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Evaluation and options in Managing Subfertile Couple
Dr Edawati Dahrawi Edrus Obstetrics dan Gynaecology
Hospital Umum Sarawak
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MARRIED COUPLE
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Not Pregnant ?
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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.
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Average incidence globally: 15% (varies in different population)
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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
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• 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
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• 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
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NORMAL
• Female reproductive organ
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• Menstrual cycle
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NORMAL
• Male reproductive organ
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Male spermatogenesis
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Factor for Infertility
30-40%
UNEXPLAINED 5-15%
Couple does not conceive and no definite of infertility can be diagnosed after a complete
evaluationcause
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FEMALE FACTOR
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OVARIAN FACTOR
• Anovulation
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Anovulation
• Hyperprolactinaemia
• Obesity
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Ovarian Failure
• Repeated surgery on ovaries
• Chemoradiation• Primary Ovarian Failure• Pemature Menopause
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Pelvic Inflammatory Disease (PID)
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• Tubal block
• Previous tubal surgery/Ectopic pregnancy
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• Uterine Factor
• Uterine Fibroid
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• Adenomyosis
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• Uterine Septum
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• Uterine polyp
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• Submucosa Fibroid
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• Uterine adhesions
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• Transcervical Resection
• TCRF (firbroid)• TCRP (polyp)
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MALE FACTOR
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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%
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MALE FACTOR
• Oligospermia
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• Asthenospermia
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• Teratozoospermia
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• SUPPLEMENT FOR oligoasthenoteratozoospermia
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• CLOMID
• HCG and MENOPUR injection
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• Azoospermia
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SURGICAL MANAGEMNT FOR AZOOSPERMIA
• PERCUTANEOUS SPERM ASPIRATION (PESA)
• Testicular Biopsy (TESE/TESA)
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Assessment of Subfertility Patient
Assessment of Female and Male partnerFemale – Ovulation , Tubal PatencyMale – Sperm Analysis
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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
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Female• Infective screening - Hepatitis B/C/HIV/VDRL - Rubella Ig G
Male• Semen Analysis• Infective screening - Hepatitis B/C/HIV/VDRL
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HYSTEROSALPINGOGRAM (HSG)
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GENERAL ADVICE
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Management of Infertility
• Timed Sexual Intercourse (TSI)
• Intrauterine Insemination (IUI)
• Invitro Fertilization (IVF)/Intracytoplasmic Sperm Insemination (ICSI)
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OVULATION INDUCTION
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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
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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
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• IUI
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IVF VS ICSI
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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
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IVF/ICSI
• IVF/ICSI stimulation
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IVF stimulationTransvaginal scan (TVS)
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OOCYTE RETRIEVAL (OR)
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EMBRYO TRANSFER(ET)
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EMBRYO TRANSFER (ET)DAY 2/3/5
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Luteal Support
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Post Embryo Transfer
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Succcess Rate
Depends on Factor of Infertility and maternal ageFactors lower success rate1. Advanced age2. Poor responder3. Endometriosis4. Adenomyosis5. PID with Hydrosalphinx6. Male Factor
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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
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COMPLICATIONS
Ovarian Hyperstimulation Syndrome (OHSS)
Multiple Pregnancy
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WELCOME TO KUCHING
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THANK YOU