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INFERTILITY

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INFERTILITY Assessment and treatment of patients with fertility problems Dr Nitu Raje-Ghatge ... – PowerPoint PPT presentation

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Title: INFERTILITY


1
INFERTILITY
  • Assessment and treatment of patients with
    fertility problems
  • Dr Nitu Raje-Ghatge

2
Why
learn about it?
  • Its in the curriculum !
  • Infertility primary/ secondary
  • Investigations eg hormone tests
  • Knowledge of subfertility
  • secondary care investigations
  • Primary care management
  • Knowledge of specialist treatments
  • and surgical procedures

3
Why learn about it..
  • Expectations from secondary care services!
  • Inappropriate timing of referrals (early/late)
  • Incomplete /inadequate investigations

4
What is infertility?
  • NICE
  • Failure to conceive after regular UPSI for 2
    years in the absence of reproductive pathology.
  • P.S NICE suggests offer clinical
    investigations if failure to conceive after 1
    year of UPSI.
  • GP NOTEBOOK
  • Infertility is the failure of conception in a
    couple having regular, unprotected coitus for 1
    year, provided that normal intercourse is
    occurring not less than twice weekly.

5
Natural conception rates
  • 80 of couples will be pregnant after 12
  • cycles.
  • 50 of remaining will conceive during a
  • 2nd year ( hence cumulative rate 90)
  • 50 in the following 4 years.

6
PRIMARY/SECONDARY INFERTILITY
  • PRIMARY Couple without a prior pregnancy
  • SECONDARY Couple with previous pregnancy
    including miscarriage/ectopic.

7
Etiology
  • Male factors
  • Female factors
  • Unexplained -20
  • Mixed 15

8
Male
  • Account for 25
  • Hypogonadotrophic hypogonadism
  • Obstructive azoospermia
  • Surgery
  • Erectile dysfunction
  • Anatomical
  • - Hypospadias
  • - Undescended/
  • maldescended testis

9
Female
  • Peritoneal factors 40,
  • - Endometriosis.
  • Tubal blockage 20.

10
Etiology (female)
  • Ovulatory dysfunction 15-20
  • - Hypothalamic/hypogonadotrophic
  • hypogonadism
  • - Hypothalamic pituitary dysfunction
  • (PCOS)
  • - Ovarian failure
  • Uterine cavity abnormalities
  • - Asherman's syndrome
  • - Uterine fibroids.
  • Cervical hostility 5-10,
  • - Infection
  • - Female sperm antibodies.

11
  • Fertility may be impaired in poorly controlled
    diabetes.

12
History taking (female)
  • Symptoms (past or present)
  • - P I D / STD,
  • - dysparenuria
  • - galactorrhoea,
  • - thyroid symptoms
  • Obstetric history

13
History taking (female)
  • Menstrual history
  • - irregularities
  • Surgical history
  • D C, abdominal/pelvic surgery
  • Contraception
  • - IUCDs
  • Cervical smear

14
History taking (male)
  • Symptoms
  • h/o genital tract infection e.g. mumps
    orchitis, prostatitis
  • Surgical history
  • - Hernia repair
  • - Testicular surgery for torsion/
    undescended /maldescended
  • testis
  • - Prostate surgery

15
History taking (male)
  • Trauma to the male genital or inguinal region
  • Occupational history
  • - exposure to lead, cadmium
  • Drug history
  • - Sulphasalazine impairs spermatogenesis
  • - Phenothiazines/ typical antipsychotics/
    metoclopramide
  • increase prolactin levels
  • - Immunosuppresants

16
IN BOTH
  • Smoking
  • Alcohol intake
  • Psychological factors

17
EXAMINATION
  • General health and nutritional status
  • BMI
  • lt19 (F)
  • gt 29.(M/F)
  • SSC

18
Female
  • Hirsuitism, galactorrhoea
  • Bimanual examination
  • - adnexal masses (tubo/ovarian, ovarian cyst)
  • - tenderness (PID/ endometriosis)
  • - Uterine fibroids

19
Male
  • Hypospadias
  • Size and consistency of each testicle and
    epididymis
  • Presence of varicocele or hernia
  • Size of prostate.
  • Gynaecomastia

20
Now what??
  • Investigate
  • Or
  • Refer

21
Early referral if..
  • Male
  • Undescended testes
  • Previous genital pathology
  • Previous urogenital surgery
  • In Both
  • Prior treatment for cancer
  • HIV, Hep B, Hep C
  • Female
  • Age gt35 years
  • Amenorrhoea/ oligo menorrhoea
  • PID
  • Abnormal pelvic exam

22
Investigations
  • Primary care
  • Female
  • Assess ovulation.
  • Other hormonal tests
  • Tests for PID
  • Male
  • Sperm analysis
  • Secondary care
  • Tubal patency
  • Uterine abnormality

