Quid Refert, Dummodo non Desinas, Tardius Ire
INFERTILITY 2
GYNECOLOGY
INFERTILITY
1 year of unprotected intercourse without pregnancy
- So we are not talking about the marriages or the wedding instead we
are talking about their sexual activities. If so happen that they are
having premarital sex for more than 1 year but still at this point hindi
ka pa rin nabuntis still you are diagnose with infertility.
CLASSIFICATION
PRIMARY INFERTILITY
No previous pregnancies have occurred
SECONDARY INFERTILITY
A prior pregnancy, although not necessarily a live birth, has
occurred
With history of regardless of what happen to that pregnancy
either you end up with abortion or fetal death that means you
are already diagnosed with secondary infertility.
CUASES OF INFERTLITY
The exact incidence of the various factors causing infertility varies among
different population and cannot be precisely determined
Not true causes of infertility
Anti-sperm antibody
Luteal phase defect
Subclinical genital infections
Hypothyroidism
Hypo-prolactinemia
AGE AND DECREASE OVARIAN RESERVE
An association between the age of the woman and reduced fertility has
been well documented.
The decline in fecundability begins in the early 30s and accelerates during
the late 30s and early 40s.
Chronologic age is the strongest determinant of reproductive success in
both spontaneous and ART cycle
Fertility rates began to drop after 30 years of age.
Ovarian reserve refers to the size of the nongrowing, or resting, primordial
follicle population, which presumably determines the number of growing
follicles and the “quality” or reproductive potential of their oocytes.
Age is the best predictor of ovarian reserve,
Inhibin B
Secretion increases during the luteal–folicular transition
Reflects the overall granulosa cell function
Suppresses the production of FSH by the pituitary gland.
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DR. NER 3
SPONTANEOUS ABORTION
Another factor contributing to decreased fecundity among older
reproductive–age women is the increased risk of spontaneous abortion in
this population.
One major cause for the increase in spontaneous losses among older
women is their increased incidence of chromosomally abnormal
conceptuses.
AGE OF MALE PARTNER
There is little doubt that increasing age is accompanied by reduced female
fecundity.
The age–related decline in fecundity for men is more controversial.
Male fertility peaks at about 35 years of age and declines sharply after 45
years of age.
FEMALE AND MALE FACTORS
Infertility may be a result of one or more male or female factors
Female and make factors are almost equally responsible for infertility
- There a lot of causes of infertility almost 50% either male factor or
female factor.
Evaluating both partners is essential
Cases to ask to the patient of what maybe the reason for infertility
Sexual timing
Positioning
Multiple ejaculation (number of ejaculation) --. Causing oligospermia
REQUIREMENTS FOR FEMALE INFERTILITY
Adequate sexual drive and sexual function
Vagina capable of receiving sperm
Normal cervical mucus to allow sperm passage
Patent fallopian tubes
Ovulatory cycles
Uterus capable of developing and sustaining pregnancy
Adequate hormonal status to maintain pregnancy
Normal immunologic responses to accommodate sperm and conceptus
Adequate nutritional and health status to maintain nutrition and
oxygenation of placenta and fetus.
- If you are malnourished the tendency is you will not have a good egg
or good uterine lining. You will not end up with healthy viable tissue
inside leading to fetal death causing your secondary infertility.
CAUSES OF FEMALE INFERTILITY
Pelvic inflammatory disease (PID) leading to blocked or damaged fallopian
tubes
May interfere with fertilization and transport of egg
One problem most of the time today is Pelvic inflammatory disease
with vaginal discharge. Because binabalewala lang to the point that
the infection wen up already to the area of fallopian tube causing a
lot of adhesions
Ovarian dysfunction resulting in absent or diminished egg production
Local factors in the uterus and cervix
May interfere with implantation and woman’s ability to carry
pregnancy to term
LUTEAL PHASE DEFECT
Results in low production of progesterone may lead to early
miscarriage.
 Jay 
 There are females that have a short cycle. So there is luteal phase
defect. After ovulation the corpus luteum dies early leading to
decrease progesterone.
Production of anti-sperm antibodies can interfere with fertilization
Females whose vaginal secretions seems to be allergic with sperm
leading formation of anti-sperm antibodies.
CAUSES OF INFERTILTY AFFECTING BOTH PARTNERS
- Cigarette smoking and excessive caffeine consumption have been
shown independently in several studies to decrease chances of
coneption
- Vaginal douching also reduces the chance of conception by 30%
FAMILY HISTORY
Genetically related illnesses
Birth defects
History of age of menopause in female family members

