infertility.ppt

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2013/6/11 1

Our topics todayUterine prolapse

Amenorrhea

Dysfunctional uterine bleedingPCOS

Infertility

Peri-menopause period syndrome

Zhao aimin MD.Ph.D

SSMU



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Uterine prolapse



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Definition

The uterus gradually

descends in the axis of the

vagina taking the vaginalwall with it. It may present

clinically at any level, but is

usually classified as one of three degrees.



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Degrees of uterine prolapse

First degree :cervix still inside vagina



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Second degree :the cervix appears outside the

vulva. The cervical lips may become congested and

ulcerated



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Third degree :complete prolapse.In the picture the uterusis retroflexed,and the outline of bladder can be seen.This issometimes called complete procidentia.



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Causes

The stretching of muscle and fibrous

tissue

Increased intra-abdominal pressure



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In recent years,the incidence of prolapse

is greatly reduced .The more liberal use

of caesarean section and the elimination

of labours are probably the two most

important factors.



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Symptoms

Something coming down

Backache

Increased frequency of micturition

A ‘bearing down’ sensation

Stress incontinence

Coital problems

Difficulty in voiding urine



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Treatment

Pessary treatment

Indications

Patient prefers a pessary.Pelvic surgery risks

Prolapse amenable to pessary

The patient is not fit for surgery

Patient wishes to delay operation



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Surgery

Anterior colporrhaphy

(and repair of cystocele) Posterior colpoperineorrhaphy

(including repair of rectocele)

Manchester repair

Vaginal hysterectomy



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Dysfunctional Uterine Bleeding

(DUB)



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Definition

an abnormal uter ine bleeding without an

obvious organic abnormali ty (neoplasma,

pregnancy, inf lammation, trauma, blood dyscrasia,hormone adminstration ，at el)

unnormal releasing of sex hormones



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Anovulatory functional bleedingovulatory functional bleeding

DUB occur inbefore the menopause(50%)

after menarche(20%)

in reproductive times(30%).



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Anovulatory functional bleeding



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Etiology of DUB:

1. disorders of

hypo thalamus---p i tui tary ---ovary axis

immature of feedback regulation in young women

ovarian function failure in climacteric women

2.other Factors: the effects of sex hormones

nervous

circumstance

PCOS,TSH↑,PRL↑

excessive physical exercise



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Pathology

Change in the endometrium

simple hyperplasia(Cystic hyperplasia , benign)

complex hyperplasia(Adenomatous

hyperplasia ,precursor of carcinoma)

atypital hyperplasia(10%-25%→ carcinoma)

proliferative phase of endometrium (nosecretive change )

atrophic endometrium



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Mechanisms

Anovulation ----

have developing folliculi

no mature follicle

no corpus luteum

only have estrogen, but no

progestin

breakthrough bleeding, spoting



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Clinical presentation

oligomenorrhea.

polymenorrhea

hypermenorrhea

hypomenorrhea

irregular intervals and duration



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Diagnosis

1.History

history of age of menarche,

initial regularity of cycle,

cycle length, amount, duration of flow,

parity, contraceptive pill

abortion, ectopic pregnancy,

endometriosis,

pelvic inflammatory disease



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hemorrhagic diseases,

endocrinopathies,

traumas,

nutritional status

To decide :the dysfunctional bleeding or

anatomic abnormality



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2.physical examinationpelvic vaginal examination (PV)

3.laboratory diagnosis bleed count, coagulation studies,

endocrine studies

curettage



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Treatment

medicine treatment1. to arrest the acute bleeding progesterone--- secretive change,

high doses of estrogen---rapid hemostasis

2.maintenance therapy

( restoration of normal menstruation, artificial cyclical therapy )

cyclic estrogen-progestin therapy

cyclic low dose oral contraceptive for 3 month ( for adolescent)

continue cyclic low dose oral contraceptive,( no fertility demands)

3. induce ovulationClomiphene, HMG, FSH,GnRH)



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Curettage

for adults

rarely use for teenagers unless bleeding is

very severe)

aims 1.arrest an acute severe bleeding quickly and

effectively

2.to prevent chronic recurrence of DUB3.diagnosis



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Hysterectomy: for older patient,

never been done in adolescent



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Ovulatory functional bleeding

A significant percentage of patient is

women of childbearing age.