23
Assessing ovulation
  • Do if
  • regular cycles with gt 1 year of infertility
  • irregular cycles
  • 1) Serum progesterone
  • 2) LH/FSH levels

24
INVESTIGATIONS (Female)
  • 1) Serum progesterone
  • (mid luteal phase ie day 21 of 28 week
    cycle)
  • Timing is important!!!
  • Regular cycles - 7 days before next MP
  • Irregular cycles - day 28/35 wk then weekly
  • till menstruation
    occurs

25
Interpretation of test
26
Assessing ovulation
  • 2) LH/FSH levels
  • High levels poor ovarian function
  • High LH compared to FSH -PCOS

27
Other hormonal tests
  • E2, Testosterone levels PCOS
  • Prolactin ONLY if
  • - ovulation problems
  • - galactorrhoea,
  • - pituitary problem.

28
Other hormonal tests
  • Thyroid tests
  • - only with symptoms/ signs
  • Other androgen profile (DHEAS,
  • Androstenedione, SBHG)
  • as per etiology

29
Tests for PID
  • HVS
  • Chlamydia screening

30
Dont forget!!
  • Rubella status
  • - check immunity
  • - Vaccinate if non immune, avoid conception for
    3 months

31
Cervical hostility
  • Post coital test
  • - no longer recommended by NICE
  • Mucus invasion test
  • - doubtful significance

32
Investigations (Male)
  • Semen analysis
  • Needs prior appointment with lab
  • Abstinence for atleast 3 days
  • Transport to lab in 30- 60 min
  • Repeat abnormal test in next 3 months, earlier if
    gross abnormality

33
Semen analysis- interpretation (WHO values)
  • Volume 2 mls or more
  • Sperm concentration - 20 million/ml
  • Sperm morphology - atleast 30 normal
  • Sperm number - 40 million/ ejaculate
  • Sperm motility 50
  • Vitality 75
  • WBC - lt1 million/ml
  • Anti sperm antibody tests- not recommended by NICE

34
Investigations in secondary care
35
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

36
Management in primary care
  • Principles of care
  • Couple centred management
  • Access to evidence based information
  • Counselling (third person)
  • Contact with fertility support groups
  • Specialist teams

37
Positive approach
  • Reassure about cumulative pregnancy rates

38
Management in primary care
  • Lifestyle changes
  • - Weight reduction,
  • BMI 19-29
  • - Smoking cessation- offer support
    groups
  • - Alcohol reduction
  • lt1-2 units/week for women
  • lt3-4 units/week for men
  • - S I every 2-3 days
  • - Information about OTC/ recreational
    drugs

39
Management in primary care
  • Pre conceptual advice
  • - Folic acid supplementation
  • - Rubella status
  • - Cervical screening
  • Management of erectile dysfunction
  • - psychosexual couselling
  • - drugs

40
Management in secondary care
  • Depends upon the etiology..

41
Hypogonadotrophic hypogonadism
  • Pulsatile GnRH
  • Gonadotrophins with LH activity
  • Bromocriptine ( for hyperprolactinaemia)

42
Ovarian dysfunction ( hypothalamic dysfunction)
  • 1) Anti- oestrogens eg Clomiphene/ Tamoxifen
  • - 1st line
  • - use for atleast 12 months if ovulating
  • - initiated in secondary care
  • - under USG guidance ( to adjust dose)
  • - shared care when dose established
  • - S/E risk of multiple pregnancy, OHSS

43
Ovulatory dysfunction- treatment
  • 2) Metformin
  • - not licensed for ovulatory disorders in UK
  • - used 2nd line with Clomiphene in
  • - anovulatory women with PCOD
  • BMI gt25
  • no response to CC

44
Others
  • 3) Gonadotrophins
  • 4) Luteal phase support
  • - progesterone,
  • - clomiphene
  • 5) Laparoscopic ovarian drilling

45
Peritoneal problems (endometriosis)
  • Laparoscopic surgical ablation/ resection of
    endometriosis adhesiolysis
  • If ovarian endometriomas, laparoscopic cystectomy

46
Uterine/ tubal factors
  • Tubal factors
  • - Laparoscopic tubal surgery/ tubal
    microsurgery
  • - Salpingography tubal catheteristion
  • - Hysteroscopic tubal cannulation
  • Uterine factors
  • - hysteroscopic adhesiolysis
  • - myomectomy

47
Assisted reproduction techniques
  • Intra uterine insemination (IUI)

48
In vitrio fertilisation
  • Intracytoplasmic sperm injection (ICSI)
  • Donor insemination
  • Oocyte donation

49
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52
ACON at CRH
  • Satellite IVF unit
  • Counselling, monitoring and most of treatment ,
    except egg retrieval and embryo transfer.

53
Central unit
  • Clarendon Wing, LGI
  • SJUH, Leeds
  • CARE, Manchester

54
Questions..zzzz??
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