Psychological SYMPTOMS
Sexual behavior may reflect couple’s desire not to have children Endocrine disorders
Immunological incompatibility Weight changes
May cause sperm agglutination Skin changes
Unknown causes  Look if the female is obese or not, look also for signs and
Very alarming nowadays because you don’t know what will be the symptoms of PCOS such as hyperpigmentation, acne
etiology causing your infertility. formation, and alopecia.
PHYSICAL EXAMINATION
BASIC WORK UP FOR INFERTLITY Extreme of body mass
Skin changes
Evaluating both partners is essential Thyroid size
Detailed history and PE for both Breast secretion
Male factor: Sperm analysis Abnormal pain on abdominal or pelvic exam
- Important initial examination. Anybody can undergo seminalysis just Assessment of the vagina and cervix
abstain for 3 days and after you submit your ejaculate to the Vaginal ultrasound
laboratory.
Female factor LABROARTORY TEST
- There are a lot to document in female.
HEALTHY ASYMPTOMATIC WOMEN
FEMALE FACTORS CBC
Blood type and RH type
CAUSES Rubella status
Decreased ovarian reserved Pap smear within 12 mos
- Then try to look for the possibility that the woman is older already so Cystic fibrosis screening
the follicles are now decreasing kaya hindi na siya mag-kakaanak, Currently recommended for all women as well as other genetic
wala nang follicle na lumalabas. test in certain populations
Ovulatory disorders (ovulatory factor) Infectious disease screening
Tubal injury, blockage, paratubal adhesions Chlamydia
- Try to look also for the problem in the fallopian tube. For example Gonorrhea
you have 3 or 4 boyfriend in the past and all of them have history of Syphilis
chlamydial infection ( ang harsh naman ni doc) therefore lahat sila HIV
nakahawa sayo ng chlamydial infection without feeling anything hepatitis
nadamage na pala yung fallopian tube. WOMEN >35 y/o
Uterine factors FSH
- For example myomas. In myoma there is an increase in vaginal FSH values are abnormal if > 10 miU/ ml  suggestive of
menstrual bleeding, and pain trying to increase the size of the decrease ovarian reserve which is the pool of viable oocytes
uterus. remaining in the ovary
Systemic conditions Estradiol
Cervical and immunologic factors >15mU/mL: poor ovarian reserve
Unexplained factors >20mU/mL: bad prognosis
E2 >70pg/mL: decreases prognosis regarding ovarian reserve
EVALUATION ADDITIONAL TESTING
Measurement of serum TSH and prolactin in ovulatory women
Diagnostic evaluation should be thorough and completed as rapidly as Luteal-phase endometrial biopsy
possible Measurement of anti-sperm antibodies in both male and female
Preliminary information that the woman is ovulatory provided by a history Bacteriologic cultures of the cervical mucus and semen
of regular menstrual cycle Hamster egg penetration test
If woman have regular menstrual cycle --. Serum progesterone should be Anti- mullerian (AMH) or mullerian inhibiting substance has become a
measured in the mid-luteal phase valuable standard for assessing ovarian reserve produce by granulosa cells
Serum progesterone of > 10ng/ml is indicative of adequate luteal function of small growing follicles suppressing FSH stimulation of sustained
MEDICAL HISTORY follicular growth.
Previous pregnancy complication
Previous pelvic surgery OVULATORY FACTORS
Significant dysmenorrhea
Dyspareunia or sexual dysfunction Account for 30-40% of all cases of female fertility
Abnormal cytology or cervical abnormalities Most easily diagnosed and most treatable causes of infertility
Use of medications The normal length of the menstrual cycle in reproductive–age women
Drugs and tobacco use varies from 25 to 35 days, and most women have cycle lengths of 27 to 31
- For women who smoke a lot their ovulation tends to be irregular. days.
Sometimes because of the nicotine content there is blockage of the Ovulation must be documented as part of the basic assessment of
blood supply of the ovaries leading to poor growth and development Infertile anovulation (complete absence of ovulation)
of the follicles. Oligo–ovulation (infrequent ovulation).
Women with minimal symptoms are almost always ovulatory

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 Premenstrual breast swelling - First sign of ovulation seen by the pathologist is the presence of
Dysmenorrhea vacuoles. The presence of vacuoles in the basal part of the cell
signifies that ovulation had occurred.
METHODS TO DOCUMENT OVULATION Diagnostic of luteal phase defects
BASAL BOSY TEMPERATURE 2-3 days before expected onset of menses

