FEMALE INFERTILITY

Sharon Treesa Antony

First Year M.Sc Nursing
Govt College Of Nursing
Kottaym
Infertility is a failure to conceive
within one or more years of
regular unprotected coitus.
Review of physiology of reproductive
system
 GnRH ( hypothalamas)

 FSH/LH(pituitary)

 Estradiol (ovary)
Ovarian cycle
 Recruitment of groups of follicles (FSH)
 Selection of dominant follicle and its
maturation(FSH, highest estrogen containing
follicle)
 Ovulation (LH surge, FSH surge)
 Corpus luteum formation(maintained by LH,
produces progesterone, life: 12-14 days)
 Demise of the corpus luteum ( due to
withdrawal of tonic LH support)
Endometrial cycle
 Stage of regeneration (2-3 daays after

menstruation)

 Stage of proliferation(D5/6 –D14, due to rising

ovarian estrogen)

 Stage of secretion( due to estrogen&

progesterone from corpus luteum.D15 to 5-6 days

before menstruation)

 Menstruation ( fall in estrogen& progesterone)

TYPES
 PRIMARY

 SECONDARY
CAUSES
OVARIAN FACTORS
Anovulation or oligoovulation
 Turner’s syndrome

 Hypothyroidism

 Ovarian tumors

 X ray/ radioactive exposure

 General ill health

 Poor diet
Cont...
• BMI <20/>24
 Use of easily digested carbohydrates (white
bread)
 PCOS
 Stress
 High insulin or glucose levels
TUBAL FACTORS
 Chronic salpingitis

 History of tubal ligation

 PID

 STDs
 IUCD
 Multiple sexual partners
UTERINE FACTORS
 Fibroids

 Congenital deformation

 Low estrogen /progesterone from ovary

 Endometriosis in ovaries/ fallopian tubes

CERVICAL FACTORS
 Coitus after 12 – 72 hours after ovulation

 Infection

 Stenotic cervical os

 Obstruction of os

 Repeated cervical surgeries

 Anti sperm antibodies

VAGINAL FACTORS
 Infections

 Sperm immobilizing or agglutinating antibodies

DIAGNOSTIC TESTS
History
 Age

 Duration of marriage

 History of previous child bearing

General Medical History
 TB
 STDs
 Diabetes mellitus
 Pelvic Inflammation
The surgical history
 Abdominal / pelvic surgery
Menstrual history

 Hypo/ oligo/amenorrhea
Previous Obstetric History
 No. of pregnancies, interval between them

 Pregnancy related complications

 Premature rupture of membranes

 Puerperal sepsis
Contraceptive Practice

 IUCD may lead to PID

Sexual problems
 Dyspareunia

 Loss of libido
General examination
 Obesity

 Marked reduction in weight

 Abnormal distribution of hairs

 Underdeveloped secondary sexual characters

Systemic Examination
 Hypertension

 Organic heart disease

 Chronic renal lesion

 Endocrinopathies
Gynaecologic Examination
 Adequacy of hymenal opening
 Adnexal masses
 Evidence of vaginal infections

 Cervical tear or chronic infections

 Undue elongation of cervix

 Uterine size, position

Speculum examination
 Abnormal cervical discharge
DIAGNOSIS OF OVULTION
Indirect methods
 Menstrual history

 Features of ovulation
 Regular normal menstrual loss
 Mittelschmerz syndrome
 PMS/ Primary dysmenorrhoea
Evaluation of peripheral/ end organ
changes
 Basal body temperature : biphasic pattern
 Cervical mucus study:
 disappearance of fern pattern after 22nd day
suggests ovulation
 Loss of stretchablity which was present in
midcycle
 Vaginal cytology:

 Vagina contains: parabasal/intermediate/

Superficial

Maturation index

Preovulatory period: 0/40/60

Mid secretory : 0/70/30

Hormone Estimation
 Serum progesterone: on D8 and D21
Increase from <1ng/ml to 6ng/ml indicates
ovulation

• Serum LH: daily in midcycle

Ovulation occurs 34-36 hours after beginning of LH
surge/ 10-12 hours after LH peak
 Serum oestradiol: peak rise 24 hours prior to LH
surge and about 24-36 hours prior to ovulation

