INFERTILITY DEFINITION of Infertility What is Infertility Infertility

INFERTILITY

DEFINITION of Infertility What is Infertility? Infertility is defined two years of unprotected intercourse without pregnancy. (WHO, one year) Primary Infertility : no previous pregnancies have occurred; Secondary Infertility: a prior pregnancy has occurred;

Causes Female factors Male factors Both male and female factors unexplained factors Percentage 40 -55 % 25 -40 % 10 %

Female Factors Ovulatory dysfunction: 1. Hypothalamic dysfunction; 2. Pituitary Insufficiency; 3. Ovarian factor (peripheral defect); 4. Others: thyroid or adrenal dysfunction; Pelvic factors. P: 1. Tubal factors: injury, blockage, adhesion; 2. Uterine factors; 3. Cervical factors; 4. Extra-genital tract factors;

Female Factors Hypothalamus Pituitary Follopian tube Uterine ovary oocyte Cervix Extra-genital tract sperm Thyroid Adrenal

Male Factors 1. Abnormal spermatogenesis congenital; chronic diseases; infectious factors; 2. Obstructive; 3. Immunologic factors; 4. Endocrine disorders; 5. Sexual dysfunction;

Both Male and Female Factors 1. No demonstrable cause; 2. Psychological factors; 3. Immunologic factors; count for 10%; autoimmune response; auto-antibodies;

Initial Visit n n n The initial visit is the most important; The infertility is a problem of couple; The male partner should be present; History: both male and female; The guide to diagnostic and treatment plans;

Examinations n n n Physical examination; Bimanual examination Rectal-Vaginal-examination Laboratory; Assistant imaging;

Examinations n n Laboratory: semen analysis hormone measurement; sperm penetration assay (SPA) postcoital examinition of cervical mucus immunologic examination; Assistant imaging : Unltrasound Hysterosalpingogram Hysteroscopy Laparoscopy

Examination and Diagnoses Initial evaluation History Physical exam Irregular menses No ovulation HSG Tubal blockage anovulation Tubal factor Normal evaluation unexplained HSG or Hysteroscopy Abnormal of uterine Uterine factor Further Investigate and Treatment Abnormal Semen analysis Male factor

Normal Values for Semen Analysis Volume Sperm concentration Motility morphology Data from WHO, 1992 > 2. 0 m. L > 20 million/m. L >50 % >30 % normal

Methods to monitor ovulation n n n Luteinizing Hormone monitoring: LH surge; after 34 -36 hr occur ovulation; Basal Body Temperature: simple, cheap, biphasic pattern; Mid-luteal serum progesterone: > 3 ng/m. L, peak; Premenstrual molimina: 95% presence; Mucus change: thick and cellular, no crystalline fern; Ultrasound monitoring: follicle size 21 -23 mm, fluid in the cul-de-sac.

Treatment-female factor Causes anovulation Tubal factor Anatomic factor immunologic azoospermia genetic disease after surgery unexplained Treatment induction of ovulation； tuboplasty, microsurgery； medication or surgery； immune inhibition； Assisted Reproductive Technologies (ART)

Induction of ovulation n 1. Clomiphen ：ER binding Gn. RH , FSH/LH dosage： 50 mg, period day 5 th， 5 days； 2. Gonadotropin therapy ： Indications: Hypogonadotropic hypogonadism; Pituitary dysfunction; COH (controlled ovarian hyperstimulation) in IVF; HMG: human menopausal gonadotropins; FSH 75 IU/LH 75 IU, IM or SC; Recombinant FSH: 75 IU, SC; 3. HCG: 5000 -10000 IU;

Induction of ovulation n 4. Gonadotropin releasing hormone agonist (Gn. RH-a)：hypothalamic factor, as COH; protocol: according the every Gn. RH-a component and feature, the time of start and discontinuation are different; zoladex; decapeptyl, dipherenline, enantone; 5. Gn. RH antagonist; 6. Bromocriptine 溴隐停: high PRL;

Assisted Reproductive Technologies (ART) n n n Intrauterine insemination ( IUI) In vitro fertilization and embryo transfer (IVF-ET) Intracytoplasmic sperm injection (ICSI); Gamete intrafallopian transfer (GIFT)

Intrauterine insemination ( IUI) n n n Indications: 1. as treatment of male factor infertility; 2. psychological factors; 3. unexplained infertility; 4. genetic defects; Types: 1. artificial insemination with husband’s sperm (AIH); 2. artificial insemination by donor (AID); Method: placement of about 0. 3 ml of washed, processed and concentrated sperm into the intrauterine cavity by trans-cervical catheterizaion.

In vitro fertilization and embryo transfer (IVF-ET) n n Indications: 1. tubal factor; 2. endometriosis; 3. unexplained infertility; 4. IUI failure; 5. Immunologic factors; Method: 1. Superovulation: COH, Gn. RH-a/FSH(HMG)/HCG; 2. Aspiration of eggs; 3. Fertilization with capacitated sperm; 4. Culture of fertilized egg in the lab; 5. Replacement of fertilized egg into the uterus;

Gamete intrafallopian transfer (GIFT) n n Indications: 1. unexplained infertility; 2. endometriosis; 3. IUI failure; 4. Premature ovarian failure (POF); 5. Immunologic factors; Method: 1. Superovulation is induced as IVF-ET; 2. HCG injection is given; 3. Follicle are aspirated via laparoscopy; 4. Sperm mixed with egg; 5. Replacement of fertilized egg into fallopian tube;

ART Complications n n n Multiple gestations Pre-eclampsia Ovarian hyperstimulation syndrome (OHSS) Premature birth Low birth weight Long term emotional, social and psychological impact