Easiest and least expensive ULTRASOUND MONONOTORING

The least expensive method of confirming ovulation is for the patient to
record her temperature each morning on a basal body temperature (BBT) You are able to see in UTZ
chart. There is an increase in sized of the follicle
The oral or rectal temperature should be determined before the patient transformation into dominant follicle
arises, eats, or drinks. presence of corpus luteum
Smoking is forbidden before temperature measurement, and irregular Development of dominant follicle until ovulation takes place
sleep patterns can interfere with the test results. Ovulation
The secretion of progesterone causes a temperature increase of about Decrease in follicular size and (+) fluid in the cul-de-sac
0.58°F over the baseline temperature of 97° to 98.8°F typically recorded Follicular size reaches about 21-23mm, although it may occur with follicles
during the follicular phase of the menstrual cycle. as small as 17 mm or as large as 29 mm
Patient records temp. daily Its use should be confirmed to the monitoring of ovulation induction or
Taken shortly after awakening only after at least 6 hours of sleep prior to superovulation
ambulation
Temperature elevation lasts 10 days during luteal phase LUTEAL PHASE DEFECT
- Slight increase in body temperature once you ovulate due to effect
of progesterone because after ovulation the remnant of the You ovulated but it is short.
dominant follicle would form into corpus luteum and this will When 2 endometrial biopsies show a delay of >2 days beyond the actual
produce progesterone affecting now the brain center so therefore cycle in the histologic development of the endometrium
increasing your body temperature. Short luteal phase by BBT
Provides information concerning the approximate day of ovulation Temperature elevation <11 days
MOA
MIDLEUTEAL SERUM PROGESTERONE Inadequate progesterone secretion  poor secretory endometrial
development  delay in endometrial maturation
Indirect evidence of ovulation Lead to: failure of implantation, early abortion
Normal luteal phase serum progesteron levels vary in a pulsatile manner CAUSES:
A serum progesterone level of >10ng/mL is indicative of adequate luteal Inadequate follicular development
function. Inadequate FSH secretion
Levels of 10 ng/mL or higher are found during at least 1 day of the luteal Abnormal LH secretion
phase of normal ovulatory cycles in which conception occurred Abnormal effect of progesterone on the endometrium
When used to document ovulation, serum progesterone measurement Associated with hyperprolactinemia
should coincide with peak progesterone secretion in the midluteal phase (+) discomfort and inconvenience in repeated endometrial biopsies.
(typically on days 21–23 of an ideal 28– day cycle). Luteal deficiency can be determined by
finding serum progesterone levels consistently below 10 ng/ml 1
LH MONOTORING week before menses
Histologic evidence of a delay in development of the normal
Prior to ovulation if you are going to monitor the LH there is slight increase secretory endometrial pattern indicating inadequate progesterone
this is what we call the LH surge (sudden increase). What trigger the production in the endometrium.
sudden increase of LH? It’s the estradiol (E2) produce by granulosa cell This finding must be found in atleast 2 cycles to meet the
(theca cell). criteria
Reproducible method of predicting ovulation
Ovulation occurs 34-36 hours after the onset of LH surge and 10-12 hours PCOS
after LH peak
Detection of true elevation difficult The most common cause of oligo–ovulation and anovulation—both in the
Because of peak levels of LH occur 1 day before ovulation measurement of general population and among women presenting with infertility
LH by urinary LH immunoassay is the best way to determine the optimal The diagnosis of PCOS is determined by exclusion of other medical
time to have intercourse or insemmination conditions and the presence of two of the following conditions
Oligo–ovulation or anovulation (manifested as oligomenorrhea or
amenorrhea).
Hyperandrogenemia (elevated levels of circulating androgens).
Hyperandrogenism (clinical manifestations of androgen excess).
Treatment
Ovulation induction refers to the therapeutic restoration of the
release of one egg per cycle in a woman who either has not been
ovulating regularly or has not been ovulating at all.
WEIGHT LOSS
A body mass index (BMI) above 27 kg/m2 is considered
excessive; moreover, an increase in BMI is associated with an
increased risk for insulin resistance.
CLOMIPHENE CITRATE
Figure 30.5 Relative hormonal fluctuations in normal, ovulatory, 28 day Insulin sensitizers ( metformin)
menstrual cycle Gonadotropin therapy
Surgical treatment
ENDOMETRIAL BIOPSY Wedge resection of the ovaries  reduce the volume of
androgen producing tissue
Proliferative endometrium- pre-ovulatory cycle pa lang siya
Secretory endometrium – confirms ovulation ( post ovulatory)

