fertility disorder on female - silvia

7/27/2019 Fertility Disorder on Female - SILVIA

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Infertility : (Chuang et al, 2007)- Conception (-)- Regular sexual activity (intercourse)- Contraceptioion (-)- 1 year (12 ovulation cycles)

Indonesia : 200 million citizen 2010 40% in fertile

INTRODUCTION

age 10% infertility cases.

Etiology of infertility :

(Moeloek, 2001) 45%

40%

?15%


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DEFINITION

PrimaryCouple has never conceived

No conception during first year without contraception

SecondaryCouple has had at least one prior conception


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HISTORY TAKING (FEMALE )

Symptoms (past or present)- P I D / STD,- dysparenuria- galactorrhoea,- thyroid symptoms

Obstetric history

Menstrual history- irregularities

Surgical history- D & C, abdominal/pelvic surgeryContraception- IUCDs

Cervical smear


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EXAMINATIONGeneral health and nutritional statusBMI

29.(M/F)

Hirsuitism, galactorrhoeaBimanual examination

- adnexal masses (tubo/ovarian, ovarian cyst)- tenderness (PID/ endometriosis)- uterine fibroids


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BIMANUAL EXAMINATION


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P ELVIC INFLAMMATORY DISEASE

(PID )


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Pelvic inflammatory disease (or disorder ) (PID ) is a term for inflammation of the uterus , fallopian tubes , and/or ovaries as it

progresses to scar formation with adhesions to nearby tissues andorgans. This can lead to infertility.

Although an STI is often the cause, many other routes arepossible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or intrauterine device (IUD) related, and

hematogenous spread.

Symptoms in PID range from subclinical (asymptomatic) to severe.If there are symptoms, then fever , cervical motion tenderness,lower abdominal pain , new or different discharge, painfulintercourse , or irregular menstrual bleeding may be noted.

Laparoscopic identification is helpful in diagnosing tubal disease,6590% positive predictive value in patients with presumed PID.

Treatment is usually started empirically because of the seriouscomplications that may result from delayed treatment


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ENDOMETRIOSIS


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Endometriosis is a gynecological medical condition in which cellsfrom the lining of the uterus (endometrium ) appear and flourishoutside the uterine cavity , most commonly on the peritoneum whichlines the abdominal cavity. The uterine cavity is lined withendometrial cells, which are under the influence of femalehormones .

Endometrial-like cells in areas outside the uterus (endometriosis)are influenced by hormonal changes and respond in a way that is

.with the menstrual cycle .

Endometriosis is typically seen during the reproductive years; it hasbeen estimated that endometriosis occurs in roughly 610% of women. Symptoms may depend on the site of activeendometriosis. Its main but not universal symptom is pelvic pain invarious manifestations. Endometriosis is a common finding inwomen with infertility.


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In principle the various stages show these findings:

Stage I (Minimal)Findings restricted to only superficial lesions and possibly a fewfilmy adhesions

Stage II (Mild)In addition, some deep lesions are present in the cul-de-sac

Stage III (Moderate)

As above, plus presence of endometriomas on the ovary andmore adhesions.Stage IV (Severe)

As above, plus large endometriomas, extensive adhesions.

Endometrioma on the ovary of any significant size (Approx. 2 cm +)

must be removed surgically because hormonal treatment alone willnot remove the full endometrioma cyst, which can progress to acutepain from the rupturing of the cyst and internal bleeding.Endometrioma is sometimes misdiagnosed as ovarian cysts.


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P OLYCYSTIC OVARY SYNDROM(PCO)


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Polycystic ovary syndrome (PCOS ) is one of the mostcommon female endocrine disorders. PCOS is a complex,heterogeneous disorder of uncertain etiology , but there is

strong evidence that it can to a large degree be classified as agenetic disease .

PCOS produces symptoms in approximately 5% to 10% of women of reproductive age (1245 years old). It is thought to

be one of the leading causes of female subfertility and the most.

The principal features are anovulation , resulting in irregular menstruation , amenorrhea , ovulation-related infertility, andpolycystic ovaries; excessive amounts or effects of androgenichormones, resulting in acne and hirsutism ; and insulinresistance , often associated with obesity , Type 2 diabetes , andhigh cholesterol levels . The symptoms and severity of thesyndrome vary greatly among affected women.


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The World Health Organization criteria for classification of anovulation include the determination of oligomenorrea(menstrual cycle >35 days) or amenorrea (menstrual cycle > 6months) in combination with concentration of prolactin, folliclestimulating hormone (FSH) and estradiol (E2).

