FEMALE
 History suggestive of ovulatory disorders: (excessive exercise, cyclical pelvic pain, hirsutism, galactorrhoea, stress, eating disorders.)  STD (Chlamydia, Syphilis, Gonorrhoea)

MALE
 Epidydmitis  Mumps Orchitidis  Galactorrhoea (spiromide, cimetidine)  STD

MEDICAL HISTORY
FEMALE
 PID (lower abd. pain, vaginal discharge (colour, odour, itching, smell, amount, consistency)  Chronic illness (D.M, Ch HTN, renal disease)  Endocrine Dis. (Hypo, Hyper thyroidism, PCOS)  Endometriosis  H/O Anosmia  Impaired Visual Field

MALE
Infections Bact(TB, Small pox) Respiratory  Systamic illness (D.M., MS) Anosmia Impared Visual Field

SURGICAL HISTORY
FEMALE  Tubal surgery (salpingectomy, salpingostmy)  Ovarian surgery  Pelvic surgery for endometriosis  Previous laparoscopy  Appendectomy MALE  Orchiectomy (CA Testis, Torsion)  Retroperitoneal Surgery  Pelvic Surgery  Inguinal Surgery  Scrotal Surgery  Herniorrhaphy  TURP

DRUG HISTORY
FEMALE  Antihistamines (dec mucus production, dec vaginal lubrication)  NSAIDS (LUFs)  Barbiturates (Dec GnRH release MALE  Gonadotoxins (Chemotherapy, Cimetidine, Sulphasalazine, Nitrofurantoin, Alcohol, Androgenic steroids, Spiromide.)  Chemicals (Pesticide, Tobacco, Recreational drugs, smoking)

OCCUPATIONAL HISTORY
FEMALE  Radiation Exposure (POF) MALE  Toxin exposure  Thermal Exposure  Radiation Exposure

SEXUAL HISTORY
FEMALE  Timing (Fertile period)  Frequency  Dysparunia  PCB MALE  Timing  Frequency  Potency  Lubrication  Orgasm  Masturbation

DEVELOPMENTAL HISTORY
FEMALE  Age @ menarchae  Onset of puberty MALE  Onset of puberty  Undescended testis  Testicular torsion  Testicular trauma

EXAMINATION

GENERAL EXAMINATION
 Height  Weight  BMI  BP  Eyes (Exophthalmos, BTH, Retinopathy)  Eunuchoid proportion, klinefelter)  Height  Weight  BMI  BP (Orthostatic hypotension)

GENERAL EXAMINATION
 Nose (Anosmia)  Neck (L.N, Thyroid)  Breast (Galactorrhea)  Eyes (Exophthalmos, BTH, Retinopathy)  Neck (L.N, Thyroid)  Lungs (wheeze, rhonchi, rales) kartegner synd, CF, youngs synd  Breast (gynaecomestia) alkohlism, klinefelter synd, inc eastrogen, spiromide, reifenstein synd

ABD EXAMINATION
FEMALE  Shape  Contour  Symmetry  Scar  Striae  Prominent veins  Masses  Organomegally (alcoholism, inc liver size)  Groin inguinal hernia) MALE  Groin (inguinal hernia)  Organomegally (alcoholism ,inc liver size)  Prior cyptorchidism

PELVIC EXAMINATION
INSPECTION  Vagina for septa, infection, HVS

 CX (ectopy, polyp, accessibility for insemination, scarring after cryotherapy, LEEP, cone biopsy
BIMANNUAL EXAM

 UT size, shape, position, mobility, adenaxal masses and tenderness

GENITALIA EXAMINATION
FEMALE MALE  Size & shape of vulva  Presence, location & &vagina vol. of testis  Labia majora &  Penis for hypospadias, minora (POF) epidydmitis  Clitoris (Excess  Vasadefferentia Androgen )  Vericocele

