INFERTILITY

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INFERTILITY

• DR. ANDREAS CHRYSOSTOMOU
• SPECIALIST OBSTETRICIAN GYNECOLOGIST

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INTRODUCTION

• Infertility cause considerable anxiety and
  careful consideration should be offered in
  appropriate
• settings. The investigation and management is
  time consuming and this needs to be clear to the
• couple. The investigations should address
  problems of ovulation, transport and male
  factors. (Fig1.2)
• In this case base-line hormonal levels including
  FSH, LH and thyroid function should be measured.
• Hyperprolactinaimia is unlikely in women with a
  normal menses. A midluteal phase progesterone
• levels should be checked to confirm ovulation and
  ultrasound to assess for uterine or tubal
  pathology.
• If suggestion of uterine tubal pathology
  hysterosalpingography should be offered.
  Laparoscopy to
• rule out endometriosis. Sexual transmitted
  disease can lead to tubal pathology which is the
  main
• cause of infertility in developing countries and
  adequate treatment should be offered. HIV status
  of
• the couple should be determined after adequate
  pre and post test counselling. HIV positive
  patient
• should be denied treatment for infertility as
  this leads to the spread of the epidemic.
  Initial
• Investigation should be semen analysis of a
  specimen produced at least 3 days after the most
  recent
• ejaculation. Abnormal semen analysis should
  always be repeated particularly when the
  abnormality is
• azoospermia. Medical students must be able to
  take a history, initiate baseline investigations
  to offer
• treatment of STD and refer patients to secondary
  or tertiary institutions.

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DEFINITION

• Inability to achieve pregnancy after one year of
  adequate sexual exposure

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COMMON CAUSES

• Tubal diseases (damages)-57
• Anovulation-29
• Cervical factor-7
• Uterine pathology-6
• Endometriosis-4
• Male factor (abnormal semen)-36
• Unexplained-3,4

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EPIDEMIOLOGY

• Incidence is 15-20 of women failing to conceive
  ( 1 in every 5-6 couples)
• AGE
  INFERTILE
• 20-24 4
• 25-29 5.5
• 30-34 9.4
• 35-39 20

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TIME REQUIRED FOR CONCEPTION

• DURATION OF EXPOSURE
• 3 months
• 6 months
• 1 year
• 2 years

• PREGNANT
• 57
• 72
• 85
• 93

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THE PATERN OF INFERTILITY - SA

• Younger age
• Secondary infertility
• PID (tubal factor)
• Increased HIV
• 5 unexplained infertility

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APPROACH TO EVALUATION

• History
• -age
• -primary/secondary infertility
• -previous reproductive history
• -previous contraception
• -previous PID treatment
• -menstrual history

• -BMI (19.1-25)
• -breast development
• -skin abnormalities
• -previous surgery
• -drugs
• -medical disorders
• -sexual history
• -social history ( alcohol smoking)

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APPROACH TO EVALUATION

• 2.Phisical examination
• -Secondary sexual characteristics
• -Breast development
• -Abdominal examination
• -Gynecological examination

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APPROACH TO INVESTIGATION

• There is not consensus about what test is ideal.
• Semen analysis
• -volume 2-6 ml
• -count gt20 million/ml
• -motility gt30
• -forward progression gt2
• -morphology gt15

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APPROACH TO INVESTIGATION

• Presence of ovulation
• CLINICAL
• -normal length cycle ( 26-32days)
• -mid cycle pain
• -biphasic BBT
• -mucus secretion at mid-cycle

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APPROACH TO INVESTIGATION

• Presence of ovulation
• LABORATORY
• -21 day Progesterone gt30nmol/l
• -Estradiol day 12-14 ( 700-1200pg/l
• -FSH gt20 iu on 3 occasions ( POF )
• - LHFSH 2-31 ( PCOS )

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ASSESSING UTERUS TUBAL PATENCY

• HSG
• Ultrasound
• Laparoscopy-the best in assessing uterus, tubal
  pathology presence of endometriosis

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OTHER INVESTIGATIONS

• RPR
• HIV (Pre-test and post-test important!!!!)

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REMEMBER THIS!!!

• ROAD MAP TO INVESTIGATION OF INFERTILE COUPLE

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SETTING PRIORITIES

• Acknowledge that infertility is a health problem.
  South Africa has to comply with Human Tissue Act
  1997 allowing insemination of a single woman by a
  donor.
• Induction of ovulation with clomiphene (clomid)
  can be offered in the public sector.
• Intra-uterine insamination with sperm washed
  following ovulation (administration of HCG 5 10
  000iu imi to trigger ovulation.

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Implementation of effective strategies

• Preventive strategies
• The policy of we do not investigate infertility
  in public sector due to the fact that we
• cannot offer assisted reproduction help aimed at
  pregnancy is wrong. Patient with
• primary or secondary infertility hide the problem
  and usually present at the clinic
• complaining of something else. The treatment
  received (antibiotics, DDC, tubal
• surgery) is not cost effective.
• Development of feasible interventions and
  guidelines
• Development of guidelines with regionalisation
  into primary, secondary and tertiary
• centres dealing with infertility. In such extent
  patient diagnosed in primary centre
• referred to secondary for investigation and
  management and thereafter to tertiary
• institutions where induction of ovulation,
  intra-uterine insamination at least can be
• offered.
• An HIV patient should not be denied treatment.
  Management includes-
• Prevention in management of STDs
• Counselling
• Antiretroviral therapy (according to CD4 count
  and viral load)
• Mode of delivery, breast feeding