Infertility
Content
INFERTILITY ² DEFINITION, CAUSES, DIAGNOSTIC PROCEDURES AND COUNCELLING
DEFINITION
Infertility is the lack of conception after 1 year of unprotected sexual intercourse.(Hughes and Hammond 1990) Primary infertility: identifies those women who have never conceived. Secondary infertility: indicates those women who have formerly been pregnant but have not
FEMALE CAUSES
Ovulation Hypothyroidism Hypothalamic anovulation Hyperprolactinaemia Luteal phase defect: there is decreased hormone production by the corpus luteum as well as decreased level of FSH and LH. Polycystic ovaries Excessive male hormone (androgens) Physical stress, psychological stress and extreme lifestyle changes.
Conti.. Cervical infertility
Inadequate or inhospitable cervical mucus due to the presence of local sperm antibodies or due to low pH of the mucus at midcycle. Cervical stenosis( tight internal os) Infections of the cervix with common sexually transmitted diseases (chlamydia, gonorrhea, or trichomonas, as well as mycoplasma hominis and ureaplasma urealyticum) Loss of mucus due to amputation of
Conti
Pelvic causes
Scar tissue or "adhesions" Endometriosis Tubal factor infertility Pelvic inflammatory disease (PID): usually caused by invasion of either gonorrhea or chlamydia from the cervix up to the uterus and tubes. Benign tumors (fibroids)
Conti..
Uterine causes
Thin or abnormal uterine lining Anatomic problems (polyps,abnormal shape of the uterus, septum within the uterus, mullerian anomalies, prior exposure to DES Diethylstilbestrol) Uterine atrophy, absence Tuberculous endometritis Intrauterine adhesions ( Ashermand s syndrome) due to previous overzealous curettage or previous surgery on the uterus.
Conti..
Coital errors
Apareunia and Dyspareuni Frequency and timing of coitus: coitus has to take place every 48 hours during the fertile period to offer the optimum chance of conception. Unexplained Infertility Difficulty in picking up the egg by fallopian tube Failure of implantation of the embryo into the uterus Failure of the sperm to fertilize the egg when in contact with each other
MALE CAUSES:
Exposure to hazardous toxins, chemicals, or radiation Infections such as mumps, or venereal diseases Testicular injury (sports or work injury) Childhood illness (failure of a testicle to descend properly) Immune reaction against sperm (antisperm antibodies)
conti
Blockage of one of the ducts allowing flow of sperm from the testicle Injury, infection or prior vasectomy Genetic absence of these ducts (cystic fibrosis) Testicular failure and other hormonal problems Chronic medical illness (thyroid disease, diabetes, and hypertension) Spinal cord injuries and paralysis Varicocele
DIAGNOSTIC PROCEDURES
HISTORY AND PHYSICAL EXAMINATION:
Ages, occupations, previous marriages Duration of marriage and the period of time during which contraception has been practiced. Past gynecological, surgical, medical history. Exposures to tobacco, alcohol, environmental toxins A history of sexually transmitted diseases A careful menstrual history
Conti. Is coitus normal and painless, how frequently it is practiced and at what time in the cycle. A history of any past pregnancies, a thorough review of all organ systems, and any other relevant information. Drugs, e.g. mefenamic acid taken for mittelschmerz pain, may interfere with ovulation. Drugs used for treating hypertension ( guanethidine) may cause impotence and salazopyrine( for ulcerative colitis),cytotoxic drugs, immunosuppressives and nitrofurantoin reduces the sperm count. Alcohol intake may reduce the potency and frequency of coitus.
LABORATORY TESTS
Hormonal Levels: Blood and urine tests High FSH & LH levels and low estrogen levels suggest premature ovarian failure. High LH and low FSH may suggest polycystic ovary syndrome or luteal phase defect. High FSH and high estrogen levels on the third day of the cycle predict poor success rates in older women trying fertility treatments.LH surges indicate ovulation. Blood tests for prolactin levels and thyroid function are also measured.