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 OTHER ANOVULATORY DISORDERS  Prophylaxis is important especially if the patient has
multiple partners either male or female.
HYPERPROLACTINEMIA  Because there is a high prevalence of current or past
Can be associated with ovulatory factor infertility. chlamydial infection among infertile women and
After exclusion of a pituitary macroadenoma or other intracranial complications of HSG associated pelvic infection could
pathology, correction of the hyperprolactinemic state with further compromise fertility
bromocriptine is followed by restoration of ovulation in 90% of  it is reasonable to Prescribe antibiotic prophylaxis to
patients patients scheduled for HSG.
Women with anovulation have hypoprolactinemia treatment with HSG usually is performed between cycle days 6 and 11.
bromocriptine have been shown to cause resumption of ovulation During menses, HSG should be avoided because there is increased
enhanced fecundity. incidence of vascular intravasation caused by dilatation of
periuterine veins.
HYPOGONADOTROPIC HYPOGONADISM The procedure can also determine whether salpingitis nodosa is
Anovulation in the presence of low serum LH, FSH, and estradiol present in the interstitial portion of the oviduct.
levels COMPLICATIONS
Reflects dysfunction within the hypothalamic–pituitary axis. Pelvic infection
Causes Uterine perforation
Craniopharyngiomas Hemorrhage
pituitary adenomas Allergic reaction
arteriovenous malformations CONTRAINDICATIONS
central space–occupying lesions History of salpingitis
HYPOTHYROIDISM With pelvic tenderness
The prevalence of abnormal TSH levels in the general infertility
population has been reported to be 6.3%, 4.8%, 2.6%, and 1.5% LAPAROSCOPY
For women in couples diagnosed with anovulatory infertility,
unexplained infertility, tubal infertility, and male infertility, Direct visualization of the fallopian tube. Inject a dye in the uterine
respectively. cavity.
Women with anovulation have hypothyroidism treatment with “gold standard” for diagnosis of tubal and peritoneal diseases
thyroid replacement have been shown to cause resumption of Visualization of all pelvic organs
ovulation enhanced fecundity. Permits detection of
intramural and subserosal uterine fibroids
TUBAL/PERITONEAL FACTORS peritubal and periovarian adhesions,
endometriosis
30-40% of cases of female infertility The most thorough technique for diagnosing tubal and peritoneal
Damage or obstruction of fallopian tube disease is laparoscopy.
Previous PID This was an obligatory final step in the fertility investigation when all
Pelvic/tubal surgery other test are normal
Endometriosis
One – 12% FALLOPOSCOPY
Two – 23% Small guide wires to permit direct visualization of the lumen of the
Three – 54% fallopian tube
50% - with documented tubal damage but no identifiable risk factors Via laparoscopy or hysteroscopy
Subclinical chlamydia infection Based on principles similar to selective salpingography but allows
- Chlamydial infection is so rampant in the Philippines. Wherein the direct fiberoptic visualization of tubal ostia and intratubal
female has no manifestation that’s why you don’t know that you are architecture.
suffering from chlamydial infection. That’s why prophylaxis is very Allows the visual identification of
important such as tetracycline or monocycline. Minimum dose once tubal ostial spasm
day for three days. abnormal tubal mucosal patterns
The incidence of infertility caused by damage of to the FT has increased Intraluminal debris causing tubal obstruction.
because of an increased incidence of salpingitis
Distal obstruction is much more common than proximal obstruction
Prognosis depends on the amount of damage to the tube as well as the
location of the obstruction
Other causes of apparent tubal blockage
salpingitis isthmica nodosa
benign polyps within the tubal lumen
tubal endometriosis, tubal spasm
intratubal mucous debris

HYSTEROSALPINGOGRAPHY (HSG)

Used to test the patency of the tube. You always do it before the
time of ovulation approximately day 6-11 of the cycle. Take note if
you are doing it after ovulation there is a possibility that you already
have a zygote in the fallopian tube and you will be pushing it towards
the abdominal or peritoneal cavity.
Initial test of tubal pregnancy
Days 6-11
ESR prior to procedure in patients suspected on chronic PID
Prophylactic antibiotic and NSAIDs
Doxycycline 100 mg BID; start a day before HSG and continued
for 3-5 days