1.Luteal phase defect

Pathology :

corpus luteum is short-lived

luteal phase is short

inadequate secretion of progesterone



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Clinical presentation

polymenorrhea-

premenstrual staining

diagnosis basal body temperature (BBT)—-bi-directional

endometrium biopsy specimen taken just

before menses reveal to bad for secretive phase



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treatment HCG (5000-10000U 14th day)

progestin(15th day X 10 days)

ovulation induction

(Clomiphone, HMG, FSH,

mature follicle --- good corpus luteum)



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2. Irregular shedding of endometrium

pathology persistent corpus luteum

estrogen and progesterone

maintain to effect the endometrium



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Clinical presentation:

delayed onset of menses with hypermenorrhea Regular cycles with hypermenorrhea

Diagnosis:endometrium biopsy specimen taken on 5th days

after the onset of bleeding, reveal a mixture of

persistent secretive glands with the proliferative

glands



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Treatment progestin ( 5 days before next

menstruation, feedback)

ovulation induction



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Amenorrhea

It is symptom, not a disease

have many causes.



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Definition

Primary amenorrhea

lack of menarche by age of 16 years

No secondary sexual signs by age

of 14 years

Secondary amenorrhea

the cessation of menstruation for at

least 6 months (or 3 cycles) in womenwho has her menarche.



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Etiology

Physiologic causes:

childhood

pregnancy

lactation

menopause

Pathologic causes:1.uterus or lower reproductive tract endometrial destruction (Asherman’s syndrome)

cervical stenosis congenital dysgenesis (imperforate hymen, no

uterus)



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2.Ovary ovarian tumor,

premature ovarian failure

resistant ovary syndrome

polycystic ovarian syndrome

gonadal dysgenesis

( 75% chromosome abnormality,

Turner’s syndrome,45,XO)



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3.central nervous system

hypothalamus – pituitary tumors or other organic lesions

amenorrhea- galactorrhea syndromes(PRL↑)

empty sella syndrome

Sheehan Syndrome

hypogonadotropic hypogonadism

pituitary insufficiency



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4. psychogenic psychosis

emotional shock

pseudocyesis(假孕)

5.systemic chronic disease

nutritional disorders

hepatic and renal dysfunction



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6. other endocrine cause

adrenal hyperplasia, tumors ,or insufficiency

hyperthyroidism or hypothyroidism

diabetes mellitus

steroidal contraception

7. congenital anatomic

developmental anomalies



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Diagnosis

History

physical examination

determination : T4 ,T3,TSH, PRL ,E2, P, T, FSH, LH,

medicine withdrawal test(step by step)

chromoseme test

MRI,CT



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No menses

↓

↓ ↓

progesterone therapy PRL↑

↓

↓ ↓

menses no menses

I°

amenorrhae ↓ estrogen – progesterone therapy

↓

↓ ↓

menses (II°amenorrhae) no menses

↓ ↓ uterus amenorrhea



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↓

determination of LH ,FSH↓

↓ ↓

high GnRH, low estrogen normal, or low gonadotropins

↓ ↓

ovarian failure pituitary ,or hypothalamus amenorrhea↓give GnRH

↓ ↓

LH ,FSH high LH ,FSH low

↓ ↓

hypothalamus pituitaryamenorrhea amenorrhea



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Treatment

remove etiologic factors

estrogen-progesterone therapy

achieving normal menstruation,

achieving normal sexualfunction

preventing carcinoma

ovulation induction (fertility)

surgical correction (tumor, congenital

anatomic)



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Polycystic Ovary Syndrome(PCOS)



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Pathology

an inversion of the normal

LH/FSH ratio

lack of ovulation

increased levels of male

hormones ("androgens")

insulin resistance



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Presentation

irregular or absent

menstruation/ovulation

infertility

undesired hair growth and acne

small benign cysts on the ovaries

increased risk of miscarriage

obesity

endometrial cancer, heart disease

and diabetes



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Diagnosis

BBT (basal body temperature)

B ultrasound:

multiple small ovarian cysts

enlarged ovary Endometrium biopsy(Curettage )

before menses reveal to proliferative glands

Determination of LH,FSH,E2,P,T,PRL，Ins，

(LH:FSH≧3:1) Laparoscopy



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Treatment

If pregnancy is desired ------cause ovulation

anti-estrogens(clomiphene)

Gonadotropinsinsulin-lowering agents

anti-androgens (agents that lower

androgen levels)

gonadotropin releasing hormoneagonists (GnRHa)



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If pregnancy is not desired

to reduce the risk of endometrial cancer( birth control

pills)

cyclical progesterone (MPA, Provera)

insulin-lowering agents (metformin ,Glucophage)

anti-androgens.