CLOMIPHENE CHALLENGE TEST
Used to test for ovarian reserve. With this test, FSH is measured on day 3 of the cycle. The woman takes clomiphene orally on days 5 and 9 of the cycle. Then FSH measured on the tenth day. High levels of FSH either on day 3 or day 10 indicate a poor chance for a successful outcome.
Tissue Samples: To rule out luteal phase defect, premature ovarian failure, and absence of ovulation, tissue samples are taken of the uterus 1 - 2 days before a period to determine if the corpus luteum is adequately producing progesterone. Tissue samples taken from the cervix may be cultured to rule out infection. Tests for Autoimmune Disease Importance of BMI and obesity: BMI Obesity > 30 Average =25kg/m2 Requires treatment> 28
IMAGING TESTS AND DIAGNOSTIC PROCEDURES TRANSVAGINAL ULTRASOUND ENDOMETRIAL BIOPSY: Involves scraping a small amount of tissue from the endometrium shortly before menstruation is due- between 11 and 13 days following ovulation. It is performed to determine if the lining of the uterus is sufficiently developed and can support preembryonic implantation
POST-COITAL TEST
Give information how the cervical mucus and sperm interact, to determine whether the mucus in the cervix is "hostile" to sperm. The test must be done within one to two days before or after ovulation. A couple should abstain from intercourse for 2 days before ovulation, then have intercourse 2-8 hours prior to the hospital visit for the post-coital test.
Ferning - When the cervical mucus dries on a microscope slide, it should take on the appearance of ferns. This assures that the mucus has been exposed to adequate levels of estrogen without any exposure to progesterone. In other words, that the timing is correct. Amount - Cervical mucus production normally increases dramatically just prior to ovulation. Clarity - It should be very clear, almost watery.
Cellularity - There should be relatively few cells present, other than sperm. Spinnbarkeit ± This is the stretchiness of the cervical mucus. It should be almost elastic and may stretch 10 cms or more.
HYSTEROSALPINGOGRAM
It is essentially an x-ray procedure in which a dye is injected through the cervix into the uterus and fallopian tubes. The radioopaque material is injected slowly from a syringe; the amount required varying from 2-20 ml
BASAL BODY TEMPERATURE CHARTING
To identify the time of ovulation. Charting involves taking one's temperature every morning upon waking up and recording the results. When the temperature goes up 0.5 degrees, the woman is in the process of ovulating.
HYSTEROSCOPY
It uses a hysteroscope, which is a thin telescope that is inserted through the cervix into the uterus. This procedure allows to determine whether there are any abnormalities such as fibroid tumors, polyps, scar tissue, a uterine septum, or some other uterine problem
HYSTEROCONTRAST SONOGRAPHY HyCoSy
A combination of air and saline or contrast medium (Echovist-200) is introduced into the uterus transcervically. The flow of the medium seen in some unanaesthetised women is more through the uterus and tubes, and its spill in the pelvis with water soluble than with oily or non-ionic media is monitores by ultrasound. Complications like immediate pain, vomiting, shock and hypotension can occur.
FALLOPOSCOPY
The falloposcopy is a visual examination of the inside of the fallopian tubes. This involves the insertion of a tiny catheter through the cervical canal and into the uterus to the fallopian tubes. It is then, an even smaller fiber optic endoscope is threaded through the catheter, into the fallopian tube. From here, the fallopian tubes can be examined on a monitor from which a camera is attached on the outside end of the fallopscope.
LAPAROSCOPY
It requires general anesthesia and is performed in an operating room. The surgeon makes a very small incision below the belly button and inserts an instrument called a laparoscope
Laparoscopy picture of a hydrosalpinx, fallopian tube that is blocked and dilated with fluid.This is evidence of PID
TESTS FOR MALE INFERTILITY
SEMEN ANALYSIS The specimen is collected after 3 days of abstinence, masturbating directly into a dry and clean wide mouthed glass container. The semen analysis should include basic parameters such as sperm number, motility, and morphology (shape) The technician looks at how well the sperm are moving and counts the total percentage of motile sperm moving.
