Download - Pcos and infertility
PATHOLOGICALCLINICO-
CORRELATION
SUPERVISOR:DR. TAN NUGROHOCIPTO RIYANTO
MOHD
HANAFISURYA
RAJMICHAEL
WONGANGEL
KWANNUR
AINURAFATIN
AKMALCPC
HISTORY
• 33 | nullipara | obese• Fertility | after 5 years marriage
• Menarche: 13 (regular)• Currently: Irregular menses | Weight gain
• Day 2: FSH 3.5 mIU/ml | LH 5 mIU/ml
Infertility is defined as failure to conceive after one year of unprotected coitus at frequent intervals.
Primary Infertility
happened in woman who has never conceived
Secondary Infertility
happened in a woman who has conceived before
DEFINITION: INFERTILITY
AETIOLOGY: INFERTILITY
Unexplained infertility; 28
Male factor; 21Ovulatory disorder; 18
Tubal diseases; 14
Endometriosis, Fibroid; 9
Coital problems; 5
MALE: INFERTILITY ADVICES
– 2nd most common cause– BMI > 29 may reduced fertility. – increased scrotal temperature. – excessive alcohol consumption
(NICE,2004). – smoker’s sperm concentration is
on average 13-17% lower than non-smokers. (Jenkins et. al 2003)
FEMALE: INFERTILITY ADVICES
– declines with age. (NICE, 2004)
– Moderate weight loss (Health Education Authority, 1996).
– limit their alcohol intake (Jensen et al 1998).
– stop smoking (RCOG, 1998). – Genital tract infection
(Winter and Ahmad, 1998)
COMMENT THE
FINDINGS?ULTRASOUND
1
WHAT IS THE SUGGESTIVE
AND HOW TO DIAGNOSE
THAT DISEASE?
2
DIAGNOSIS?
POLYCYSTICOVARIAN SYNDROME
• Is a heterogenous disorder affecting the reproductive, endocrine and metabolic systems.
• PCOS is often complicated by chronic anovulatory infertility and hyperandrogenism with the clinical manifestation of oligomenorrhoea, hirsutism and acne
WHAT IS PCOS
Genetically have insulin receptor disorder and thus insulin resistance- HYPERINSULINAEMIA
During puberty- GH spurt- IGF1 ↑↑Hyperinsulinaemia+IGF1 cause ovarian hyperstimulation
Ovarian hyperstimulation- cause thecal cell hyperplasia and excessive androgen production
PATHOPHYSIOLOGY: PCOS
HYPERINSULINAEMIA- also act on liver to reduce sex hormone binding globulin (SHBG)- increase free testosterone
Increased LH production by anterior pituitary relative to FSH. Cause theca cell stimulation. Cyst formation
Follicles do not mature due to premature surge in LH. Decreased FSH:LH cause inability of ovary to convert androgen to estrogen.
PATHOPHYSIOLOGY: PCOS
• Rotterdam criteria for diagnosis• The diagnosis of PCOS requires the
exclusion of all other disorders that can result in menstrual irregularity and hyperandrogenism:
HOW TO DIAGNOSE: PCOS
congenital adrenal hyperplasia
cushing syndrome
androgen secreting tumours
hyperprolactinaemia
1
• polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume up to 10mm3)
• -via TVUS
2• oligo- or anovulation (manifested as oligo- or amenorrhea)
3• clinical and/or biochemical signs of hyperandrogenism.
Rotterdam criteria for diagnosisTwo or more of the three following criteria:
HOW TO DIAGNOSE: PCOS
Clinical
• Early sign-acne• Later develop
hirsuitism or even male pattern alopecia
Biochemical
• Free serum testosterone level (not more than 5nmol/L)
CLINICAL AND/OR BIOCHEMICAL
SIGNS OF HYPERANDROGENISM
A raised luteinising hormone/follicle-stimulating hormone ratio (LH:FSH 2:1) is NO LONGER
a diagnostic criteria!!!!
SCENARIO
• Husband: Seminal fluid – severe oligoasthenoteratoazoospermia
• Day 21 serum progesterone – not ovulating
• Ovarian stimulating induction + IVF
• Advice patient - abstinence from sex and masturbation for 2 - 7 days prior
• collected in a private room near the laboratory to limit the exposure of the semen to fluctuations in temperature and to control the time between collection and analysis
• semen sample needs to be complete & should report any loss of any fraction of the sample
PREPARATION: SEMEN SAMPLING
• obtained by masturbation and ejaculated into a clean and wide mouthed container
• specimen container should be kept at ambient temperature, between 20 °C and 37 °C
• placed on the bench or in an incubator (37 °C) while the semen liquefies.
