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Investigations to evaluate Infertility

Investigations to evaluate Infertility. Dr Atin Singhai Assistant Professor Department of Pathology KGMU, Lucknow. Background. Definition: 1 yr unprotected coitus without conception 10-15% couples affected Etiology Couples: 35% Tubal and pelvic pathology 35 % Male problems

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Investigations to evaluate Infertility

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  1. Investigations to evaluate Infertility Dr Atin Singhai Assistant Professor Department of Pathology KGMU, Lucknow

  2. Background • Definition: • 1 yr unprotected coitus without conception • 10-15% couples affected • Etiology • Couples: • 35% Tubal and pelvic pathology • 35 % Male problems • 15% Ovulatory dysfunction • 10% Unexplained • 5% unusual causes

  3. Background • Etiology • Women: • 40% Tubal and pelvic pathology • 40% Ovulatory dysfunction • 10% Unexplained Infertility • 10% Unusual causes • Normal couple: • 25-30% chance of pregnancy per ovulatory cycle • Fertility decreases with age

  4. Infertility Time of Exposure% Pregnant 3 months 60% 6 months 70% 1 year 85% 18 months 90%

  5. Approach to Infertility • DDX • Tests/Inv • Dx • Rx

  6. Approach to Infertility • Production • Storage • Delivery

  7. Male Infertility 1. Production: • Hypothalamus • Anterior Pituitary • Testes

  8. Hypothalamic-Pituitary-Gonadal Axis

  9. Male Infertility • 1. Production • Hypothalamus • Congenital abnormalities of hypothalamus • e.g. Kallman’s syndrome • Starvation, stress or severe illness • Tumors (craniopharyngioma, metastatic tumor) • Head injury • Inflammation (sarcoidosis) • Infection (tuberculosis) • Drugs: marijuana

  10. Male Infertility • 1. Production: • Pituitary • Endocrine: thyroid, prolactin • Tumors • Inflammation: sarcoidosis, meningitis • Infiltration • Infarction • Trauma/XRT • Drugs: anabolic steroids

  11. Male Infertility • Production: • Testes: • Congenital: Klinefelters (XYY), developmental disorders • Disorders of gonadal steroidgenesis • Infection: chlamydia, prostatitis, mumps orchitis • Autoimmune • Cryptorchidism • Tumors; chemo/XRT • Drugs / alcohol • Vascular: testicular torsion

  12. Male Infertility • 2. Storage: • Temperature • Rise in scrotal temperature • Occupation • Varicocoele

  13. Male Infertility • 3. Delivery: • Impotence/Ejaculation • Neurogenic: medications (α-blockers, methyldopa) • Endocrine: diabetes • Congenital: absence vas deferens (CF) • Genetic: cystic fibrosis • Primary ciliary dyskinesia: Kartagener syndrome • Hypospadia • Vasectomy

  14. Male Infertility • History: • Previous children • Infections: prostatitis, STD, mumps orchitis • Trauma to head or testicles • Surgery to testicles or hernia • Occupation (sitting, bio hazards) • Chemo or Radio therapy • Ethanol or Smoking • Medication • Medical history (DM, HTN) • Previous investigations

  15. Male Infertility • Physical • Anatomy (meatus) • Testicular size • Varicocele (valsalva) • Rectal exam (protatitis, discharge)

  16. Male Infertility • Investigations: • semen analysis • Abstain 2-4 days prior • At least 2 samples over different period of time • If abnormal: • Blood work: FSH, LH, TSH, testosterone, PRL • Testicular U/S • Chromosomal analysis

  17. Male Infertility • Semen analysis: • WHO (1992) • Volume > 2.0 mL • Sperm > 20 million/mL • Motility > 50% forward progression or > 25% rapid progression within 60 min • Morphology > 30% normal forms • WBC < 1 million/mL

  18. Male Infertility • Tx / Interventions: • Treat underlying causes • Intrauterine Insemination (IUI) • Intracytoplasmic Sperm Injection (ICSI)