Semen Analysis Parameter
Volume pH Sperm concentration Motility
Normal Values
2.0 ml or more 7.2-8.0 20,000,000/ml or more 50% or more with forward progression
Rapid forward progressive motility 25% or more 30% or more normal forms (WHO criteria) -or11% or more normal forms (Strict criteria) 75% or more live
Morphology
Vitality
SPERM FUNCTION TESTS
SPERM PENETRATION ASSAY/ HAMSTER EGG TEST: In this test, the husband's sperm is mixed with hamster eggs to see whether they penetrate the eggs. Healthy sperms penetrate most, specially processed hamster ova from which the zona has been removed, and produce a significant degree of polyspermy per egg.
Human zona binding assay: In this test, the husband's sperm is mixed with pieces of human egg shells (zona pellucidas) to see how many will bind to the shells. There are a lot less false positives and false negative results as compared to the hamster egg test. VARICOCELE ASSESSMENT : Varicocele is the collection of dilated veins in the spermatic cord. Exact cause for infertility is not known but it may be associated with ipsilateral testicular volume, elevated scrotal temperature and pain, impaired sperm quality- WHO 1992. In 31% cases only treatment of varicocele has resulted in improves sperm count.
SPERM ANTIBODY TESTING
Semen is known to be highly antigenic and sperm antibodies are a known cause of infertility. Agglutination is the sticking together of sperm in variable patterns. It is caused by anti-sperm antibodies which are usually IgA or IgG. Further tests like immunobead or mixed anti globulin reaction (MAR) test can be done for the detection of these antibodies in semen.
HORMONAL ASSESSMENT IN MEN
A raised FSH level reflects failure of spermatogenesis. Low levels of FSH and LH are diagnostic of hypo-gonadotrophic hypogonadism. Normal FSH levels with normal testes but azoospermia suggest obstruction Raised LH level with low testosterone levels indicate Leydig cell dysfunction.
INFERTILITY COUNCELLING
The basic aim of counseling is to ensure that the patient understands the implications of their treatment choice, the patient receives adequate information and emotional support, and that they can cope in a healthy way with the consequences of treatment.
IMPLICATION COUNCELLING
It is to enable couples to understand the implications of the proposed treatment for themselves, their family and for any children born as a result. This may of particular relevance for couple seeking treatment with donor eggs, donor sperm, donor embryos or surrogacy. Genetic counselling should be offered when there is an increased risk of passing on an inherited disease to the offspring. Psychological counselling should be offered for partners suffering from psychosexual problems.
SUPPORT COUNSELLING
To give emotional support and information from the start of the treatment. It is primarily the task of the clinical team but unfortunately, tension often erases much of the information, which has been given, and many patients will not have fully digested what have been said. Infertility counselors need to address these defects and detects any tensions showed by the patient's poor understanding
THERAPEUTIC COUNSELLING
To help couples understand their expectation including the prospects of failure and adjusting to childlessness, counselling can with time, help people adjusts and accepts the situation. Therapeutic counselling also focuses on certain issues such as sexual and menstrual problems
Role of a Counselor
The role of counselor is to help infertile couples process their emotions and to arrive at a situation with which they feel comfortable and with which they can live a normal life. It is essential that counselling must be informal and effective and not a hindrance and waste of time. Counselors should have up-todate knowledge of infertility and assisted reproductive treatments.