The patients are classified as

-WHO1 (15%) - hypo- gonadotropic , hypo- estrogenic ,- - - -,-WHO3 (5%) - hypper-gonadotropic, hypo-estrogenic.

The vast majority of anovulation patients belong to the WHO2

group and demonstrate very heterogeneous symptoms rangingfrom anovulation, obesity, biochemical or clinicalhyperandrogenism and insulin resistance. The patients of PCOSform a large subgroup of the WHO2 group.


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Some common symptoms of PCOS include:

Menstrual disorders : PCOS mostly produces oligomenorrhea

(few menstrual periods) or amenorrhea (no menstrual periods),but other types of menstrual disorders may also occur.Infertility : This generally results directly from chronic anovulation(lack of ovulation).

Hyperandrogenism : The most common signs are acne and,hypermenorrhea (very frequent menstrual periods) or other symptoms. [12][7] Approximately three-quarters of patients withPCOS (by the diagnostic criteria of NIH/NICHD 1990) haveevidence of hyperandrogenemia.

Metabolic syndrome :[11] This appears as a tendency towardscentral obesity and other symptoms associated with insulinresistance .[7] Serum insulin , insulin resistance and homocysteinelevels are higher in women with PCOS.


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UTERINE FIBROID


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INVESTIGATIONS

Primary care

Secondary care

Assess ovulation.Other hormonal testsTests for PID

Tubal patencyUterine abnormality


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A SSESSING OVULATION

Do if regular cycles with > 1 year of infertilityirregular cycles

1) Serum progesterone(mid luteal phase ie day 21 of 28 week cycle)-Regular cycles - 7 days before next MP-Irregular cycles - day 28/35 wk then weekly

till menstruation occurs2) LH/FSH levels

High levels poor ovarian functionHigh LH compared to FSH -PCOS


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3) E2, Testosterone levels PCOS

4) Prolactin ONLY if - ovulation problems- galactorrhoea,

- pituitary problem.

5) Thyroid tests- only with symptoms/ signs

6) Other androgen profile (DHEAS, Androstenedione, SBHG) as per etiology


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A SSESSING OVULATION


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TESTS FOR PID

HVSChlamydia screening

CERVICAL HOSTILITY

Post coital test

- no longer recommendedMucus invasion test

- doubtful significance


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Sample of cervical mucus on thevagina, endocervix and exocervix,taken between 9-24 hours post-coitus.

POST COITAL TEST

Progressive concentration andmotility of spermatozoa is observed.

It is considered normal in thepresence of progressive motilesperm in the endocervix.


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The womans cervix usually produces a barrier of tick mucus thatprevents the invasion of bacteria and other organisms fromentering the uterus.

As you all know, the mucus becomes thinner and more elastic toenable sperm to move freely into the uterus during the time of ovulation.

CERVICAL MUCUS TEST

Then, your doctor can determine the quality and consistency of the cervical mucus by taking a sample at the time of suspectedovulation .


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TESTS FOR UTERINE /TUBAL PROBLEMS

HSG/hystero salpingo-contrast USG

Laparoscopy + dye testDone only when ovulation tests/Sperm testsnormal.Choice of tests depends upon co morbidities


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M ANAGEMENT IN PRIMARY CARE

Lifestyle changes- Weight reduction, BMI 19-29- Smoking cessation- offer support groups- Alcohol reduction


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M ANAGEMENT IN SECONDARY CARE

Depends upon the etiology..

Ovarian dysfunction :

- antiestrogen ( )- metformin- laparoscopic ovarian drilling

Peritoneal problems :- laparoscopic surgical resection- if ovarian endometriomas laparoscopic cystetomy


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LAPAROSCOPIC


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Tubal factors:- Laparoscopic tubal surgery/ tubal microsurgery- Salpingography + tubal catheteristion- Hysteroscopic tubal cannulation

M ANAGEMENT IN SECONDARY CARE

- hysteroscopic adhesiolysis- myomectomy

IUI

IVF-ICSI


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Sperm is washed andcollected into vagyna,cervical canal or inthe uterus.

IUI

Sperm could be fromspouse or anonymous

donor.


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is a process by which egg cellsare fertilized by sperm outside thebody, in vitro .

The process involves hormonally

IVF

controlling the ovulatory process,removing ova (eggs) from thewoman's ovaries and lettingsperm fertilise them in a fluidmedium. The fertilized egg(zygote ) is then transferred to thepatient's uterus with the intent toestablish a successful pregnancy.


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Havea nice study

fertility disorder on female - silvia

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