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Peri-menopausal Period Syndrome(Climacteric Syndrome)



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Definition

Menopause the cessation of menses for a year or more.

It is caused by ovarian failure.

It marks the end of a women’s reproductive life

It occurs normally between the ages of 45 – 55 years and at a mean age of 51 years.

It is a physiological process

Peri-menopause is a period immediately beforeand after the menopause.



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Premature ovarian failure ----- the

cessation of menses before the age of 40years.

Artificial menopause ------ the cessation of menses is secondary to some causes,

such as oophorectomy, radiation therapy.



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Peri-menopausal Period Syndrome

peri-menopause accompanied by the symptoms

of climacteric, including hot flashes, excessive

perspiration, night sweets, depression, agitation,

vaginal dryness, insomnia

The basic causes of the climacteric syndrome

are a progressive decline in ovarian production

on estrogens and other sex hormones



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Negative Feedback

Secretion of estrogens decreased (ovary)

↓

FSH increased (40-45 years old)

↓

FSH,LH increased(45-50 years old)

↓

FSH increased 14 times

LH increased 3 times(menopause)

↓

FSH, LH gradually decline (3 years after menopause)



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Symptoms and signs

1. Early Symptoms and signs

1) menstraution disorder

Oligomenorrhea--- intervals greater than 35 days. Polymenorrhea---- intervals less than 21 days

hypermenorrhea

amenorrhea

menopause



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2) vasomotor symptoms( hot flashes, sweats)

oestrogen depletion result in instability in the

vessels of the skin.

The hot flashes begins on the chest and spreads

quickly over the neck, face and upper limbs

which lasts only seconds but may recur many

times one day. Sweat often follows hot flashes.



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3) mood changes and sleep disturbances

insomnia, headache, backache, depression, hate,

having difficulty falling asleep and waking up

soon after going to sleep

4)urinary tract problem

atrophic change in the urethrovesical epithelium

decreased elastic tone of the uterine and

urethrovesical supporting structures



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5) vaginal dryness and genital tract atrophy

atropic vaginitis, dyspareunia

the vaginal skin become thin and loses its

rugose appearance

small red spots appear on the vagina



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2. Late symptoms and problems

6)osteoporosis Accelerated bone loss in women is clearly

related to the loss of ovarian function.

Studies show that a rapid decrease in bonemass occures within 2 months of ovariotomy



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After natural cessation of ovarian function, bone

loss 3% yearly for the first 6 years

By age 65, half of women have bone density

decreased by 2 standard deviations below the

perimenopausal mean.

Beyond age 45, the incidence of wrist fractures is

12 times higher in women than in men of same

age



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There is now general agreement that

postmenopausal osteoporosis is related toestrogen deficiency

Estrogen reduce bone resorption more than theyreduce bone formation

Other factors

lack of exercise

Malabsorption of calcium



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7) cardiovascular lipid changes

atherosclerosis(动脉硬化)

HDL,LDL, total cholesterol ,

perimenopaual women have a lower incidence of coronary heart disease than men of same age.

This observation led to the supposition thatestrogen might be a key factor.

But recent data suggest that Estrogen has nosuch protection against heart disease

Diagnosis



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Diagnosis

1) Historymenstrual abnormality

2) Symptoms: vasomotor symptoms, vaginal

dryness, urinary frequency, insomnia,irritability, anxiety, skin change, breastchanges, urinary tract problem, pelvic floor change( cystocele. Rectocele. Prolapse),

skeletal change(backache, ) and so on.



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3)Physical examination:

The clinical findings vary greatly depending onthe time elapsed since menopause and theseverity of the estrogen deficiency

Skin: thin ,dry

Breast loss turgor

The labia are small

The uterus becomes much smaller

The muscles of the pelvic floor are looser in toneand are thin

Prolapse may be present



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4) Laboratory diagnosis

Cytologic smear from the vaginal wall

E2, FSH, LH determination

Radiography, X-ray densitometry



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Treatment 1) education, understanding, reassurance

2) hormone replacement therapy(HRT)

Estrogen therapy

The use of estrogens can relieve themenopausal symptoms.

The hot flashes , sweats and other complaints

disappear or improve within a few days of starting estrogens therapy .



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The adminis t rat ion of estrogen wi thout progestogen increases the r isk of

endometr ia l cancer and breast cancer.

So, co rrect cy cl ical therapy , w ith 10 days

progestogen per month , can reduces the

inc idence of c ancer .