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 CAUSES AND TREATMENT OF TUBAL INFERTILITY Extent of adhesion
Nature of adhesions
Therapies that directly correct tubal factor infertility are entirely surgical Diameter of the hydrosalpinx
and include Appearance of the endosalpinx
Correction of periadnexal disease Thickness of the tubal wall – best prognostic factor
correction of proximal, distal, or combined tubal disease
Correction of iatrogenic tubal abnormalities (e.g., tubal sterilization) STERILIZATION REVERSAL
As success rates for ART continue to improve, the indications for surgical Pregnancy rates are lowest (49%) after the reversal of sterilization
approaches in the treatment of tubal factor infertility have become procedures involving unipolar electrocautery.
increasingly limited. In contrast, post-procedure pregnancy rates rose to 67% when the
sterilization technique involved
PROXIMAL TUBAL OCCLUSION Fallope rings or spring–loaded clips and 75% when Pomeroy tubal
ligation was employed.
If no dye enters the tube during HSG  consider the diagnosis of Tubal length is also an important prognostic consideration
proximal tubal blockage
False–positive finding by HSG when proximal obstruction is CERVICAL FACTORS
demonstrated.
Tubal spasm <5% of cases of infertility
temporary mucous plugging Post coital test – assess:
underfilling of the tube Quality of cervical mucus
The confirmation of proximal occlusion by repeat HSG or Presence and number of motile sperm in the female reproductive
laparoscopic chromo-pertubation should be considered. tract after coitus
Treatment Interaction between cervical mucus and sperm
Can be corrected at the time of diagnosis by HSG. Done 1-2 days before ovulation
Selective salpingography Ask the couple to have sex early in the morning and after get sample
To overcome obstruction resulting from mucous plugging. mucus in the endo-cervical canal and look under the microscope and
proximal tubal cannulation document if the sperm is motile or check if there is sperm in the
used if salpingography fails to recreate tubal patency, cervical canal.
Performed using a guidewire under radiologic guidance. Important from a physiologic standpoint ( cervical mucus being
Microsurgical tubocornual anastomosis important for sperm transport)
primary surgical Now rarely indicated as a necessary part of the infertility
Less invasive and has fewer complications. investigation
Adjunctive procedure for surgical tubal reconstruction A normal PCT is one which at least 5 motile sperm are visible in
Prophylactic antibiotics normal cervical mucus obtained from the upper canal just prior to
Intra-peritoneal corticosteroids ovulation.
Post-op hydrotubation CAUSES OF ABNORMAL PCT
Tubal stents Poor timing
Hormonal abnormality
DISTAL OCCLUSION AND HYDROSALPINX Production of poor quality cervical mucus
Anatomic factors
secondary to a variety of inflammatory conditions Infection
infection Some meds: CC
endometriosis
Prior abdominal or pelvic surgery. UTERINE FACTORS
Because of the secretory capacity of cells lining the oviductal lumen,
fluid can accumulate within the occluded fallopian tube. Cause of infertility in 15% of couples seeking treatment and diagnosed in
It is important to perform HSG and laparoscopy before surgical 50% of infertile patients
reconstruction Uterine abnormalities
HSG will determine if the tubal obstruction Endometrial polyps
Complete or partial Submucous myoma
Size of distal sacculation Intrauterine adhesions
Appearance of mucosal folds Mullerian anomalies
Rugal pattern of the endosalpinx Exposure to DES
Laparoscopy assist in determining Luteal phase defects
Size of hydrosalphinx - If you think that the myoma is the one causing infertility you can just
Amount of muscularis remove by performing hysteroscopic myomectomy.
Thickness of the tube
Treatment TUBERCULOSIS
Fimbrioplasty DIAGNOSIS
lysis of fimbrial adhesions or the dilation of fimbrial Endometrial biopsy
phimosis culture
used if the distal end of the tube are relatively normal RADIOGRAPHIC FEATURES
with only partial occlusion by adhesions or fimbrial edges Calcifies LN or granulomas of the pelvis
salpingostomy Tubal obstruction in the distal isthmus or proximal ampulla
also known as salpingoneostomy (“pipe-stem”)
involves the creation of a new tubal opening in an Multiple strictures along the couse of the tube
occluded fallopian tube Irregularityto the contour of ampulla
Required if the distal end is completely occluded Deformity or obliteration of the endometrial cavity without
Salphingolysis curettage
Used if the distal tubal ostium is completely normal but Anti-tuberculosis medication should be initiated
peritubal adhesions are present Tubal reconstruction are not indicated
Results of tubal reconstruction correlate with the degree of tubal ( +) Tb on the tube offer invitro fertilization ( IVF)
damage according to the severity of five factors