 Urinary LH: ovulation occurs within 14-26 hours of

urinary LH surge
 Endometrial biopsy: sharman curette /pipelle
endometrial sampler. Done D21- D23.
Evidence of secretory activity in 2nd half of cycle.
 Sonography
 Graffian follicle prior to ovulation(18-20mm)
 Recent ovulation (collapsed follicle and fluid in
POD)
Direct methods
 Laparoscopy
 Recent corpus luteum
 Detection ovum in aspirated peritoneal fluid from
the POD
CONCLUSIVE
 Pregnancy
LUTEAL PHASE DEFECT ( poor
function of corpus luteum)
 BBT chart
 Slow rise of temperature taking 4-5 days following
the fall in midcycle
 Rise of temperature sustains < 10 days
• Endometrial biopsy (D25 –D27)
Lagging at least 2 days
 Serum progesterone
D8: <10ng/ml
Luteinised Unruptured Follicle
 Sonography: persistence of echo free dominant
follicle beyond 36 hours after LH peak

 Laparoscopy

 Ovarian biopsy: ovum in the middle of corpus

luteum
DIAGNOSIS OF TUBAL FACTORS
Dialatation and insufflation test
 Done in post menstrual phase at least 2 days
after stoppage of bleeding.
 Air/ CO2
 Fall in pressure when raised> 120 mmHg
 Hissing sound in illiac fossa
 Shoulder pain
Hysterosalpingography
 Dye injection

 Reveals site of block, uterine abnormalities

Laparoscopy and chemopertubation
 Done in secretory phase

 can see recent corpus luteum and take

endometrial biopsy

 Laparoscopic visualisation of pelvis, tubes and

ovaries

 Inject methylene blue to check tubal patency

 Sonosalpingography

 Under USG

 Inject saline / air through a foley’s catheter

 Detects tubal patency, peritubal adhesions,

unsuspected endometriosis
Hysteroscopy and falloposcopy
 To study interstitial part of tube

 A soft pliable cannula can be used to brake small

synechiae
Ampullary and fimbrial salpingoscopy
 To study the mucosa of fallopian tube

 Inject starch into pouch of Douglas; presence of

starch in cervical mucous 24 hours after injection
indicates tubal patency
Salpingoscopy
 Rigid endoscope is inserted through the fimbrial
end of tube through a laparoscope
DIAGNOSIS OF UTERINE FACTORS
 USG

 HSG

 Hysterscopy

 Laparoscopy
DIAGNOSIS OF CERVICAL FACTORS
Post coital test
 Done D12- D13
 Report to clinic within 8-12 hours of intercurse
 Aspirate endocervical mucus
 Visualise under high power microscope

 10 progressively motile sperm/HPF : normal

 Immotile sperm with normal sperm count:
immunological factors
Sperm cervical mucous contact test
 In vitro cross over test

 Midcycle endocervical mucous & semen

Vs
Donor’s mucus and semen
TREATMENT
Couple instructions
 Assurance

 Obtain optimum BMI

 No alcoholism and smoking

 Have intercourse during midcycle

 Detect urine LH surge

OVULATORY DYSFUNCTION
ANOVULATION
 Ovulation Induction

 Psychotherapy

 Reduce weight
Drugs
 Stimulation of ovulation
 Clomiphene citrate
 Letrozole
 hMG
 FSH
 hCG
 GnRH
 GnRH analogues
 Correction of biochemical abnormality
 Metformin
 Dexamethasone
 Bromocriptine
 Substitution Therapy
 Thyroxin
 Anti diabetic drugs
Clomiphene Citrate
 INDICATIONS

 Normo gonadotrophic normo prolactinemic with

normal cycles& absent/ infrequent ovulation

 PCOS with oligomenorrhea/ amenorrhea

 Hypothalamic amenorrhea
 ACTION
 Blocks estrogen receptors in hypothalamas

 Increased GnRH pulse amplitude

 Increased gonadotrophin secretion

 DOSE

 Initial 50mg daily; max: 250mg daily

 Start between D2-D5, for 5 days

 Ovulation expected to occur about 5-7 days after

last day of therapy

 Usually 6 cycles
Letrozole
 Inhibits aromatase in granulosa cells

 Suppress estrogen synthesis

 25mg from D3 – D7

 Stimulates development of ovarian follicle

Gonadotrophins
 Ovarian reserve must be present(FSH<10 IU/L 0n
D3)