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Contraindication

thrombo-embolish

hypertension

diabetes

chronic liver disease

myomo, endometriosis,

breast disease

gallbladder disease



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3) traditional medicine therapy



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Infertility Lin jianhua



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Definition

defined as not being able to get

pregnant despite trying for one

year.

10 percent of couples are affected

Primary infertility: never conceived

Secondary infertility: at least oneprevious pregnancy



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Pregnancy is the result of a chain of events.

A woman must release an egg from one of her

ovaries (ovulation).

The egg must travel through a fallopian tube

toward her uterus (womb). A man's sperm must join with (fertilize) the egg

along the way.

The fertilized egg must then become attachedto the inside of the uterus.



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Causes

The incidence of male factors andfemale factor infertility are similar

Ovary factor 25% (anovulation)

Tubal and pelvic factor 25％ Uterine factor<5%

Cervical factor <5%

Male factor 30%

Unexplained infertility 15%



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Ovulatory factor Ovulatory disfunction

Anovulatory Amenorrhea

Investigated as follow by means of Mid-luteal (day 21-23)progesterone in serum

Endometrium biopsy at the end of a cycle

BBT(basal body temperature)

Mid-cycle LH surge in urinary

Blood test: LH, FSH, pro lact in, thy roid fun ct ion ,

androgen

*ultrasound



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Anatomical factor:Tubal disease following pelvic

inflammatory disease(PID)

Intraperitoneal

scarring(PID,endometriosis)



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Uterine factor:

Polyps

Submucosal fibroids

Endometrial scarring



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Cervical factors:

By mid-cycle(day 13-15) ample clear watery mucus with good

stretchability is produced

Be favorable to sperm survival

Abnormal cervical factor may relate to

poor cycle timing,

poor mucus production (surgery,inflammation) an abnormal male factor

Male factor



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Male factor:semen analysis

Volume 1.5-5.0ml

Count>20 million/ml. 40X106/total

Initial motility(<1 hour)50%

Normal Morphogy>30%

No clumping or significant WBC(<1 million/ml)

Information on coital frequency and ejaculatorydifficulty should be sought



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The step of test

The assessment of both partners should beginsimultaneously

History

Physical examination

Ovulation detection(menstrual histo ry,BBT,serium

progester ine,ur inary LH,serial ul trasound )

Evaluation of tubal patency (Hysterosalpingogram, HSG,

Laparoscopy)

Evaluation of uterine cavity (HSG, Hysteroscopy)

Cervical factor (postcoital testing, PCT)



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Male infertility factor

unexplained infertility

t t t



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treatment

Depending on the test results, different treatmentscan be suggested

Various fertility drugs may be used for women withovulation problems.

should understand the drug's benefits and sideeffects.

Ovulation induction:

Clomiphene HMG(human manopausal gonadotropin)

FSH(follical stimulating hormone)

HCG(human chorionic gonadotropin)



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surgery can be done to repair

damage to a woman's ovaries,

fallopian tubes, or uterus.



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Assisted reproductive technology (ART)

uses special methods to help infertile couples.

ART involves handling both the woman's eggsand the man's sperm.

Success rates vary and depend on many factors.

ART can be expensive and time-consuming.

But ART has made it possible for many couplesto have children that otherwise would not havebeen conceived.



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Intrauterine insemination

Artificial insemination with husband’s sperm(AIH)

Artificial insemination by donor (AID)

IVF(i it f tili ti )



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IVF(in vitro fertilization) 1978 birth of Louise Brown, the world's first " tes t

tube baby”. used when a woman's fallopian tubes are blocked or

when a man has low sperm counts.

A drug is used to stimulate the ovaries to producemultiple eggs.

Once mature, the eggs are removed and placed in aculture dish with the man's sperm for fertilization.

After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are

dividing into cells. these fertilized eggs (embryos) are then placed in the

woman's uterus



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Gamete intrafallopian transfer

(GIFT):

is similar to IVF, but used when the

woman has at least one normalfallopian tube.

Three to five eggs are placed in

the fallopian tube, along with the

man's sperm, for fertilization inside

the woman's body.



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Zygote intrafallopian transfer

(ZIFT),

ICSI (intracytoplasmic sperm

injection)



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ART procedures sometimesinvolve the use of donor eggs

(eggs from another woman) or

previously frozen embryos.

Donor eggs may be used if a

woman has impaired ovaries or

has a genetic disease that couldbe passed on to her baby.

Key Word



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Key Word

Infertility

Ovulation induction

ART

IVF

What are the causes of infertility?

Explaining the steps of infertility

test.



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infertility.ppt