بسم الله الرحمن الرحيم

بسم الله الرحمن الرحيم Problem Based Learning Infertility

A 33 YEARS OLD WOMAN ATTENDS TO INFERTILITY CLINIC HAVING BEEN TRYING TO CONCEIVE FOR 24 MONTHS. SHE HAS HAD TWO PREGNANCIES, WHICH RESULTED IN THE BIRTH OF HER SON 3 YEARS PREVIOUSLY BY EMERGENCY CESAREAN SECTION FOR FETAL DISTRESS AND A MISCARRIAGE AT 10 WEEKS GESTATON, FOLLOWING WHICH SHE REQUIRED UTERINE EVACUATION. CASE

What are the basic requirements for conception?

Basic Requirements of Conception Conception requires the juxtaposition of male and female gametes at the optimal stage of maturation followed by transportation of the conceptus to the uterine cavity at a time when the endometrium is supportive of its continued development and implantation.

Basic Requirements of Conception For these events to occur the male and female reproductive system must be anatomically and physiologically intact and coitus must occur with sufficient frequency for the semen to be deposited in close temporal relationship to release of the oocyte from the follicles.

When would infertility be considered?

When a couple of reproductive age fail to achieve conception after 1 year of regular sexual intercourse without contraception.

What do you want to know and do about this case ? History Examination Investigation

Classification Primary Without previous pregnancy Secondary When it follows a previous conception Infertility

In general infertility could be due to: Male fertility factors (35%) Ovulatory factors (25%) Peritoneal factors (25%) Cervical factors (5%) Uterine factors (5%) Idiopathic (5%)

This is a case of secondary infertility, the male factor is considered normal here. The possible causes of infertility here are: Ovulatory causes Peritoneal causes Cervical causes Uterine causes

History Age Duration of trying to achieve pregnancy Any previous pregnancies

History Menstrual history: Secondary amenorrhea-LMP Regularity (irregularity seen in anovulation) Cycle length (if 35→irregular ovulation) Variation between cycles ( if >7→irregular ovulation) Dysmenorrhea Premenstrual symptoms

History Endocrine system: –Headache, galactorrhea, Visual changes. “pituitary adenoma-hyperprolactenemia” –Excessive exercise, extreme emotional stress, excess hair growth. “hypothalamic – pituitary failure” –Symptoms of hypo- and hyperthyroidism. –Hot flashes, vaginal dryness “premature ovarian failure-menopause”

History Reproductive system: Pelvic pain dysuria, fever >> PID or STD Premenstrual spotting, dysmenorrhea, dyspareunia >> endometriosis Previous ectopic pregnancy Previous D & C Contraception: type, duration, complications Especially previous IUD  pelvic adhesion

History Marital history husband's age intercourse frequency history of impotence usage of lubricants Past history systemic disease previous pelvic surgery previous STD or PID

History Drug history Name - Dose - Duration - Side effect Social history smoking, alcohol diet ( e.g. caffeine) expose to chemical or radiation (e.g. DES) stress and emotion lifestyle

Examination Vital sign BMI (obesity) Signs of androgen excess Signs of Thyroid disease Galactorrhea Pelvic scar Pelvic tenderness Vaginal discharge

Investigations Hormonal level –Serum progesterone –FSH level –LH level –inhibin B level Basal body temprature measure temperature before arising in the morning and record in chart

Investigations Endometrial biopsy biopsy is taken in the luteal phase Hystrosalpingography Oil or water-soluble contrast injected through cervix and fallopian tube for fluoroscopic x-ray Postcoital test For cervical mucus analysis

Investigations Laparoscopy Ultrasound MRI Genetic Testing Test for Autoimmune Disease

INFERTILITY MANAGEMENT

Basic work-up to evaluate infertility 1- Documentation of ovulation; 2-Semen analysis; 3- Postcoital test; 4- Evaluation of tubal patency; 5-Diagnostic laproscopy

Cervical factors 1- Infection……………Doxycycline 2-Poor mucus quality ……….estrogen from day 7 until ovulation 3-IUI

Ovulatory factors 1-Luteal phase defect……vaginal progestrone 2-Hypothalmic aminorrhea….GNRH in small doses 3-PCOS……………..….clomiphine citrate 4-Hyperprolactinaemea…….Dopamine agonists ‘bromocriptine’ 5-surgical excision of androgen producing ovarian stroma (wedge resection)

So, what could be the cause of infertility in this female????? In this case, the male factor is normal, but the female factor is abnormal

1-Cervical factor In Hx: ask about previous cervical surgery (cautery), infection and in utero diethylstilbestrol expousre (DES). In Exam.: cervical abnormalities or lesions. In screening test: postcoital test that evaluate sperm cervical mucus interaction. Treatment is: Intrauterine insemination (IUI)

2-Tubal and pertonial factor In Hx: prior pelvic infection or ectopic pregnancy In Exam.: stigmata of endometrosis. In screening test: hystrosalpingogram, laproscopy with tubal lavage(gold std.) Treatment : surgery or in vitro fertilization

3- Ovarian factor In Hx: Secondary amenorrhea, irregular menses In Exam.: obesity, hirutism and galactorrhea In screening test: Measurement of daily basal body temperature Treatment : ovulation induction

Prognosis 50% of couples will successfully achieve pregnancy among the couples with an identifiable cause. 60% of couples with unexplained infertility who receive no treatment will conceive within 3-5 years

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