DIAGNOSTIC METHODS IN FEMALE INFERTILITY

8/7/2019 DIAGNOSTIC METHODS IN FEMALE INFERTILITY

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DIAGNOSTICMETHODS IN FEMALE

INFERTILITY

Dr. Deepti Patil

Dept. OfDravyaguna


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DEFINITION OF INFERTILITY

Defined as

Failure to conceive within

one or more year of regularunprotected intercourse

4/8/11 Diagnostic Methods InFemale Infertilit

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INCIDENCE

1% of women in their early 20s are infertile

By their late 20s, 16% [one in six] are infertile.

By their mid-30s almost 25% [one in four] are infertile.

By age 40, 60% [three in five] are infertile.

By age 43 it would be a rare woman who is still fertile."


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CONT

80% of couples achieve conception

within one year of having regular

intercourse.

10% will achieve conception by the

end of second year.

10% remain infertile by the end of

second year.4/8/11 Diagnostic Methods InFemale Infertilit

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RATIO

Infertility Ratio


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TYPES

Two types :

1. Primary infertility

2. Secondary infertility


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DEFINITIONS

Primary infertility:

Those couples who have never

conceived.

Secondary infertility:

Indicates previous pregnancy but

failure to conceive subsequently


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HORMONES INFLUENCINGFERTILITY

Follicle stimulating hormone (FSH)

Secreted by the pituitary gland, FSH is

responsible for taking immature

follicles to a more mature state.


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Estrogen

Secreted by the growing follicles.

Estrogen is essential for the development

of a healthy endometrial lining (in

preparation to support a pregnancy).


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Luteinizing hormone (LH)

The growing amount of estrogen in thebloodstream stimulates the Pituitaries to

cut back on producing FSH and release asurge of LH.

Responsible for full maturation of graafian

follicle and oocyte and ovulation


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Progesterone

Secreted from the luteinized theca-

granulosa cells of the corpus luteumProgesterone is used by a woman'sbody to sustain pregnancy from

fertilization through delivery.


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FACTORS INFLUENCINGFERTILITY

Lack of understanding of reproductive

biology.

Coital frequency.

Malnutrition and obesity.

Toxic factors.


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CONT

Smoking & alcohol.

Related underlying medical pathology.

Previous surgeries.

Radiation.


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CAUSES

1. Hypothalamic-pituitary factors

Hypothalamic dysfunction


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CONT

2. Ovarian factors

Polycystic ovarian syndrome.

Anovulation.

Luteal dysfunction

Ovarian cancer


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3. Tubal (ectopic)/peritoneal

factors

Endometriosis

Pelvic adhesion

Pelvic inflammatory diseases.

Tubal occlusion4/8/11 Diagnostic Methods In

Female Infertilit1818


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4. Cervical factors

Ineffective sperm penetration

-Chronic cervicitis

-Immunological factor (Presence of antisperm

antibody)

cervical stenosis


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5. Uterine Factors

Uterine malformation

Mullerian agenesis (absent uterus)

Unicornate uterus (one side uterus)

Uterus didelphys (double uterus)


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CONT

Bicornate uterus (uterus with two horn)

Septated uterus (uterine septum or

partition)

Uterine fibroid

Synechiae (ashermans syndrome)


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Unicornate

Click to edit Master text stylesSecond level

Third level Fourth level

Fifth level


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Bicornate



Fifth level


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DidelphysClick to edit Master text styles

Second level Third level

Fourth level Fifth level


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Complete Septate



Fifth level


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Subseptate

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Honeycomb AppearanceClick to edit Master text styles




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6. Vaginal factors

Vaginismus

Vaginal obstruction


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7. Genetic factors

Intersex condition like androgen

insensitivity syndrome


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GOALS OF EVALUATION OFFEMALE INFERTILITY

To identify the reversible conditions

To identify the significant underlying medicalpathology.

Genetic or chromosomal abnormalities thatmay affect either the patient or her offspring.

A large increase in the number of womenbetween 25-35 yrs suffering from infertility.


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Evaluation ofinfertility


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HISTORY

Sexual history: Dyspareunia and loss of libido.

Use of lubricants

Frequency of intercourse

Psychosomatic evaluation


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CONT

Personal history:

Habit of smoking and alcohol


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CONT

Medical history:

Tuberculosis.

Sexually transmitted diseases.

Pelvic inflammations

Diabetes.

Abdominal or pelvic surgery

( Surgical History)4/8/11 Diagnostic Methods InFemale Infertilit3434


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CONT

Menstrual history:

Amenorrhoea

Oligomenorrhoea


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CONT

Previous obstetric history

Number of pregnancies

Interval between the pregnancies

History of premature rupture of the

membranes or puerperal sepsis


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CONT

Contraceptive practice

Intra Uterine Contraceptive Devises[IUCD]


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CONT

Family history of infertility

Can help identify a possible genetic

cause


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EXAMINATION


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General examination

Obesity or marked reduction in weight

Secondary sex characters

Physical features pertaining to

endocrinopathies


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Systemic examination

Hypertension

Organic heart disease

Chronic renal lesions

Endocrinopathies


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Speculum examination

Abnormal cervical discharge.