BIBLIOGRAPHY Berek JS. Berek and Novak¶s Gynecology. 14th edition: Philadelphia, Lippincott Williams and wilkins. 2007 Rajan R. Postgraduate Obstetrics, Gynecology, Infertility and Clinical Endocrinology.1st edition: NewDelhi. Jaypee Bros publications; 2005 Kumar P, Malhotra N. Jeffcoat¶s principles of gynecology. 7th edition. New Delhi: Jaypee Bros Medical Publishers;2008 Mukherjee GG. Current obstetrics and gynecology. 1st edition. New Delhi: Jaypee bros medical publishers.2007. Ladewig PW, London ML, Olds SB. Maternal newborn nursing. California: Addison Wesley nursing; 2007 Pilliteri A. Maternal and child health nursing. Philadelphia: Lippincott Williams and Wilkins; 2007
Tietze C: Reproductive span and rate of conception among Hutterite women. Fertility and Sterility 1997; 8:89-97. Speroff L, Fitz M. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Lippincott Williams & Wilkins; 2004. Stenchever A. Comprehensive Gynecology. 4th ed. St. Louis, Mo: Mosby; 2001:1204-1206. http://www.asrm.org/Patients/FactSheets/CounselingFact.pdf http://www.advancedfertility.com/causes.htm http://www.ingentaconnect.com/content/repro http://www.rmany.com/diagnostic-procedures.aspx#1 http://www.fertilityfactor.com/infertility_natural_treatm ents_therapy.html
DEFINITION
Infertility is the lack of conception after 1 year of unprotected sexual intercourse.(Hughes and Hammond 1990) Primary infertility: identifies those women who have never conceived. Secondary infertility: indicates those women who have formerly been pregnant but have not
FEMALE CAUSES
Ovulation Hypothyroidism Hypothalamic anovulation Hyperprolactinaemia Luteal phase defect: there is decreased hormone production by the corpus luteum as well as decreased level of FSH and LH. Polycystic ovaries Excessive male hormone (androgens) Physical stress, psychological stress and extreme lifestyle changes.
Conti.. Cervical infertility
Inadequate or inhospitable cervical mucus due to the presence of local sperm antibodies or due to low pH of the mucus at midcycle. Cervical stenosis( tight internal os) Infections of the cervix with common sexually transmitted diseases (chlamydia, gonorrhea, or trichomonas, as well as mycoplasma hominis and ureaplasma urealyticum) Loss of mucus due to amputation of
Conti
Pelvic causes
Scar tissue or "adhesions" Endometriosis Tubal factor infertility Pelvic inflammatory disease (PID): usually caused by invasion of either gonorrhea or chlamydia from the cervix up to the uterus and tubes. Benign tumors (fibroids)
Conti..
Uterine causes
Thin or abnormal uterine lining Anatomic problems (polyps,abnormal shape of the uterus, septum within the uterus, mullerian anomalies, prior exposure to DES Diethylstilbestrol) Uterine atrophy, absence Tuberculous endometritis Intrauterine adhesions ( Ashermand s syndrome) due to previous overzealous curettage or previous surgery on the uterus.
Conti..
Coital errors
Apareunia and Dyspareuni Frequency and timing of coitus: coitus has to take place every 48 hours during the fertile period to offer the optimum chance of conception. Unexplained Infertility Difficulty in picking up the egg by fallopian tube Failure of implantation of the embryo into the uterus Failure of the sperm to fertilize the egg when in contact with each other
MALE CAUSES:
Exposure to hazardous toxins, chemicals, or radiation Infections such as mumps, or venereal diseases Testicular injury (sports or work injury) Childhood illness (failure of a testicle to descend properly) Immune reaction against sperm (antisperm antibodies)
conti
Blockage of one of the ducts allowing flow of sperm from the testicle Injury, infection or prior vasectomy Genetic absence of these ducts (cystic fibrosis) Testicular failure and other hormonal problems Chronic medical illness (thyroid disease, diabetes, and hypertension) Spinal cord injuries and paralysis Varicocele
DIAGNOSTIC PROCEDURES
HISTORY AND PHYSICAL EXAMINATION:
Ages, occupations, previous marriages Duration of marriage and the period of time during which contraception has been practiced. Past gynecological, surgical, medical history. Exposures to tobacco, alcohol, environmental toxins A history of sexually transmitted diseases A careful menstrual history
Conti. Is coitus normal and painless, how frequently it is practiced and at what time in the cycle. A history of any past pregnancies, a thorough review of all organ systems, and any other relevant information. Drugs, e.g. mefenamic acid taken for mittelschmerz pain, may interfere with ovulation. Drugs used for treating hypertension ( guanethidine) may cause impotence and salazopyrine( for ulcerative colitis),cytotoxic drugs, immunosuppressives and nitrofurantoin reduces the sperm count. Alcohol intake may reduce the potency and frequency of coitus.