COLLECTION: SEMEN SAMPLING
• Sample need to be completed. Report if incomplete.
• Record the time of semen production and sent to lab within 1H. Temperature kept between 20 °C and 37 °C during transport of sample
• Noted at report place of collection (home / outside the lab)
HOME: SEMEN COLLECTION
• Collected in a condom during sexual intercourse
• Only special non-toxic condoms designed used
• Information on how to use the condom, close it, and send or transport it to the laboratory.
• Record the time of semen production and sent to lab within 1H. Temperature kept between 20 °C and 37 °C during transport of sample
• Noted at report place of collection (home / outside the lab)
CONDOM: SEMEN COLLECTION
SEMEN ANALYSIS: WHO
• > 1.5 mLVolume
• ≥ 7.2pH
• 39 × 10^6 spermatozoa per ejaculate
Total Sperm Number
• 15 × 10^6 spermatozoa per mlSperm Concentration
• Sperm Motility :– Progressive motility (PR): spermatozoa moving
actively, either linearly or in a large circle, regardless of speed.
– Non-progressive motility (NP): all other patterns of motility with an absence of progression, e.g. swimming in small circles, the flagellar force hardly displacing the head, or when only a flagellar beat can be observed.
– Immotility (IM): no movement.– Total motility (PR + NP) is 40%– Progressive motility (PR) is 32%
SEMEN ANALYSIS: WHO 2010
• Sperm Vitality (membrane-intact spermatozoa): 58% or more
• Sperm Normal Morphology (regular oval head, with a connecting mid-piece and a long straight tail): > 4%
SEMEN ANALYSIS: WHO 2010
• Normozoospermia: total number of spermatozoa, and % of progressively motile (PR) and morphologically normal spermatozoa ≥ lower reference limits
• Oligozoospermia: Total number of spermatozoa <39 × 106 spermatozoa per ejaculate or concentration of spermatozoa <15 × 106 spermatozoa per ml
• Asthenozoospermia: Progressively motile (PR) spermatozoa <32%
NOMENCLATURE: WHO 2010
• Teratozoospermia: < 4% morphologically normal spermatozoa
• Azoospermia: No spermatozoa in the ejaculate
• Aspermia: no semen (no or retrograde ejaculation)
NOMENCLATURE: WHO 2010
WHAT DOESOLIGOASTHENOTHERATOZOOSPERMIAMEAN?
3
• Total number/concentration of spermatozoa, and percentages of both progressively motile (PR) and morphologically normal spermatozoa, below the lower reference limits
OLIGOASTHENOTERATOZOOSPERMIA
COMMENT ON THEREASON OF USING
DAY 21PROGESTERONE TESTTO CHECK OVULATION?
4
1. Normal menstrual cycle
2. Length of menstrual cycle (28 days)
3. Not on hormonal therapy/OCP/ hormonal contraception interfere normal hormonal changes
4. If on OCP, stop at least 1 month before test
CRITERIA FOR TEST
Ideal progesterone test done 21 days after breeding(Progesterone is high)
- Normal Day 21 progesterone level in functioning corpus luteum > 30ng/ml
- ↓ Day 21 progesterone level
Anovulatory cycles (no ovulation & no corpus luteum formation to secrete the progesterone)
Abnormal menstrual cycle
Length of the menstrual cycle
On hormonal therapy/OCP/ hormonal contraception
5
WHAT ARE THE POSSIBLE
COMPLICATIONSASSOCIATEDWITH
IVF?
• Tubal problems: blocked or damaged Fallopian tubes
• Severe endometriosis• Pelvic inflammatory disease with
severe adhesion• Male factor• Unexplained infertility
INDICATIONS OF IVF
• IVF is basically a safe procedure. • As with any medical or surgical procedure, a
few patients undergoing IVF treatment will experience side effects and complications.
• The most common complications associated with IVF treatment are the:
COMPLICATIONS OF IVF
Failure of treatment
Ovarian hyperstimulation
Multiple pregnancy,
The possibility of ectopic pregnancy.
Bladder, bowel injury and other risk related to egg retrieval
The steps of IVF are as follows:• Ovulation Induction • Retrieval • Insemination of eggs and embryos culture • Transferring embryos to the uterus
WHAT IS IVF?
