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Understanding Infertility Basic Sciences

Understanding Infertility Basic Sciences. A/Prof R Gyaneshwar FRANZCOG, MH.Ed Clinical Director of Obstetrics & Gynaecology Liverpool Health Service Conjoint Associate Professor University of New South Wales. Acknowledgement. Dr Antony Lighten – IVF Australia Dr Derek Lok – Sydney IVF.

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Understanding Infertility Basic Sciences

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  1. Understanding InfertilityBasic Sciences A/Prof R Gyaneshwar FRANZCOG, MH.Ed Clinical Director of Obstetrics & Gynaecology Liverpool Health Service Conjoint Associate Professor University of New South Wales

  2. A/Prof R Gyaneshwar

  3. Acknowledgement • Dr Antony Lighten – IVF Australia • Dr Derek Lok – Sydney IVF A/Prof R Gyaneshwar

  4. Reproductive Physiology A/Prof R Gyaneshwar

  5. Blocked or damaged Fallopian tubes eg Ectopic pregnancy Fibroids Endometriosis Miscarriage Polycystic Ovarian Syndrome Failure of Ovulation A/Prof R Gyaneshwar

  6. Causes of Infertility A/Prof R Gyaneshwar

  7. The Causes of Infertility and their Approximate Frequency (adapted from Hull et al 1985) A/Prof R Gyaneshwar

  8. Infertility • Definition • 12 months of attempting to conceive • Incidence 1 in 6 couples • Incidence increases with age A/Prof R Gyaneshwar

  9. 24 90 12 80 11 % pregnant/month 10 70 9 8 7 60 6 5 50 4 40 3 30 2 20 1 10 0 1 2 3 4 5 6 7 8 9 10 11 12 24 Natural Cumulative Pregnancy Rate Months of trying A/Prof R Gyaneshwar

  10. Natural Pregnancy Rate A/Prof R Gyaneshwar

  11. Ovarian Reserve A/Prof R Gyaneshwar

  12. LHRH LH FSH Anovulation A/Prof R Gyaneshwar

  13. LHRH LH FSH The Clues A/Prof R Gyaneshwar

  14. Ovulation Tests – Luteal Progesterone A/Prof R Gyaneshwar

  15. Tubal Factor • Peristalsis • Ciliary dysfunction • Narrowing • Blockage A/Prof R Gyaneshwar

  16. Lap / Dye A/Prof R Gyaneshwar

  17. Ectopic A/Prof R Gyaneshwar

  18. Pelvic Infection and Tubal Disease A/Prof R Gyaneshwar

  19. Pelvic Infection and Tubal Disease A/Prof R Gyaneshwar

  20. Endometriosis A/Prof R Gyaneshwar

  21. Minimal / Mild Endometriosis Monthly fecundity rate 6.1 (laparoscopic surgery) vs 3.2 (diagnostic laparoscopy) per 100 person month The Canadian Collaborative Group on Endometriosis 1997 NEJM 337:217 A/Prof R Gyaneshwar

  22. Hysteroscopy A/Prof R Gyaneshwar

  23. Septate uterus A/Prof R Gyaneshwar

  24. Congenital Anomalies A/Prof R Gyaneshwar

  25. Blocked/absent vas deferens Low sperm numbers and/or poor sperm movement High numbers of abnormal shaped sperm Failure of sperm production Antisperm antibodies Erectile dysfunction A/Prof R Gyaneshwar

  26. Male Factor • Primary Testicular Disease • Most common cause of male factor infertility • Aetiology • 66% unknown • 20% testicular maldescent • 7% trauma and torsion • 5% Klinefelter’s Syndrome • 1% mumps orchitis • 1% chemo A/Prof R Gyaneshwar

  27. Male Factor • Endocrine causes • Hyperprolactinaemia • Hypogonadotrophic hypogonadism • Hypothrooidism • Rare • Present with sexual dysfunction A/Prof R Gyaneshwar

  28. Sperm Count • Volume 2 – 5 mls • Density/Concentration > 20 mill/ml • Motility > 50% • Morphology > 14% normal A/Prof R Gyaneshwar