LABORATORY TESTS
Hormonal Levels: Blood and urine tests High FSH & LH levels and low estrogen levels suggest premature ovarian failure. High LH and low FSH may suggest polycystic ovary syndrome or luteal phase defect. High FSH and high estrogen levels on the third day of the cycle predict poor success rates in older women trying fertility treatments.LH surges indicate ovulation. Blood tests for prolactin levels and thyroid function are also measured.
CLOMIPHENE CHALLENGE TEST
Used to test for ovarian reserve. With this test, FSH is measured on day 3 of the cycle. The woman takes clomiphene orally on days 5 and 9 of the cycle. Then FSH measured on the tenth day. High levels of FSH either on day 3 or day 10 indicate a poor chance for a successful outcome.
Tissue Samples: To rule out luteal phase defect, premature ovarian failure, and absence of ovulation, tissue samples are taken of the uterus 1 - 2 days before a period to determine if the corpus luteum is adequately producing progesterone. Tissue samples taken from the cervix may be cultured to rule out infection. Tests for Autoimmune Disease Importance of BMI and obesity: BMI Obesity > 30 Average =25kg/m2 Requires treatment> 28
IMAGING TESTS AND DIAGNOSTIC PROCEDURES TRANSVAGINAL ULTRASOUND ENDOMETRIAL BIOPSY: Involves scraping a small amount of tissue from the endometrium shortly before menstruation is due- between 11 and 13 days following ovulation. It is performed to determine if the lining of the uterus is sufficiently developed and can support preembryonic implantation
POST-COITAL TEST
Give information how the cervical mucus and sperm interact, to determine whether the mucus in the cervix is "hostile" to sperm. The test must be done within one to two days before or after ovulation. A couple should abstain from intercourse for 2 days before ovulation, then have intercourse 2-8 hours prior to the hospital visit for the post-coital test.
Ferning - When the cervical mucus dries on a microscope slide, it should take on the appearance of ferns. This assures that the mucus has been exposed to adequate levels of estrogen without any exposure to progesterone. In other words, that the timing is correct. Amount - Cervical mucus production normally increases dramatically just prior to ovulation. Clarity - It should be very clear, almost watery.
Cellularity - There should be relatively few cells present, other than sperm. Spinnbarkeit ± This is the stretchiness of the cervical mucus. It should be almost elastic and may stretch 10 cms or more.
HYSTEROSALPINGOGRAM
It is essentially an x-ray procedure in which a dye is injected through the cervix into the uterus and fallopian tubes. The radioopaque material is injected slowly from a syringe; the amount required varying from 2-20 ml
BASAL BODY TEMPERATURE CHARTING
To identify the time of ovulation. Charting involves taking one's temperature every morning upon waking up and recording the results. When the temperature goes up 0.5 degrees, the woman is in the process of ovulating.
HYSTEROSCOPY
It uses a hysteroscope, which is a thin telescope that is inserted through the cervix into the uterus. This procedure allows to determine whether there are any abnormalities such as fibroid tumors, polyps, scar tissue, a uterine septum, or some other uterine problem
HYSTEROCONTRAST SONOGRAPHY HyCoSy
A combination of air and saline or contrast medium (Echovist-200) is introduced into the uterus transcervically. The flow of the medium seen in some unanaesthetised women is more through the uterus and tubes, and its spill in the pelvis with water soluble than with oily or non-ionic media is monitores by ultrasound. Complications like immediate pain, vomiting, shock and hypotension can occur.