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 EVALUATION Associated with
Assessment of endometrial cavity Menorrhea
Diagnostic imaging menstrual irregularities
Hysterosalpingogram spontaneous abortion
Sonohysterography Recurrent pregnancy loss.
Office hysteroscopy TUBERCULOSIS
Nasa taas….
UTERINE PATHOLOGY
IMMUNOLOGIC FACTORS
Sonohysterography appears to be superior to HSG in the detection of
uterine malformations, correctly identifying 90% of abnormalities in ANTIBODIES
infertile patients. Considered if you cannot identify any abnormality.
Office hysteroscopy has been proven to have superior sensitivity (100%) Antibody response to sperm could reduce fertility
and specificity (95%) in the evaluation of the endometrial cavity IgG or IgM class
IgG: seen in serum, cervical mucus and plasma
CONGENITAL ANOMALIES OF UTERUS IgA class: cervical mucus and seminal plasma
IgM: exclusively in serum
Congenital uterine anomalies may be associated with infertility, Both men and women have the capability to mount a humoral response to
spontaneous pregnancy loss in the first or second trimester, or late– sperm.
trimester pregnancy complications. Either allogenic or autoimmune response could, in turn, adversely affect
Example of anomalies fertility.
Didelphic uterus The larger IgM antibodies have difficulty traversing the genital tract
Unicornuate uterus mucosa and therefore are found exclusively in serum.
septate uteri Both sperm agglutinating ans sperm immobilizing antibodies have been
the rates of spontaneous abortion and preterm delivery are highly found in the serum of infertile women.
increased at 25% to 38% and 25% to 47%, respectively Agglutinating antibodies are found more frequently
Endometrial dysfunction during the luteal phase may result in infertility Causes have been proposed to explain the formation of antisperm
Dysfunction occurring after implantation may result in pregnancy loss. antibodies
Woman with a septate uterus might encounter recurrent pregnancy loss In women  coital trauma that disrupts the vaginal epithelium 
after having delivered a term infant. expose immune effector cells to sperm antigens  leading to
With the exception of a septate uterus, infertility associated with most antisperm antibody formation.
congenital uterine anomalies is not readily amenable to surgical treatment In men the blood–testis barrier normally shields the serum from
exposure to sperm and their antigens.
Conditions that cause breaks in this barrier could activate
IN UTERO EXPOSURE TO DES autoimmunity.
Testicular trauma or torsion
Exposure to DES in utero increases a woman's risk for occlusion of the vas deferens secondary to childhood
congenital reproductive tract malformations inguinal herniorrhaphy or cystic fibrosis
obstetric complications vasectomy reversal
preterm labor Genital tract infections have been suggested to elicit
cervical incompetence antisperm antibody formation.
The most common malformation was the T–shaped uterus Men with these antibodies can be treated with
Corticosteroid therapy
ACQUIRED ABNORMALITIES OF THE UTERUS Sperm washing techniques

INFECTIONS
LEIOMYOMAS
Uterine leiomyomas might alter uterine contractility and thereby Chlamydia trachomatis/Ureaplasma urealyticum
disrupt normal sperm migration. PID
Depending on the location fibroids may decrease the chance of 20% of salpingitis
conception and increase the miscarriage rate Recovred in cervical mucus and semen of infertile couples
Male: Interfere with normal sperm function
ENDOMETRIAL POLYPS Treatment improved with fertility rate
Even in the absence of abnormal uterine bleeding, endometrial Doxycycline can eradicate this organism
polyps may be discovered in women with infertility. Chlamydia may produce asymptomatic infection in the female
Due to the influence of circulating estrogen genital tract, and it is likely that some women experience silent tubal
higher incidence seen in the infertility population may be related to infection.
the hyperestrogenemia associated with prior cycles of COH Bacterial vaginosis
pregnancy rates were not affected
ASEHRMAN SYNDROME higher risk for spontaneous abortion than matched controls
Some researchers have suggested that asymptomatic or occult infection of
Causes of intrauterine adhesions the upper female genital tract and male genital tract is a cause of
Iatrogenic infertility.
intraoperative or postoperative complications Ureaplasma urealtycum
uterine evacuations for menorrhagia Old name T mycoplasma
pregnancy termination, Could to interfere with normal sperm function and sperm transport.
Postpartum hemorrhage. Treatment:
intrauterine infection Tetracycline
schistosoma Doxycycline
Mycobacteria. Other organism found in female genital tract
SEVERE FORM OF ASHERMA SYNDROME Mycoplasma hominis
Due to intrauterine adhesions  interfere with embryo Mycoplasma fermentans
implantation