  29. Male Infertility • Semen Analysis (WHO 1999) • 3 days of abstinence, collection technique, 72 days for sperm to be ejaculated • Vol > 1 ml • Concentration > 20 x 106 / mL • Motility > 50% • Morphology (WHO Strict Criteria 99) > 15% normal • Note: SA best performed in andrology lab; If abnormalalways repeat A/Prof R Gyaneshwar

  30. Sperm Count Variation in a Healthy Man A/Prof R Gyaneshwar

  31. A/Prof R Gyaneshwar

  32. Important Concepts • Age • Duration of infertility • Primary versus secondary infertility • Multiple causes of infertility • Sub-fertility versus sterility A/Prof R Gyaneshwar

  33. History • Duration • Previous pregnancies • Wt / Ht / BMI • Full menstrual history • Androgenising signs • Pelvic pain • Previous investigations • Past medical history • Past surgical history • Medications / cigarettes / alcohol A/Prof R Gyaneshwar

  34. History • Previous paternities • Sexual dysfunction • Mumps / STD • Trauma • Undescended testes • Previous investigations • Past medical history • Past surgical history • Medications / cigarettes/ alcohol A/Prof R Gyaneshwar

  35. RANZCOG Statement C-Obs 3 March 2004 • Tests recommended at the first antenatal visit of each pregnancy: • Blood group and antibody screen • Full blood examination • Rubella Antibody status • Syphilis serology • Hepatitis B serology • Midstream urine examination by culture: eg dipslide • HIV serology • Hepatitis C serology • Cervical cytology A/Prof R Gyaneshwar

  36. Prognostic Factors • Age • Duration of infertility • Primary versus secondary infertility • Multiple causes of infertility • Sub-fertility versus sterility A/Prof R Gyaneshwar

  37. Duration of Infertility • The longer the duration of infertility, the greater the likelihood of a cause of infertility; ie the less likely that the situation is due to bad luck • Treatment is more successful in patients where a specific treatable cause is found A/Prof R Gyaneshwar

  38. Prognosis A/Prof R Gyaneshwar

  39. Effect of Multiple Minor Abnormalities A/Prof R Gyaneshwar

  40. Tubal Patency HSG Lap & Dye Ovulation Midluteal P4 Testosterone, TSH,Prolactin, LH, FSH asindicated Rubella, Varicella Hep B, C, HIV, VDRL Semen Analysis LH, FSH, Prolactin as indicated Karyotype Hep B, C, HIV, VDRL Investigations A/Prof R Gyaneshwar

  41. Hormone / Ovulatory Tests • Day 2-3 hormones • FSH, LH, Oestradiol • Testosterone, SHBG • Others: • 17-OH P, DHEAS, Androstenedione, cortisol • TSH, prolactin • 75g GTT & fasting insulin • Luteal Progesterone • 7 days prior to estimated date of period if regular • If irregular, start 7 days prior to shortest cycle date and repeat every 5-7 days till next period arrives A/Prof R Gyaneshwar

  42. Treatment Options A/Prof R Gyaneshwar

  43. Ovulation Induction PCOS 1st line Clomiphene – 60% pregnant after 6 months 2nd line Metformin FSH Surgical Ovarian Drilling A/Prof R Gyaneshwar

  44. Ovarian Drilling A/Prof R Gyaneshwar

  45. Ovarian Induction Hypothalamic amenorrhoea FSH Pulsatile GnRH Hyperprolactinaemia Carbergolide A/Prof R Gyaneshwar

  46. Intrauterine Insemination Indications Unexplained Mild male factor Success/Cycle Natural 10-15% Stimulated 15-20% A/Prof R Gyaneshwar

  47. In Vitro Fertilisation Indications Prolonged unexplained Tubal factor Severe male factor Unsuccessful OI / IUI / fertility surgery A/Prof R Gyaneshwar

  48. In Vitro Fertilisation Success / Cycle 40 – 5-% Single embryo transfer Now gold standard Twin rate 1% A/Prof R Gyaneshwar

  49. Sperm Preparation 49 A/Prof R Gyaneshwar

  50. 50 A/Prof R Gyaneshwar

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