  19. Female Infertility • Fecundability: probability of achieving a pregnancy within 1 menstrual cycle (25%) • Fecundity: ability to achieve a live birth within 1 menstrual cycle (6%)

  20. Female Infertility • Production • Storage • Delivery

  21. Female Fertility • Production: • Hypothalamus • Pituitary • Ovary

  22. Hypothalamic-Pituitary-Gonadal Axis

  23. Female Infertility • Hypothalamus: • Stress • Exercise • Eating disorders • Psychogenic • Congenital/genetic: Kallman’s syndrome (hyposmia & hypoplasia olfactory lobes of brain) • Starvation/stress or severe illness • Tumors (craniopharyngioma, metastatic tumor) • Head injury • Inflammation (sarcoidosis) • Infection (tuberculosis) • XRT • Drugs

  24. Female Infertility • Pituitary: • Sheehan syndrome • Tumors: Pituitary adenoma, metastatic • Empty sella syndrome • Inappropriate gonadal steroid feedback: • estrogen excess: obesity/ tumors • estrogen deficiency: aromatase deficiency/ ER gene mutation • androgen excess: adrenal or ovarian • PCOS • Testicular feminization (46 XY) - absenceandrogen receptors

  25. Female Infertility • Ovary • Gonadal dysgenesis - Turner’s Syndrome 45XO or mosaics 46 XX/45 XO • Testicular feminization • XRT / Chemo for childhood malignancies • Premature ovarian failure

  26. Female Infertility • Storage (R.P.L. unless severe) • Uterine abnormalities • Mullerian Agenesis: Mayer-Rokitansky-Kuster-Hauser syndrome • Leiomyoma • Luteal phase deficiency

  27. Female Infertility • Delivery: • Uterine abnormalities • Vaginal septum • Tubal Disease • Infections/ STD/PID • Ruptured appendix • Septic abortion • Endometriosis

  28. Female Infertility • History: • Age • GTPAL • Regulatory of period • Prolactin S/S • Thyroid S/S • Infections, Surgeries • Medication, Smoking, Ethanol • Medical history • Previous investigations

  29. Female Infertility • Examination: • Thyroid • Breast (milk) • Abdomen (masses, scars) • Vaginal (abnormalities) • Bimanual (Uterus, masses)

  30. Investigations • Blood work: • TSH • PRL • D3 FSH • D3 LH • Luteal phase Progesterone • Imaging: • Pelvic Ultrasound • HSG • Diagnostic • Laparoscopy (later)

  31. Treatment • Treat the underlying cause • Medical • Surgical

  32. Treatment • Anovulation: • Clomiphene induction  IUI • Gonadotropin  IUI • IVF • Bilateral tubal disease • Unexplained infertility after Gonadotropin + IUI failure. • Failure of the above • ICSI • Male factor • Unexplained infertility

  33. Take Home Points • DDx – Hx – Px – Inv - Rx • Age is important factor for female • Hypothalamic-Pituitary-Gonadal axis central in working up both male and female infertility • Investigations: • Male: Sperms • Female: Tubes (HSG) + Ovaries (FSH, LH, PRL, TSH)

  34. Multiple Choice Questions

  35. Infertility is defined as unprotected coitus for ___ months, without conception : • 3 • 6 • 9 • 12

  36. Spermatogenesis and sperm maturation is regulated by : • Leydig Cells • Sertoli Cells • Vas Deferens • Intermediate Cells

  37. Cause/s of male infertility is / are : • Kallaman’s syndrome • Craniopharyngioma • Marijuana abuse • All of the above

  38. Normal semen count is ___ million / ml • ≥ 15 • ≥ 20 • ≥ 25 • ≥ 30

  39. Indication/s for semen analysis is / are : • Investigation for infertility • to check effectiveness of vasectomy • for selection of donor for artificial insemination • All of the above

  40. Thank you

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