Anovulation- the most frequent cause of female infertility. It can be connected with:

1. Anovulation- the most frequent cause of female infertility. It can be connected with: • Irregular menstruation • Oligomenorrhea • Amenorrhea • Regular menstruations can also occur

2. Anovulation- the reasons: • Hyperprolactinemia • Hypothalamic- pituitary dysfunction • Ovarian failure • PCO Diagnostic methods: • PRL/MCP, FSH, LH, E2 serum concentrations between 3 - 6 day of cycle. • P test and ultrasound ovarian assessment.

3. Hyperprolactinemia: • PRL > 20 ng/ml, MCP > 300% • Causes: stress, hypothalamic failure, PCO, psychotropic drugs (e.g. trnquilizers), rare - adenoma • When PRL>27.8 ng/ml determine TRH - hypothyreosis? • Syndroms: Oligomenorrhea or amenorrhea, infertility- anovulation, deficient activity of the corpus luteum, galactorrhea in 33%. • Treatment: Bromocriptine

4. Hypothalamic- Pituitary dysfunction • P test - negative, FSH, LH <5 mj/ml or normal, E2<40 pg/ml • Causes: the most frequent congenital hypothalamic- pituitary insufficiency, stress, excessive exercise, weight loss, malnutrition. • Management: • Elimination risk factors • GnRH • hMH, FSH

5. Ovarian failure • FSH >20mj/ml • Possible in each age: • In younger women (age 30) frequently genetic causes- karyotype evaluation. • In woman atreproductive age it can be transient or permanent. • Causes:idiopathic, autoimmunological- thyroid inflammation, myasthenia, thrombocytopenia, rheuamtoid disease, adrenal failure, vitiligo, hemolytic anemia. past surgeries, chemio- or radiotherapy, inflammations, 17- hydroxylase hypoactivity, hormonal ovarian resistance.

6. Ovarian failure- treatment • E/P, in women at the beginning of ovarian failure ovulation can be restored in about 20% of women. • hMG treatment is ineffectiveness and autoimmunologic process can intensify

7. Obesity 38 - 50% Dysmenorrhea Infertility in 75% Hyperandrogenism in 48% Without syndroms 20% Hormonal diagnostics: T, A LH LH:FSH Insulin level in fasting state PRL SHBG Variety of syndroms in PCOaccording to Balen et al.

8. Body weight reduction • Decreasing the E1 and LH concentrations • Decreasing the P 450C activity and free Testosterone concentration

9. Metformin • Decrease the insulin level and restore correct steroidogenesis (take place the proper cytochrome P 450 C 17 alfa phosphorylation)

10. INFERTILITY DIAGNOSIS

11. Hysterosalpingography (HSG) • Hysterosalpingogram- x-ray imaging of the uterus and fallopian tubes after instillation of a contrast liquid • Routine infertility evaluation (basic test) • Assess morphology of endocervical canal, uterine cavity, tubes. • Rule out tubal occlusion, synechiae, uterine anomalies.

12. Contraindications to HSG: • active PID with abdominal tenderness or palpable mass • recent uterine/tubal surgery • active uterine bleeding • pregnancy (schedule exam before ovulation to avoid early pregnancy)

13. Normal hysterosalpingogram.A smooth triangular uterine cavity and spill from the ends of both tubes.

14. HSG showing a normal uterus and blocked tubesNo "spill" of dye is seen at the ends of the tubes

15. Hysterosalpingogram showing a uterus with a myoma that is pushing in to the cavity.

16. A hysterosalpingogram indicate intrauterine adhesions (synechia)

17. Tubal Recannulization and Selective Salpingography

18. Selective hysterosapingography, or proximal tubal cannulization may open the tubes avoiding surgery.

19. LAPAROSCOPY

20. The camera and instruments are inserted into the abdomen or chest through small skin cuts allowing the surgeon to explore the whole cavity without the need of making large standard openings dividing skin and muscle.

21. After the cut is made in the umbilical area a special ( Veress) needle is inserted to start insufflation. A pressure regulator CO2 insufflator is connected to the needle. The pressure obtained should not be beyond 15 mmHg.

22. After satisfactory insuflation the needle is removed and a 10 mm trocar is inserted through the previous umbilical wound.

23. Laparoscopic view of a normal pelvis.Uterus in midline. Tubes and ovaries (white structures) also visible.

24. Contraindications to laparoscopy: • Circulatory and respiratory insufficiency • Hypovolemic shock • Ileus • Peritonitis • Abdominal or diaphragmic hernia • Tumors in abdominal cavity

25. Pelvic laparoscopy is also not recommended for patients with: • severe obesity • existing severe pelvic adhesions from previous surgeries

26. Pelvic Laparoscopy: Risks • Risks for any anesthesia are: • reactions to medications • problems breathing • Risks for any surgery are: • bleeding • infection • damage to adjacent organs

27. HYSTEROSCOPY • Assess the endocervical canal, uterine cavity and uterine openings of the oviducts. • Enables to make the intrauterine operations.