 INDICATIONS
 Hypogonadotrophic hypogonadism
 Clomiphene failed/ resistant
 Unexplained infertilty
 DOSE SCHEDULE
 hMG stimulates follicular growth (75IU IM/day)
 Start on D2-D5
 Continue for 7-10 days
 monitor follicular growth &s. Estradiol
 Optimum levels
 S.estradiol-500-1500pg/ml
 Max follicular diameter:18-20mm
 At opt.levels,hCG 5000-10000IU IM to induce

ovulation ( favourable if endometrial thickness is

8-10mm)

 Ovulation occurs 36 hours after hCG

administration
Gonadotrophin releasing
hormone
 Stimulates physiolgic levels of pituitary
gonadotrophin secretion
 INDICATIONS

 Hypothalamic amenorrhea

 Hypogonadotrophic hypogonadism

 Women with hyperprolactinemia

 DOSAGE

 IV/SQ infusion pump

 5 microgram IV every 90 minutes
 Follicular growth is similar to a normal menstrual
cycle
GnRH Analogues
 INDICATIONS
 Refractory to gonadotrophins
 Elevated LH
 Premature follicular luteinisation
 Premature ovulation due to premature LH surge
 ACTION

For down regulation of pituitary gland by

desensitisation of pituitary GnRH receptors

 hCG is administered as in hMG therapy

GnRH antagonists
 Blocks pituitary GnRH receptors

 Luteal phase support by hCG/ progesterone

Luteal Phase Defect
 Natural progesterone PV 100mg TDS from day of
ovulation until menstruation/ 10th week of
pregnancy.
 hCG
 Clomiphene citrate
 IVF
Luteinised unruptured follicle
 hCG

 Ovulation inducing drugs with hCG

 Bromocriptine in hyperprlactinemia
SURGERY
 Laparoscopic ovarian drilling or laser vaporisation
( multiple puncture of cysts in PCOS)
 Wedge resection of ovaries bilateral
 For pituitary prolactinomas
 For removal of ovarian or adrenal tumor
Tumour and peritoneal factors
 Salpingo ovariolysis: peritubal adhesions
 Proximal tubal block
 salpingography
 tubal cannulation under hysteroscopic guidance
 Distal tubal block:
 fimbrioplasty
 Neosalpingostomy
 Midtubal block : reversal tubal ligation
Adjuvant therapy
 Antibiotics
 Adhesion prevention devices
 hydrotubation
CERVICAL FACTORS
 Conjugated estrogen 1.25 mg daily from D8 for 5

days

 Chlamydia/M.Hominis: Doxycycline 100 mg BD

IMMUNOLOGICAL FACTOR
 Antisperm antibodies: dexona o.5 mg at bedtime
in the follicular phase
UTEROVAGINAL SURGERY
 Myomectomy

 Metroplasty

 Adhesiolysis

 Enlargement of vaginal introitus

 Removal of vaginal septum

 Amputation of cervix

 Gilliam type operation

Attempt for pregnancy after infertility
surgery
 Microsurgical tubal anastamosis:6 weeks

 Uterotubal implantation: 6 months

 Salpingostomy:6-12 mon

 Surgery for endometriosis: soon following surgery

 Myomectomy/metroplasty: 3-6 months

 Adhesiolysis: soon after surgery

Unexplained infertiliy
 Induction of ovulation

 IUI

 Superovulation+IUI

 ART
ARTIFICIAL INSEMINATION

FALLOPIAN TUBE
INTRAUTERINE SPERM
INSEMINATION PERFUSION
Intra Uterine Insemination
INDICATIONS
 Hostile cervical mucus

 Cervical stenosis

 Oligospermia/asthenozoospermia

 Immune factors

 Male : impotency/anatomical defect

 Unexplained infertility
Procedure
 Washing
 Swimming up
 Centrifugation
 injection
Timing
 Spotnaneous cycles:IUI*2 on D12 and D14

 Clomiphene citrate induced cycles: 5& 7 days after

completion of CC

 Urinary LH detection: 24 hours after detection

 Use hCG & sonography: hCG at 18 mm of follicle

IUI *2 following 34-40 hours of hCG administration

THANK YOU