• optional if women can ovulate normally • the stimulatory phase of an IVF cycle must begin
on the third day of the menstrual cycle.• patients receive daily injections of gonadotropins
– hormones, which stimulate your ovaries to produce multiple eggs.
• The ultimate goal of IVF stimulation is to achieve the maximum number of mature follicles- eggs-without over stimulation.
OVULATION INDUCTION
OVARIAN HYPERSTIMULATION SYNDROME (OHSS)
majority of women have a mild or moderate form of the syndrome and invariably resolve within a few days unless
pregnancy occurs, that may delay recovery.
complain of pain, a bloated feeling and mild abdominal swelling.
In a small proportion of women, the degree of discomfort
Mild to Moderate
OVARIAN HYPERSTIMULATION SYNDROME (OHSS)
Very rarely is severe and the ovaries are very swollen.
The woman will feel ill, with nausea and vomiting, abdominal pain.
Fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. Reduction in the amount of urine
produced. These complications require urgent hospital admission to restore the fluid and electrolyte balance, monitor progress, control pain and in some very
serious cases, termination of pregnancy.
Complications associated with severe OHHS include blood clotting disorders, kidney damage and twisted ovary (ovarian torsion).
Severe
Women with polycystic ovaries.
Over response to fertility drugs.
Young thin women.
High estrogen hormone levels and a large number of follicles or eggs.
Administration of GnRh agonist.
The use of hCG for luteal phase support.
CAUSES OF OHSS
When the eggs are “ready”, that is, the majority of eggs are ripe for harvesting but
they are not yet truly mature.
Retrieval is done after at least 3 mature follicles of 18
mm or more to produce a mature egg, a final injection
must be taken.
This final shot is called HCG.
minor surgical-Follicles are located by ultrasound and
then a needle is guided through the vaginal wall into the ovary to aspirate the eggs
from the follicles.
It is at this time, shortly rafter the conclusion of the egg
retrieval,
that we ask the male partner to produce a semen sample
Mature eggs will be collected by ultrasound guided needle
aspiration.
This technique is performed in the office with IV sedation.
RETRIEVAL
ICSI
intracytoplasmic sperm injection
inject a single sperm into each egg.
48 hours the fertilized eggs – now called embryos – will be left alone in
the incubator- for 3 to 5 days.
the embryos will have been carefully examined
INSEMINATION OF EGGS AND EMBRYO CULTURE
IVF
In-Vitro Fertilisation
decision regarding the number of embryos to transfer is not always easy
depends on such things as patient age, past IVF cycles and the quality of the embryos.
objective is to maximize the chance of pregnancy while minimizing the chances of multiple
pregnancies.
the embryos will be transferred by placing very small flexible catheter into your cervix and injecting the embryos.
continue to take Progesterone (shots, pills or pessaries)
A pregnancy test will be done 2 weeks after the transfer
If the test is positive Progesterone shots are continued as instructed (serum B-HCG).
TRANSFERRING EMBRYOS TO UTERUS
6TH WEEK AFTER IVF
• c/o lower abdominal pain associated with per vaginal bleed for 2/7
• pain more marked on right side radiated to the back
• vomited several times• pain temporarily relieved by analgesia
• Blood pressure: 90/60 mmHg (↓)• Pulse rate: 110 beats per minute (↑)
• Abdomen examination: tender on the right iliac fossa (RIF) with no mass palpable
• Vaginal examination: cervical os was closed with some old blood seen on
posterior fornix• Minimal cervical excitation and no adnexal
mass palpable
ON EXAMINATION
DIAGNOSIS
POSSIBLE
-RELATED
PREGNANCY
LIST 46
Ectopic pregnancy• Pregnancy occurring in sites other than endometrium of the
uterus.
Threatened miscarriage• Vaginal bleeding (usually fresh bleed and painless) with a closed
cervix prior to 22 weeks of pregnancy
Molar pregnancy• Pregnancy in which a hydatid mole develops from the
trophoblastic tissue of the early embryonic stage of development
Impending miscarriage (inevitable)• Onset of miscarriage process and will end as either complete,
incomplete or septic miscarriage
7COMMENT THE
FINDINGS?ULTRASOUND
Empty uterus, free fluid in pouch of Douglas (POD)
a gestational sac extra uterine
ECTOPICDX
PREGNANCY
RUPTURED
EVENTUALLY
• An emergency laparatomy was done and found to have 2 litres of haemoperitonium
and ectopic pregnancy of right tube.
• Subsequently, right salphingectomy was done and she was discharged after 3 days
from ward.
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