28. Hysteroscopic view of a uterine septum.A septum can cause recurrent miscarriage.

29. A large polyp at the top of the uterine cavity

30. Contraindications to hysteroscopy: • Infections of reproductive organs • Massive bleeding from uterus • Pregnacy • Cervical cancer

31. Hysteroscopy. Risks. • Uterine perforation • Bleeding • Infection • Pulmonary embolism (rare)

32. Polycystic ovarian syndrome (PCOS) occur in5-10% of reproductive-aged women PCOS  ovulatory dysfunction or absent ovulation  infertility  infrequent or irregular menstrual cycles absence of ovulation  no progesterone production in the second half of the menstrual cycle  the risk for an abnormal buildup of the lining of the uterus (endometrial hyperplasia) or cancer.

33. Another feature to PCOS is clinical or laboratory hyperandrogenism  increased circulating amounts of or increased responsiveness to "male" hormones like testosterone or DHEAS Symptoms: oily skin or acne and excess hair on the face, between the breasts, or on the lower abdomen.

34. Changes in the ovaries in ultrasound Ultrasound findings: poly (many), cystic (small collections of fluid). The eggs in the ovaries do not develop to maturity  many small "follicles" (small fluid-filled sacs containing immature eggs) seen on ultrasound. The ovaries of women PCOS are often enlarged as well.

35. Another common feature of PCOS is increased body weight and trouble in losing weight. Mechanism: insulin resistance (the cells of women with PCOS do not respond as well to their bodies' own insulin)  women with PCOS are at higher risk for developing diabetes during pregnancy or later in life.

36. Treatment Strategies The aim: to help regulate menstrual cyclicity and prevent endometrial hyperplasia. Oral contraceptives (birth control pills- BCPs). BCPs also help reduce acne and facial hair in most patients with PCOS. In women who do not require oral contraception, progesterone given for 10-12 days every 30- 60 days will induce a reliable menses. For women with PCOS who desire pregnancy, ovulation induction(COH) is often necessary. Drugs that increase insulin sensitivity in PCOS- Metformin  help induce ovulation  help women to lose weight

37. In women who cannot tolerate oral medications or have failed several different regimens of medication, surgical induction of ovulation can also be attempted (laser or electrosurgical techniques to place small holes in the ovaries in an effort to normalize the hormonal environment and allow ovulation to occur)

38. ANDROLOGY Dr hab. Rafał KurzawaCLINIC of REPRODUCTION and GYNECOLOGY POMERANIAN ACADEMY of MEDICINE

39. Infertility- epidemiology

40. Symptomatology of male infertility • TYPE I – erection problems (0,3-7%) • TYPE II – azoospermia (0,9%-16%) • TYPE III – immunological infertility (3,4%-25%) • TYPE IV – abnormal seminal quality (23%-48%) • TYPE V – idiopathic sperm dysfunction (0-25%)

41. Diagnosis • General examination • Semen analysis • Other diagnostic tests: • USG • Hormonal diagnostic • Diagnostic tests for Assisted Reproductive Technology

42. TYPE I – erection problems (0,3-7%) • Normal ejaculation • Hypospermia (semen volume < 2,0 ml) – chronic prostatitis • Impotence • Retrograde ejaculation • Neurogenic– DM, SM • Anatomical • Jatrogenic – drugs, operations • disejaculation • Functional – anorgazmia • Neurogenic – spinal injury • Jatrogenic – drugs, chemiotherapy, radiotherapy, operations

44. TYPE II – azoospermia (0,9%-16%) • Pre-testicular causes • Hypothalamic or pituitary disorder – LH, FSH deficiency, Kallman syndrome, trauma, tumors, inflammation, meningitis • Testicular causes • Primary testicular failure • Congenital – 47XXY, del Y, AZF • Acquired- mumps, testicular torsion, castration • Jatrogenic – radiotherapy, chemiotherapy • Post-testicular causes • Congenital – CBAVD, CF • Acquired – inflammations (gonorrhea) • Jatrogenic – vasectomy, hernia operation

45. Diagnostic tests for Assisted Reproductive Technology- ICSI • FSH • If < 12IU – sperm biopsy is effective in 80-90% • Blocked ejaculatory duct (Micro-Epidydymal Sperm Aspiration –MESE) • Other (Testicular Sperm Extirpation- TESE, Testicular Sperm Aspiration- TESA)

46. TYPE III – immunological infertility (3,4%-25%) • antisperm antibodies – the immune system may produce antibodies that attack and weaken or disable sperm • Auto-immunological diseases • Concequences of testicular trauma

47. Congenital Undescended testicles Sexually transmitted disease (gonorrhoea) or testicular infection (mumps) Vascular Testicular torsion Varicocoeles Diseases: Thyroid faiure; Addison disease, hepar diseases; DM, auto-immunological diseases; Environmental factors Drugs (sulfasalazine, T, chemiotherapy) Temperature Other factors (X-rays, lead, cigarette smoke, alcohol; marijuana, frequently wearing tight-fitting pants and underwear) Immunological Testitis Genetic del Y, aberrations (count and structure of chromosomes) Idiopathic [46%] TYPE IV – abnormal sperm quality (23%-48%)

48. Morphologic images

49. Treatment • Risk factor elimination • Give up smoking • Testicular temperatue decrease • Regular sexual intercourses (2-3 per week) • Antioxydants • Vitamin E, C, Zinc • Tetracicline • Chlamydia Trachomatis infection

50. Treatment (pharmacotherapy) • Risk factor elimination • Hormonal treatment • Testosterone • hCG • FSH • C.C, tamoxyphen