INVESTIGATION OF FERTILITY PROBLEMS AND MANAGEMENT STRATEGIES

INITIAL INVESTIGATIONS (Female)

 CBC  Urinalysis  Pap smear  Vaginal wet mount  Appropriate vaginal cultures  Ovulatory assessment (dont advise BBT: stressful! & inacurate)

EVALUATION OF OVULATION

OVULATION
 A history of regular menstruation suggests regular ovulation  Ovulatory predictor kits (expensive)  Serum progesterone (seven days before first day of LMP), should be >30 nmol/L  The majority of ovulatory women experience  Fullness of the breasts  Decreased vaginal secretions  Abdominal bloating  Absence of PMS symptoms may suggest anovulation  Mild peripheral edema  Slight weight gain  Depression

ANOVULATION

CAUSES OF ANOVULATION
         
POF Genetic [Turner] Autoimmune Iatrogenic Sec ovarian failure PCOS Excessive wt loss or gain Hypopithutarism Hyperprolactenemia Kallman synd

ANOVULATION

Symptoms
 Irregular menstrual cycles  Amenorrhea  Hirsuitism  Acne  Galactorrhea  Increased vaginal secretions

Evaluation*
 Follicle stimulating hormone  Lutenizing hormone  Thyroid stimulating hormone  Prolactin  Androstenedione  Total testosterone  DHEAS

*Order the appropriate tests based on the clinical indications

INTERPRETATION OF FEMALE INX

PROGESTERONE <30NMOL/L ANOVULATION Check cycle length Scan for PCO Advise wt reduction May need OI Clomiphene should not be started without test of tubal patency

INTERPRETATION OF FEMALE INX

FSH >10 IU/L REDUCED OVARIAN RESERVE May respond poorly to OI

May need egg donation LH >10 IU/L PCO USG to confirm USG to confirm

INTERPRETATION OF FEMALE INX

TESTOSTERONE >2.5NMOL/L PCO USG to confirm PROLACTIN >1000IU/L MAY BE PITUTARY ADENOMA Repeat level Exclude hypothyroidism Arrange MRI/CT If confirmed hyperprolactenemia, start dopamine agonist

INTERPRETATION OF FEMALE INX

HSG/HyCoSy ABNORMAL MAY BE TUBAL FACTOR Arrange Lap & dye May Intra UT Abn Evaluate by hysteroscopy

INTERPRETATION OF FEMALE INX

LAP & DYE BLOCKED TUBES TUBAL FACTOR Suitable for transcervical cannulation, surgery or IVF (depends on semen quality) ENDOMETRIOSIS ENDOMETRIOSIS Assess severity, may benefit from diathermy, laser Medical suppression not helpful for fertility May need IVF

INTERPRETATION OF FEMALE INX

RUBELLA NON IMMUNE OFFER IMMUNIZATION AND 1 MONTH CONTRACEPTION

HORMONAL RESULTS PLAN

 If Prolactin level is normal then give Progesterone to cause withdrawal bleeding.  If there is withdrawal bleeding then ask for TVS to exclude PCO, If its PCO then treat.  If no withdrawal bleeding then ask for LH & FSH.  If LH & FSH normal then treat with Clomiphene or Gonadotrophins.  If LH & FSH raised think about premature ovarian failure.  If LH & FSH low think about hypothalamic cause (kallman), ask for Karyotype.  If anovulation associated with hirsuItism think about PCO, ask for TVS, LH & FSH, androgens.

OTHER TESTS

SCREENING FOR CHLAMYDIA TRACHOMATIS

Main cause of tubal damage should be done before uterine instrumentation and HSG and prophylactic antibiotics should prescribe.

PostPost-coital testing of cervical mucus

 It is useful in predicting spontaneous

conception in couples with a short duration of infertility (<3yr) where female causes of infertility have been excluded.