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 SYSTEMIC ILLNESS have baby then advise them to have surrogacy. And offer them the last
solution which is adoption.
any severe systemic illness Remember orgasm is not an important factor…. what is more important is
renal failure the male able to deposit sperm in the cervical canal.
liver failure If the couple wish to have a male or female baby tell them if you want a
metastatic cancer, male baby always time your sexual intercourse at the time of ovulation
Can lead to disruption of the hypothalamic–pituitary–ovarian axis and then you will have higher chance to have a male baby because male
cause infertility. carrying sperm ( Y sperm) are more motile therefore it easily fertilized the
The association of antiphospholipid antibodies, particularly anticardiolipin egg ( mas nauna siya kumbaga)… if you wish to have female baby ask
antibodies and the lupus anticoagulant, with recurrent pregnancy loss led them to have sex before the woman will ovulate because the female
to the investigation of a role for these antibodies in infertility. These carrying sperm ( x carrying sperm) last for 3 days therefore wala nag
antibodies are more prevalent in the infertility population. lalaking sperm dumating si egg so ang magferfertilized na lang is the x
carrying sperm or female carrying sperm. So it’s the sperm that will tell if
ENDOMETRIOSIS you have a male baby or female baby.
Method to increase fecundibility of couples with normal diagnostic
ENDOMETRIOSIS is frequently encountered in an infertility population (20- evaluation
40%) Controlled ovarian hyperstimulation
Diagnosis  via laparoscopy Intrauterine insemination
Women have endometriosis have ART’s ( assisted reproductive technologies)
Reduced fecundity in relation to the extensiveness of the disease
Mechanical ( obstructive cause of infertility FOR OVULATORY FACTOR
Drugs
Initial treatment Clomiphene citrate
COS( controlled ovarian stimulation) Gonadotrophins
IUI ( intra-uterine insemination) Pulsatile GnRH therapy
Pregnancy does not occur in 3-6 cycles  IVF is offered as the next Bromocriptine
step Dexamethasone supplemenntation

UNEXPLAINED INFERTLITY AGENT OVULATION PREGNANCY MULTIPLE COMMON

Any previous infertility investigations should be reviewed and repeated if RATES RATES PREGNANCY SIDE EFFCTS
the results are in doubt. RATES
If the basic evaluation reveals normal semen parameters, evidence of Clomiphene ≤ 80% ≤ 40% 5-8% Hot flushes,
ovulation, patent fallopian tubes, and no other obvious cause of infertility, nausea,
the couple is diagnosed with unexplained infertility. breast
If uncertainty surrounding the interpretation of such tests exists, the tenderness,
midluteal serum progesterone level can be assessed to confirm ovulation. visual
TREATMENT symptoms
diagnostic laparoscopy and prior exclusion of endometriosis Bromocriptine ≤ 95% ≤ 85% <1% GIT
Treatment typically involves irritation,
superovulation (increasing female gametes) orthostatic
used clomiphene citrate hypotension,
 increase the fecundity rate in ovulatory women nasal
with unexplained infertility is that of superovulation conngestion,
IUI ( intrauterine insemination) headache
 considered a standard adjunct to any
superovulation treatment in unexplained infertility OVULATION INDUCTION
collecting, washing, and concentrating the semen (increasing
motile sperm) For anovulation treatment
Bypassing a potential cervical factor using IUI. CLOMIPHENE CITRATE
The routine empirical treatment is ovarian stimulation with First line regimen
clomiphene or gonadotropins coupled with IUI. Weak synthetic estrogen, but acts as estrogen antagonist in
Age is significant factor in terms of efficacy of treatment pharmacologic doses
Younger woman ( 30s)- routine empirical treatment Block estrogen RC in hypothalamus  increase GnRH pulse
Older woman- direct IVF ( in vitro fertilization) amplitude  increase gonadotrophin secretion
Most pregnancies: 1st 6 months
TREATMENT OPTIONS First line pharmacologic agent for treating women with
oligomenorrhea and those with amnorrhea who have sufficient
If you able to identify the problem always start talking to the couple and ovarian estrogen production
tell them what causing the infertility. Offer them the different Clomiphene citrate is thought to have anti-estrogenic effects on the
management or options and let them choose. hypothalamic–pituitary axis, resulting in a decrease in the
If oligospermic then try to treat it but if untreated offer them intrauterine suppression of FSH production by the pituitary.
insemination and if no improvement after 6 trial. Offer them to have test
tube baby. GONADOTROPIN THERAPY
If a female factor is involvement of fallopian tube there is no way that they Indicated when estrogen levels are low ( < 30 pg/ ml)
can have a normal process of having a baby so they should undergo in- Lack of withdrawal bleeding after progesterone administration of
vitro fertilization. progesterone signifies state of unresponsive oral therapy such as
If the problem will be ovulation or the female identified with no follicle clomiphene and letrozole
due to premature menopause, the only solution for her to get pregnant is HMG gonadotropins
to get a donor female who will give her an egg. Also in male. Original preparations of gonadotropin
If all the process such as in-vitro fertilization, intrauterine insemination, Extracts from postmenopausal urine
and donor sperm is already ask, but still no pregnancy but still wishing to Has large amounts of proteins
HCG

