1. INFERTILITTY SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

2. INFERTILITY Failure to conceive after one year of unprotected intercourse Incidence 15% of couples 1ry /2ry infertility The normal fecundability rate 20% What are the causes of infertiliy? Anovulation 10-25% Tubal blockage & endometriosis 30-50% Male factor 30-40% Cervical factor 5-10% Unexplained 5%

3. EVALUATING INFERTILE COUPLES History Age of both husband & wife Length of time conception has been attempted Previous pregnancies Frequency of intercourse/ dysparunea Menstrual history/ dysmenorrhea Headache visual changes & galactorrhea Excessive stress or exercise Symptoms of thyroid disease Pelvic surgery / appendicitis PID/ septic aborrtion/ ectopic pregnancy/IUCD Cervical conization or cryocautery / trauma D&C

4. HISTORY Husband Does he have children from another wife Testicular injury or surgery Mumps Medical diseases  DM, renal disease, chemotherapy Exposure to heat, drugs,alcohol, smoking

5. PHYSICAL EXAMINATION Signs of androgen excess Signs of thyroid dysfunction Obesity Emaciation / anorexia nervosa Galactorrhea Pelvic examination  Signs of pelvic infection -Uterosacral ligament nodularity -Immobility of the uterus -Irregular shape of the uterus -Pelvic mass

6. INVESTIGATIONS Semen analysis To test for ovulation -BBT -Endometrial biopsy -Serum progestrone FSH, LH, prolactin, TFT HSG Laparoscopy Post coital test

7. TREATMENT Depends on the cause 1-Anovulation PCO -Clomiphene citrate  Ovulation 70%  Pregnancy 40%  Twins 5-10% -HMG / pure FSH -Glucophage -Ovarian drilling -IVF

8. TREATMENT OF ANOVULATION Hypothalamic – pituitary failure “ Hypogonadotropic hypogonadism ” Kalman ’ s syndrome / Anorexia nervosa / Stress -HMG  pergonal -Synthetic pure FSH  puregon / gonal F -Pregnyl (HCG)  act like LH The risk of gonadotropin therapy  Hyperstimulation syndrome Multiple pregnancy 10-15%

9. TREATMENT OF ANOVULATION Hyperprolactinemia Bromocriptin 2.5 mg bd Surgical excision Hypothyroidism / hyperthyroidism  anovulation due to altered estrogen metabolism Anovulation due to ovarian failure Premature menopause

10. TREATMENT OF PERITONEAL FACTORS Tubal blockage -Laparoscopic salpingostomy  for distal obstruction -Hystroscopic tubal canulation for proximal obstructuion -Microsurgery -IVF Endometriosis 10-25% -Surgical treatment  Laparoscopic cauterization of endometriotic spots or laser ablation  preg rate mild/mod dis 60% severe dis  35%

11. TREATMENT OF PERITONEAL FACTORS Medical treatment of endometriosis OCP continuously 6M  preg rate 40-50% Danazole GnRH analogues

12. TREATMENT OF CERVICAL FACTORS / MALE FACTOR / UNEXPLAINED INFERTILITTY Superovulation + IUI Assissted reproductive techniques TREATMENT OF UTERINE FACTOR Asherman syndrome Hystroscopic lysis of adhesions followed by estrogen therapy Pregnancy rate  70%

13. ASSISSTED REPRODUCTIVE TECHNIQUES IVF GIFT ZIFT ICSE