 Intervention rates were higher in women subjected to this investigation

TESTS OF OVARIAN RESERVE

 Women have a finite number of primordial ovarian follicles, which show an age related decline.  Tests for ovarian reserve have been used to predict ovarian response to stimulation as part of infertility treatment

ENDOMETRIAL BIOPSY
 The role is not established except in cases where endometrial pathology is suspected  Not offered for luteal phase defect  No evidence that treatment of the luteal phase defect improves pregnancy rates

ASSESSING UTERINE ABNORMALITIES

 Three dimensional ultrasonography  HSG  Hysterosalphingo-contrast ultrasonography Hysterosalphingo-

CAUSES OF UTERINE ABNORMALITIES

CONGENITAL ABNORMALITIES

CAUSES OF UTERINE ABNORMALITIES

ACQUIRED DISORDERS

 Intrauterine scarring  Can be caused by curettage, Endometriosis, scarring from surgery, tumors of the uterus  Fibroids  Polyp

ASSESSING TUBAL DAMAGE

The results of semen analysis and assessment of ovulation should be known before a test for tubal patency is performed.
 HSG  Hysterosalphingo-contrast Hysterosalphingoultrasonography  Laparoscopy and dye

HYSTEROSALPINGOGRAM
 An X-ray that Xevaluates the internal female genital tract  architecture and integrity of the system  Performed between the 7th and 11th day of the cycle  Diagnostic accuracy of 70%

ASSESSMENT OF MALE INFERTILITY

INITIAL INVESTIGATION

EVALUATION OF ABNORMAL SEMEN ANALYSIS

 Repeat semen analysis in 30 days after first abnormal report  Laboratory tests  Testosterone level  FSH (spermatogenesis- Sertoli cells) (spermatogenesis LH (testosterone- Leydig cells) (testosterone Referral to urology  Physical examination  Testicular size  Varicocele

SA

NORMAL

ABNORMAL

FEMALE INVESTIGATION

REPEAT

NORMAL

ABNORMAL

ABNORMAL

ASTHENOSPERMIA

AZOSPERMIA

OLIGOSPERMIA

CHECK ANTIBODIES

CHECK FSH & TESTOSTERONE

<5 MILLION PER EJACULATE

ALL NORMAL

RAISED FSH RAISED FSH LOW FSH & NORMAL & LOW & TESTOSTERONE TESTOSTERONE TESTOSTERONE

CHECK CF CARRIER STATUS & KARYOTYPE

OBSTRUCTIVE

SPERMATOGENESIS FALIURE

COMPLETE TESTICULAR FAILURE

HYPOGONADOTROPHIC HYPOGONADISM

OTHER TESTS
 Chromosomal and genetic studies  CF screen for men with CBAVD which is associated with defects in the CFTR gene  Microbiology of semen, (significance of asymptomatic infection as demonstrated by WBCs in ejaculate is unclear)  SEMEN CULTURE is indicated in men with microscopic evidence of infection  Male partners of women with CHLAMYDIA should be screened  Imaging of male genital tract, RETROGRADE VENOGRAOHY IS GOLD STANDARD, other are USG, DOPLLER, RADIONUCLIOTIDE ANGIOGRAPHY, THERMOGRAPHY.

Cont.
 For scrotal tumors SCROTAL USG in obstructive lesion, VASOGRAPHY to locate site of lesion  In vitro tests of sperm function (tests of acrosome reaction , zona binding, zona free hamster egg penetration tests) ART has reduced their significance  Testicular biopsy to differentiate b/w obstructive and non obstructive azoospermia but risks are (reduced testicular mass, devascularization, fibrosis, autoimmune response)  ASA, THE PRESENCE of sperm agglutination should alert the laboratory to the potential presence of ASA. subsequent tests shoud be done include MAR and IMMUNOBEAD TEST

UN EXPLAINED INFERTILITY

TREATMENT

TREATMENT OF FEMALE

TREATMENT OF ANOVULATION
 PCOS Is most common cause of sec amenorrhea and is responsible for 75-80% 75of anovulatory infertility  Wt loss should be the Ist line of treatment  Loss of 5-10% of body wt can restore body 5function in 55-100% women in 6 months 55-

