DR. ZEINAB ABOTALIBDR. ZEINAB ABOTALIB

Associate Professor & ConsultantAssociate Professor & Consultant

Ob/Gyne Dept.Ob/Gyne Dept.

DEFINITION:DEFINITION:A couple is considered infertile after unsuccessfully A couple is considered infertile after unsuccessfully attempting to achieve pregnancy for one year.attempting to achieve pregnancy for one year.

TYPES:TYPES:PrimaryPrimarySecondarySecondary80% of couple will conceive within the first year:80% of couple will conceive within the first year:25% within 1st month25% within 1st month60% within 6 months60% within 6 months75% by 9 months75% by 9 months90% by 18 months90% by 18 months

After 18 months of unprotected sexual intercourse, the After 18 months of unprotected sexual intercourse, the couple have low monthly conception rate without couple have low monthly conception rate without treatment.treatment.

CAUSES:CAUSES:

1.1. Female:Female:– Ovulatory – PCO, hyperprolactinemia, thyroid dysfunction, Ovulatory – PCO, hyperprolactinemia, thyroid dysfunction,

obesity, age, stress.obesity, age, stress.– Tubal – Adhesions, ectopic, PIDTubal – Adhesions, ectopic, PID– EndometriosisEndometriosis– ? Fibroid? Fibroid– CervicalCervical

2.2. Male Male – OligospermiaOligospermia– AzozpermiaAzozpermia– AsthermospermiaAsthermospermia– Poor morphologyPoor morphology

3.3. UnexplainedUnexplained30% of couples will fall into this category30% of couples will fall into this category

4.4. Multiple causes will be in 40% of cases.Multiple causes will be in 40% of cases.

MANAGEMENT:MANAGEMENT:

1.1. HistoryHistory Female -Female -most women with regular cycles (every 22 to most women with regular cycles (every 22 to 35 35 days) days) are ovulating especially if they have are ovulating especially if they have premenstrual premenstrual molimina.molimina. Male -Male - especially smoking, type of work, mumps, especially smoking, type of work, mumps, sexually sexually transmitted disease.transmitted disease.

2.2. ExaminationExamination FemaleFemale MaleMale -- Height, size of the testes, Height, size of the testes,

secondary sexual charactetistics.secondary sexual charactetistics.

3.3. Investigation:Investigation: Basal body temperature chart, spinnbarkeit test.Basal body temperature chart, spinnbarkeit test. FSH, LH, Prolactin level, thyroid function (follicular FSH, LH, Prolactin level, thyroid function (follicular phase phase of the cycle)of the cycle)

Progesterone, D21 of the cycleProgesterone, D21 of the cycle Laparoscopy + dye test. HSGLaparoscopy + dye test. HSGHysteroscopyHysteroscopy

4.4. Semen AnalysisSemen Analysis

TREATMENTTREATMENT::According to the causeAccording to the cause::1.1. Ovulation inductionOvulation induction

Oral -Clomiphen citrate which is anti oestrogen Oral -Clomiphen citrate which is anti oestrogen ↑FSH ↑FSH

Injections – Gonadotropines, e.g. Menogon, Injections – Gonadotropines, e.g. Menogon, which contains FSH which contains FSH and LHand LH

Monitoring by ultrasoundMonitoring by ultrasound Risks of treatment Risks of treatment

multiple pregnancymultiple pregnancy hyperstimulation syndromehyperstimulation syndrome

2.2. Hyperprolactinemia– Bromocriptin (Dopamin receptor Hyperprolactinemia– Bromocriptin (Dopamin receptor agonist)agonist)

3.3. TubalTubal Laparoscopic adhesolysisLaparoscopic adhesolysis SalpingoplastySalpingoplasty

4.4. Intrauterine insemination (IUI)Intrauterine insemination (IUI)5.5. IVF or ICSIIVF or ICSI

IndicationsIndicationsBilateral tubal blockageBilateral tubal blockageUnexplaine infertilityUnexplaine infertilitySerial treatment cycles with IUI and no pregnancySerial treatment cycles with IUI and no pregnancyMale factorMale factor

PCO:PCO:Polycystic ovaryPolycystic ovary– Usually in obese womanUsually in obese woman– Revised FSH: LH ratio, in the proliferative Revised FSH: LH ratio, in the proliferative

phase of the cyclephase of the cycle– ↑ ↑ Oestrogen Oestrogen – HirsutismHirsutism– Raised level of circulating insulinRaised level of circulating insulin– Raised blood sugarRaised blood sugar

DIAGNOSIS:DIAGNOSIS:1.1. HistoryHistory -- irregular cycleirregular cycle

-- oligonorrhoeaoligonorrhoea-- InfertilityInfertility-- ? galactorrhoea? galactorrhoea

-- recurrent abortionsrecurrent abortions

2.2. Examination:Examination: -- Usually obese but it can happen Usually obese but it can happen in in thin patientsthin patients

-- HirsutismHirsutism3.3. Investigation:Investigation:

↑ ↑ LHLH FSH may be normalFSH may be normal ↑ ↑ OestrogenOestrogen Free testosterone may be ↑ or normalFree testosterone may be ↑ or normal Ultrasound - multiple small cysts at the Ultrasound - multiple small cysts at the

periplery periplery of the ovary looks like necklace.of the ovary looks like necklace.

Laparoscopy – thick, enlarged non-active Laparoscopy – thick, enlarged non-active ovariesovaries

TREATMENT:TREATMENT:

Weight reductionWeight reduction

Induction of ovulationInduction of ovulation

MetforminMetformin

Laparoscopic ovarian Laparoscopic ovarian diathermydiathermy

IVFIVF

HYPERPROLACTINEHYPERPROLACTINECould be due to:Could be due to: Stress – one reading is not enough Stress – one reading is not enough

to ∆ hyperprolactinemia.to ∆ hyperprolactinemia. Secondary to ↑ TRH as in cases of Secondary to ↑ TRH as in cases of

hypothyroidism.hypothyroidism. Drugs – antihypertensive or Drugs – antihypertensive or antidepressantsantidepressants Macro or micropituitary adenoma.Macro or micropituitary adenoma. Can lead to infertility by Can lead to infertility by preventing preventing ovulation or by causing ovulation or by causing luteal luteal defects.defects.

DIAGNOSIS:DIAGNOSIS:

History History e.ge.g. drugs. drugs

Examination Examination -- galatorrhoeagalatorrhoea

-- visual equityvisual equity

InvestigationInvestigation -- prolactin levelprolactin level

-- lateral skull X-lateral skull X-rayray

-- CT ScanCT Scan

TreatmentTreatment --Bromocriptin ? Bromocriptin ? SurgerySurgery

HIRSUITISM:HIRSUITISM:Pathological - PCO, adrenal cortex Pathological - PCO, adrenal cortex

tumers, Cushion syndrometumers, Cushion syndrome

ConstitutionalConstitutional

SITE:SITE:FaceFace

ChestChest

Anterior abdominal wallAnterior abdominal wall

INVESTIGATION:INVESTIGATION:Free testosterone level, ATCH, FSH, LHFree testosterone level, ATCH, FSH, LH

TREATMENT:TREATMENT:

Difficult Difficult needs reassurance needs reassurance

Hair removal by different methodsHair removal by different methods

DianeDiane

Cypretone acetate – anti-androgenCypretone acetate – anti-androgen

Treatment will take long timeTreatment will take long time