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 When the largest measured follicle reaches a maximum Metformin and other insulin sensitizers
diameter of 18 to 19 mm or more, 10,000 IU of hCG (Profasi) Metformin
administered intramuscularly Biguanides which has a role in ovulation in PCOS
Optimal pregnancy rates are achieved with IUI performed at 33 Decreases heaptic glucose production and some minor
to 39 hours after the hCG injection peripheral action leading to some decrease insulin resistance
Medical preparations of gonadotropins (LH, FSH) can be used Has direct role in inhibiting ovarian androgen steroidogenesis
to stimulate ovarian follicular development Acts on endometrium  major mechanism that help with
induce ovulation in the treatment of several conditions ovulation and pregnancy
PCOS resistant with metformin and CC ( clomiphene Side effects
citrate) GI effects ( nausea, vomiting) – primary concern
Hypogonadotropic hypogonadism Lactic acidosis- rare
Pituitary dysfunction Rosiglitazone and pioglitazone
Unexplained infertility Induce ovulation by improving the insulin hormone axis as well
Adverse effects as through direct effort on the ovary
OHSS ( ovarian hyper-stimulation syndrome) Reserved for short term used due to its teratogenic effect
 Can be life threatening Side effects
 Massive fluid shifts Teratogenic effect
 Ascites Hepatic enzyme changes
 Pleural effusion Weight gain
 Electrolyte imbalance Letrozole
 Thromboembolism Aromatase inhibitor
 Causes Not approved in US as ovulation induction
 unknown Second line therapy in Clomiphene citrate (CC) failure and woman
 maybe due to large cystic ovaries with poor response to CC
 high E2 levels Effective as primary treatment for ovulation induction
 ovarian elaboration due to VEGF  increasing MOA
the vascularity and vascular permeability Inhibition of E2 production during 5 days of administration
Negative feedback causing an increase FSH levels
 treatment Intraovarian androgen are also increased  enhancing FSh
 supportive sensitivity
 prevent thrombosis Advantages
 correct electrolytes No thickenings of cervical mucus
 maintenance of urine output No Thinning endometrium
 ICU admission occasionally
Gonadotropin Releasing hormone
Alternative for HMG
MOA
Saturate the receptors  inhibit gonadotropin release 
induce ovulation
Need to be administered in pulsatile manner at intervals of 1-2 hours
Cannot be administered orally
2 routes
Intravenously
Subcutaneous

OTHER MANAGEMENT

Weight and lifestyle management

For woman who are clomiphene resistant
May improve overall fitness and metabolic parameters as well as
ovulatory response
Ovarian electrocauterization
Laparoscopic electrical or Laser generated burn holes through the
ovarian cortex  improve ovulation rates
Advantages
Decrease the risk of hyper-stimulation and multiple pregnancy

ASSISTED REPRODUCTIVE TECHNOLOGIES

All methods of ART, by definition, involve interventions to retrieve

oocytes.
These techniques include IVF, ICSI, gamete intrafallopian transfer (GIFT),
zygote intrafallopian transfer (ZIFT), cryopreserved embryo transfers, and
the use of donor oocytes.

IN VITRO FERTILIZATION
Provided the ability to diagnose significant genetic defects before
implantation and has led to the possibility of stem cell research
Last step in the treatment of algorithm for infertile couples
Used as primary therapy for
Bilateral tubal occlusion
Sever male factor
The strategy of successful IVF is the generation of good embryo

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 COMPLICATION OF TREATMENT

Multiple gestation
Ovarian hyper-stimulation syndrome
Ectopic and heterotopic pregnancy
Risk of cancer after fertility therapy

COUNSELLING AND EMOTIONAL SUPPORT

The diagnosis of infertility can be a devastating and life-altering event that

affects many aspects of a woman’s life.
Infertility and its treatment can affect a woman and her spouse or partner
medically, financially, socially, emotionally, and psychologically.
Feelings of anxiety, depression, isolation, and helplessness are not
uncommon in women undergoing infertility treatment.
Strained and stressful relationships with spouses, partners, and other
loved ones occur among patients undergoing infertility treatment as
treatment gets underway and progresses.
It is important that every program address the emotional and social needs
of couples undergoing treatment.

KEY POINTS

END

Black- powerpoint
Blue- trans from the lecturer
Red- book (comprehensive gynecology)
Violet- Book (Novak’s gynecology)

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