TREATMENT OF ANOVULATION
CLOMIPHENE CITRATE

 Anti-estrogens for Group Antiovulation disorders (clomiphene citrate 50mg day 2-6 up to 150mg/d and coitus advised every other day from 9th day for 1 WK  Increases endogenous FSH level via ve feed back to pituitary  Ovulation expected in 80%  Pregnancy in 30-40% 30 20-25% females considered to be 20resistant

TREATMENT OF ANOVULATION
 Risk of multiple pregnancy[8-10%] pregnancy[8 Side Effects  hot flushes (10%), abd distention 2%, abd pain, nausea, vomiting, headache, breast tenderness, reversible hair loss, blurred vision, scotomas 1.5%, significant ovarian enlargement 5%, OHSS <1%, mood liability  Limited to 12 cycles (CA Ovary?)  Chance of pregnancy increases with unexplained infertility  Ultrasound monitoring ESP for the first cycle
CLOMIPHENE CITERATE

TREATMENT OF ANOVULATION
TAMOXIFEN

   

Antiestrogen 2020-40 mg/d from day 3 for 5 days Pregnancy rates same as for CC. Less potent anti estrogenic than CC esp. on cervical mucus

TREATMENT OF ANOVULATION
METFORMIN & OVARIAN DRILLING

Metformin is not currently licensed for the treatment of ovulatory disorders in the UK.
Anovulatory women with PCOS, who have not responded to CC and with BMI >25 should be offered Metformin combined with CC.

TREATMENT OF ANOVULATION
METFORMIN & OVARIAN DRILLING
OVARIAN DRILLING

 Women with PCOS who have not responded to CC should be offered with Laparoscopic Ovarian Drilling b/c operations performed by laparotomy lead to complicaions (tubal damage and adhesion formation)  Predictors of success (>10u/l LH, normal BMI, short duration of infertility)  Effects lasts for 12 to 18 months  It has less multiple pregnancy and no OHSS  Destruction of ovarian follicles and decrease ovarian reserve prevented by minimal application energy and number of diathermy burns to 4 of 4 mm  Cumulative pregnency rate similar to with 3-6 cycles 3of GT

TREATMENT OF ANOVULATION
GONADOTROPHINS PCOS women who failed to ovulate with CC after 6-12 cycles or fail with Tamoxifen should offer GT  PCOS women who ovulate but failed to become pregnant in 6m should be offered CC stimulated IUI  PCOS women should not be offered concomitant GT and GnRh agonists Preprations 1- Recumbent FSH (Puregon, Gonal-F (75 IU/D Gonalfor 7-14d) 72- Purified urinary HMG (FSH+LH (Humagon, Pergonal (225 IU for 5 12 days)

TREATMENT OF ANOVULATION
GONADOTROPHINS

REGIMEN 1 Step up protocol Chronic low dose (25IU for 14 days small increase of 25 IU at interval of 5 days maximum up to 150 IU until 2 follicles of >17-18 mm are formed >17ADVANTAGES pregnancy rate 40%,unifollicular ovulation

TREATMENT OF ANOVULATION
GONADOTROPHINS

REGIMEN 2 Step down protocol (150 IU/d until dominant follicle > 10mm then reduce to 112.5 IU/d then 75 IU/d at 3 days interval till HCG inj. Is given), pregnancy rate 24%, 34% given), risk of multiple pregnency, 4.6% risk of OHSS  Cumulative pregnancy rate 40-50% 40 Miscarraige rate 25-30% 25-

LETROZOLE
 Aromatase inhibitors used as alternatives to CC in view of their lack of anti estrogenic effects  They suppress estrogen production and mimic the central redution of ve feed back by ovarian oestrogen  Still under trial