Pin hole cervix.

Cervical polyp.

Cervical erosion.


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Gynecological examination

Hymenal opening

Vaginal infection

Cervical tear or chronic infection

Undue elongation of cervix

Uterine size, position, mobility.

Adnexal masses

Nodules in the pouch of Douglas.4/8/11 Diagnostic Methods InFemale Infertilit

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ASSESMENT OF OVULATIONv INDIRECT METHOD

Basal body temperature

Mid luteal serum progesterone

Endometrial biopsy

Ultrasound monitoring of ovulation.

v DIRECT METHOD

Laparoscopy

v CONCLUSIVE4/8/11 Diagnostic Methods InFemale Infertilit4444


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ASSESMENT OF TUBALFACTORS

Hysterosalpingography (HSG)

Laparoscopy

Sonohysterosalpingography

Falloposcopy

Salpingoscopy


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ASSESMENT OF OTHERFACTORS

The peritoneal factors are assed by laparoscopy

Uterine factors by Hysterosalpingography and

hysteroscopy

Immunological factors.

Post coital test.


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Post coital test (PCT)

PCT is to assess the quality of cervical

mucosa and the ability of sperm to

survive in it.

Presence of at least 10 progressive

motile sperm per high power field

signifies the test to be normal.


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BASAL BODY TEMPERATURE

BBT chart shows a sustained elevation

in the body temperature post ovulation

until just before the onset of menses,

indicating the approximate time of

ovulation.


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MID LEUTEAL SERUMPROGESTERONE

Done on day 8 and 21 of a cycle.

An increase in value from less then

1ng/ml to greater then 6ng/ml suggests

ovulation.


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ENDOMETRIAL BIOPSY

Done on 21-23rd day of cycle.

Findings:

Evidence of secretory activity of the

endometrial glands in the second half of

the cycle is suggestive of ovulation.


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SONOGRAPHY

Particularly helpful for conformation of ovulation

after ovulation induction.

Features of recent ovulation are collapsed follicle

and fluid in the pouch of Douglas.


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OSCO


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LAPROSCOPY

Laparoscopic visualization of recent

corpus luteum or detection of the

ovum from the aspirated peritoneal

fluid from the pouch of Douglas.


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HYSTEROSALPINGOGRAPHY


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HYSTEROSALPINGOGRAPHYIt detects the side and site of block in

the tube.

Reveal any abnormality in the uterus.

HSG has a low prognostic value, the

outcome of HSG adds little to

predicting the occurrence of4/8/11 Diagnostic Methods InFemale Infertilit 5353


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Advantages:

HSG is cheaper

Performed as an out patient

procedure.

Though it is a Painful procedure

has a low incidence of4/8/11 Diagnostic Methods In


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Fourth level

Fifth level


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Hysterosalpingiographic

cannula



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Fourth level

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Click to edit Master text stylesS d l lHSG DEMONSTRATING A CLOSED AND


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Fourth level

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HSG DEMONSTRATING A CLOSED ANDDILATED RIGHT AMPULLARY END


NORMAL


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Fourth level

Fifth level


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HSG

LAPAROSCOPY


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LAPAROSCOPY

The Indications Of Its Use Are:

Abnormal HSG findings

Failure to conceive after reasonable

period (6 months) even with normal

HSG

Unexplained infertility

Age >35 years4/8/11 Diagnostic Methods InFemale Infertilit 5959

SONOHYSTEROSALPINGOGR


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SONOHYSTEROSALPINGOGRAPHY

Normal saline is pushed within the

uterine cavity with a paediatric Foley

Catheter.

Ultrasonography of the uterus and

fallopian tubes are done.

Ultrasound can follow the fluid through

the tubes up to the peritoneal cavity4/8/11 Diagnostic Methods InFemale Infertilit 6060


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ADVANTAGES:

It can detect uterine malformation.

Synechiae or Polyps.

Tubal pathology could be detected as

that of HSG

There is no radiation exposure.4/8/11 Diagnostic Methods In


FALLOPOSCOPY


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FALLOPOSCOPY

To study the entire length of tubal

lumen with the help of a fine and

flexible fibreoptic device

It is performed through the uterine

cavity, using a hysteroscopy.


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SALPINGOSCOPY


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SALPINGOSCOPY

Tubal lumen is studied introducing a

rigid endoscope through the fimbrial

end of the tube.

It is performed through the operating

channel of a laparoscope.


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UTERINE FACTORS


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UTERINE FACTORS

Subfertility.

Submucous fibroids.

Congenital malformation.

Intrauterine adhesions.


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PREVENTION


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PREVENTION

Maintaining a healthy lifestyle

Excessive exercise, consumption of

caffeine and alcohol and smoking are

all associated with decreased fertility.

Treating or preventing existing

diseases

Identifying and controlling chronic4/8/11 Diagnostic Methods In


CONCLUSION


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CONCLUSION

Infertility is a disorder of couple and henceboth partners should be investigated.

A simplified approach will lead to asignificant reduction in both the time andcost of investigating an infertile couple.


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DIAGNOSTIC METHODS IN FEMALE INFERTILITY