evaluation and options in managing subfertile couple
TRANSCRIPT
Evaluation and options in Managing Subfertile Couple
Dr Edawati Dahrawi Edrus Obstetrics dan Gynaecology
Hospital Umum Sarawak
MARRIED COUPLE
Not Pregnant ?
Subfertility
Failure to conceive within 12 months ofregular sexual intercourse without any formof contraception.
Woman older than 35 years -- have notconceived during a 6-month period of trying.
Average incidence globally: 15% (varies in different population)
Conception & Subfertility
•The chances of spontaneously conceiving at any given menstrual cycle is 20%
• Main event leading to pregnancy is ovulation, fertilization & implantation THUS any event interfering with these results in subfertility
• The single most important determinant of a couple’s fertility is the age of the female partner:
• At the age of up to 25 years CCR is 60% at six months and 85% at one year
• At the age of 35 years or more the CCR is 60% at one year and 85% at two years
CCR – Cumulative Conception Rate
• About 84% of couples would conceive within one year of trying for a pregnancy
• Another 8% would conceive in the next year giving a cumulative pregnancy rate of 92% at the end of two years
NORMAL
• Female reproductive organ
• Menstrual cycle
NORMAL
• Male reproductive organ
Male spermatogenesis
Factor for Infertility
30-40%
UNEXPLAINED 5-15%
Couple does not conceive and no definite of infertility can be diagnosed after a complete
evaluationcause
FEMALE FACTOR
OVARIAN FACTOR
• Anovulation
Anovulation
• Hyperprolactinaemia
• Obesity
Ovarian Failure
• Repeated surgery on ovaries
• Chemoradiation• Primary Ovarian Failure• Pemature Menopause
Pelvic Inflammatory Disease (PID)
• Tubal block
• Previous tubal surgery/Ectopic pregnancy
• Uterine Factor
• Uterine Fibroid
• Adenomyosis
• Uterine Septum
• Uterine polyp
• Submucosa Fibroid
• Uterine adhesions
• Transcervical Resection
• TCRF (firbroid)• TCRP (polyp)
MALE FACTOR
NORMAL SPERM COUNT
• Parameter WHO 1999 WHO 2010• Volume 2 ml 1.5 ml• Concentration 20 million/ml 15
million/ml• Progressive motility 50% 32%• Normal forms 14% 4%
MALE FACTOR
• Oligospermia
• Asthenospermia
• Teratozoospermia
• SUPPLEMENT FOR oligoasthenoteratozoospermia
• CLOMID
• HCG and MENOPUR injection
• Azoospermia
SURGICAL MANAGEMNT FOR AZOOSPERMIA
• PERCUTANEOUS SPERM ASPIRATION (PESA)
• Testicular Biopsy (TESE/TESA)
Assessment of Subfertility Patient
Assessment of Female and Male partnerFemale – Ovulation , Tubal PatencyMale – Sperm Analysis
Investigation
FEMALE• HormoneRegular mensesD2-D5 FSH/LHD21 Progesterone
Irregular mensesD2-D5/Random FSH/LHSerum ProlactinThyroid Function Test
FEMALEPCOSTestosteroneFasting lipid profileFasting blood sugar/MOGTT
Tubal PatencyHysterosalphingogram (HSG)Laparoscopic Dye Insufflation
Female• Infective screening - Hepatitis B/C/HIV/VDRL - Rubella Ig G
Male• Semen Analysis• Infective screening - Hepatitis B/C/HIV/VDRL
HYSTEROSALPINGOGRAM (HSG)
GENERAL ADVICE
Management of Infertility
• Timed Sexual Intercourse (TSI)
• Intrauterine Insemination (IUI)
• Invitro Fertilization (IVF)/Intracytoplasmic Sperm Insemination (ICSI)
OVULATION INDUCTION
Timed SI
• Cumulative pregnancy rate 40% in 4 attempts
• May try for 3-6 cycles depends on patient age, duration of infertility and response to ovulation induction.
Suitable for• Anovulatory cycle• Patent tubes• Mild male factor
IUI
• Available in Hospital Umum Sarawak
• Success rate 10-15 %
Suitable for• Mild male factor- Sperm > 10 million /ml- Motility > 40%• Anovulation• Patent tube/tubes• Failed Times SI – 2-4
times
• IUI
IVF VS ICSI
IVF VS ICSI
IVFBlocked tubesModerate to severe endometriosisSperm count > 10 million/mlSperm motility >40%Failed IUI treatment
ICSIMale factor-moderate to severe oligospermia- Poor motility sperm- Immotile sperm- Azoospermia but sperm
available through PESA/TESE/TESA
IVF/ICSI
• IVF/ICSI stimulation
IVF stimulationTransvaginal scan (TVS)
OOCYTE RETRIEVAL (OR)
EMBRYO TRANSFER(ET)
EMBRYO TRANSFER (ET)DAY 2/3/5
Luteal Support
Post Embryo Transfer
Succcess Rate
Depends on Factor of Infertility and maternal ageFactors lower success rate1. Advanced age2. Poor responder3. Endometriosis4. Adenomyosis5. PID with Hydrosalphinx6. Male Factor
COMPLICATIONS
• OHSS• Injury to bowel ,
bladder• Injury to vessel• Puncture site
bleeding/haematoma• Pelvic Infection• Multiple Pregnancy
• Failed IVF• Miscarriage• Ectopic Pregnancy• Damage to stored
embryos• Psychological
complications• Medicolegal
complications
COMPLICATIONS
Ovarian Hyperstimulation Syndrome (OHSS)
Multiple Pregnancy
WELCOME TO KUCHING
THANK YOU