PULSATILE GnRH a
 Women with group ovulatory disorders should be offered pulsatile GnRH a or GT  Pregnancy rates of 80-90% over 12 cycles at a dose of 15-20 ug s/c or 2.5 -5 ug i/v  Monitoring performed by serum eastrogen and pelvic USG, but still unpopular d/t inconvenience & pump failure  Pulsatile GnRH a in CC resistant PCOS women is not recommended

DOPAMINE AGONISTS
 Women with ovulatory disorders due to hyperprolactinaemia should be offered bromocriptine  Dopamine like action  Shrinks 80% of macroadenomas  Normalizes prolactin level in 80-90%  Restore ovulation in 70-80%  Pregnancy rates in 35-70%

DOPAMINE AGONISTS
Side Effects  Nausea, headche, vertigo postural hypotension, fatigue, drowsiness, all can be minimized by initiating treatment with low dose of 1.25mg at bed time with snack, up to 2.5 mg TDS 2-3 WKS  Cabergoline and quinogolide (newer dopamine agonists) Fewer Side effects  Longer lives  Once daily dose for quinogolide, twice wkly for cabergoline  Surgery for intolerant or resistant to drug treatment

Complication of ovulation induction

CONCLUSION
 Normalization of body wt in under wt and obese pts can help to regain ovulation without need for medical treatment [b]

 Medical treatment of prolactinoma can help to regain ovulation [a]  WHO type 2 disorer should give CC or tamoxifen as drug of choice for 12 months [a]

MANEGEMENT OF UTERINE FACTOR INFERTILITY

 Congenital defects,lieomyomas, adhesions and polyps are treatable uterine factors.  Myomectomy can be carried out either laproscopically or by laprotomy with similar post operative pregnancy rates [a[  ART is not applicable to uterine factor infertility, however, treatment of uterine factor should be considered if failure of implantation seems to be the only cause of an unsuccessful IVF-ET IVFtreatment [e]

TUBAL AND UTERINE SURGERY

 Tubal microsurgery and laparoscopic tubal surgery  Tubal catheterisation or cannulation  Hysteroscopic adhesiolysis

CONCLUSION
 Women with mild tubal disease,tubal surgery may be more effective than no treatment.  Tubal surgery has increased risk of ectopic than IVF ET[c] ,but dec risk of OHSS.  If pregnancy does not occur within 6-12 months of 6tubal surgery reassesment with hysterosalpingiography shoud be carried out ,if blocked IVF ET indicated  For proximal tubal obstruction,selective salpingiography plus tubal cathetrization,or hysteroscopic cannulation may be treatment options b/c they improve chance of fertility [c]

MANAGEMENT OF ENDOMETRIOSIS RELATED INFERTILITY

 Medical treatment of minimal & mild ENDOMETRIOSIS is not recommended[a]  Women with minimal or mild ENDOMETRIOSIS who undergo laparoscopy, ablation or resection with adhesiolysis should be offered[a]  Ovarian endometriomas DO lap cystectomy  Surgery should be offered to women with moderate or severe E blc it improves fertility [c]  Medical or conservative surgical treatment before IVF ET can improve ovarian response but pregnancy rates remains unclear

TREATMENT OF MALE

MALE INFERTILITY TREATMENT

Semen analysis plan Non surgical treatment Surgical treatment

SEMEN ANALYSIS PLAN

 Repeat semen analysis in 30 days after abnormal report  If semen analysis after the 3rd time is abnormal, ask for FSH, LH & Androgens  If FSH, LH & Androgens are low, you have to exclude hypothalamic-pituitary cause hypothalamic If FSH, LH & Androgens are normal with azoospermia then think about obstruction  Pus cells, C/S, treat with antibiotics  If Sperm Antibodies, treat With Steroids  If All Measures (Antibiotics, Steroids & Varicocele Repair), Not Helpful Then go For IUI, GIFT, IVF.

TREATMENT (NON SURGICAL) NON SPECIFIC

 Gondadotropins  Antiestrogens  Aromatase inhibitors

TREATMENT (NON SURGICAL)

Hypogonadotropic hypogonadism

TREATMENT (NON SURGICAL) MISCELLANEOUS

 L Carnitine  Nutrition  Vitamins

TREATMENT (NON SURGICAL)

Hyperprolactinemia

TREATMENT (NON SURGICAL)

Immunologic infertility

TREATMENT (NON SURGICAL)

Ejaculatory/Erectile disorders

TREATMENT (SURGICAL)
Ejaculatory duct resection

TREATMENT (SURGICAL)
Vasal reconstruction

TREATMENT (SURGICAL)
Electroejaculation

TREATMENT (SURGICAL)
Sperm retrieval

TREATMENT (SURGICAL)
Varicocele Ligation

CONCLUSION
 Use of gonadotrophins in hypogonadotrophic hypogonadal men is effective (b)  The use of bromocriptine in men with sexual dysfunction as a result of hyperprolatinemia is effective (b)  Testicular biopsy should undertaken only in tertiary care centeres (e)  Vasectomy reversal is an effective treatment (80% chance of subsequent pregnancy) (a)  Anti oestrogens, androgens and bromocriptine are not effective in improving sperm quality (c)

CONCLUSION Cntd
 Use of steroids in the treatment of anti sperm abs is ineffective and further validation is required[b]  Surgery on the male genital tract should be undertaken only in centers where expertise is available[e]  Men found to abnormal chromosomal analysis[14% in azoospermia and 7% in severe oligo terato astheno zoospermia]shoud receive genetic counselling

 chance of natural conception falls to unhelpful level and treatment is needed.  10% of infertile couples will have a completely normal workup PREGNANCY RATES

UNEXPLAINED INFERTILITY After more than 3 years of unexplained infertility the

 After no treatment 1.3 - 4.1%

 Trial of CC 3-5 % 3-

 CC + intrauterine insemination 8.3%

 Gonadotrophins or IUI 10%.

 gonadotrophins+ intrauterine insemination 17.1%

UNEXPLAINED INFRTILITY
 Conservative management, OI with or without IVF ET are main approaches  60% conceive within 3 yr of conservative management if diagnosed after one yr (c)  Results are less good in primary infertility  Cumulative preg rate of 40% after cos with gonadotrophins and IUI (c)  Pregnancy rates after IUI alone are disappointing

UNEXPLAINED INFRTILITY Cntd

 2-3 courses of cos-IUI before IVF et are cosadvised as cos IUI may be less stressful. Less physically demanding less costly per attempt.  The cost of 3 cycles of cos -IUI is comparable to that of one IVF et with former offering a better pregnancy rate  Gift used to be the treatment of choice for IUI but with increase ectopic pregnancy and require GA (c) this method has been supplmented by IVF et

ART

BASIC STEPS IN IVF

 Ovary stimulation  Egg retrieval  Sperm retrieval-wash sperm retrieval Fertilization  Embryo transfer  Progesterone

INTRACYTOPLASMIC SPERM INJECTION

GIFT

RISKS OF ART
 To woman  Over stimulation of ovary syndrome  Multiple pregnancies  Risk of ovarian cancer (clomid, pergonal)  To baby  ICSI associated with problems (XYY)

CUMULATIVE CONCEPTION RATES INDIFFERENT TYPES OF INFERTILITY TREATED AS APPROPRIATE

 Women with Amenorrhoea do so well like the normal group. group.  Women with Oligomenorrhea on other hand do not do so well, because of their disorder are more subtle (PCO)  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 disease.  The group of Oligospermia who are defined not only by low sperm counts but by failure of mucus penetration had poor prognosis. prognosis.  The men with completely normal seminal analysis but failure of mucus penetration had also poor prognosis. prognosis.

THE ENDLESS END