FALLOPOSCOPY
The falloposcopy is a visual examination of the inside of the fallopian tubes. This involves the insertion of a tiny catheter through the cervical canal and into the uterus to the fallopian tubes. It is then, an even smaller fiber optic endoscope is threaded through the catheter, into the fallopian tube. From here, the fallopian tubes can be examined on a monitor from which a camera is attached on the outside end of the fallopscope.
LAPAROSCOPY
It requires general anesthesia and is performed in an operating room. The surgeon makes a very small incision below the belly button and inserts an instrument called a laparoscope
Laparoscopy picture of a hydrosalpinx, fallopian tube that is blocked and dilated with fluid.This is evidence of PID
TESTS FOR MALE INFERTILITY
SEMEN ANALYSIS The specimen is collected after 3 days of abstinence, masturbating directly into a dry and clean wide mouthed glass container. The semen analysis should include basic parameters such as sperm number, motility, and morphology (shape) The technician looks at how well the sperm are moving and counts the total percentage of motile sperm moving.
Semen Analysis Parameter
Volume pH Sperm concentration Motility
Normal Values
2.0 ml or more 7.2-8.0 20,000,000/ml or more 50% or more with forward progression
Rapid forward progressive motility 25% or more 30% or more normal forms (WHO criteria) -or11% or more normal forms (Strict criteria) 75% or more live
Morphology
Vitality
SPERM FUNCTION TESTS
SPERM PENETRATION ASSAY/ HAMSTER EGG TEST: In this test, the husband's sperm is mixed with hamster eggs to see whether they penetrate the eggs. Healthy sperms penetrate most, specially processed hamster ova from which the zona has been removed, and produce a significant degree of polyspermy per egg.
Human zona binding assay: In this test, the husband's sperm is mixed with pieces of human egg shells (zona pellucidas) to see how many will bind to the shells. There are a lot less false positives and false negative results as compared to the hamster egg test. VARICOCELE ASSESSMENT : Varicocele is the collection of dilated veins in the spermatic cord. Exact cause for infertility is not known but it may be associated with ipsilateral testicular volume, elevated scrotal temperature and pain, impaired sperm quality- WHO 1992. In 31% cases only treatment of varicocele has resulted in improves sperm count.
SPERM ANTIBODY TESTING
Semen is known to be highly antigenic and sperm antibodies are a known cause of infertility. Agglutination is the sticking together of sperm in variable patterns. It is caused by anti-sperm antibodies which are usually IgA or IgG. Further tests like immunobead or mixed anti globulin reaction (MAR) test can be done for the detection of these antibodies in semen.
HORMONAL ASSESSMENT IN MEN
A raised FSH level reflects failure of spermatogenesis. Low levels of FSH and LH are diagnostic of hypo-gonadotrophic hypogonadism. Normal FSH levels with normal testes but azoospermia suggest obstruction Raised LH level with low testosterone levels indicate Leydig cell dysfunction.
INFERTILITY COUNCELLING
The basic aim of counseling is to ensure that the patient understands the implications of their treatment choice, the patient receives adequate information and emotional support, and that they can cope in a healthy way with the consequences of treatment.
IMPLICATION COUNCELLING
It is to enable couples to understand the implications of the proposed treatment for themselves, their family and for any children born as a result. This may of particular relevance for couple seeking treatment with donor eggs, donor sperm, donor embryos or surrogacy. Genetic counselling should be offered when there is an increased risk of passing on an inherited disease to the offspring. Psychological counselling should be offered for partners suffering from psychosexual problems.
SUPPORT COUNSELLING
To give emotional support and information from the start of the treatment. It is primarily the task of the clinical team but unfortunately, tension often erases much of the information, which has been given, and many patients will not have fully digested what have been said. Infertility counselors need to address these defects and detects any tensions showed by the patient's poor understanding
THERAPEUTIC COUNSELLING
To help couples understand their expectation including the prospects of failure and adjusting to childlessness, counselling can with time, help people adjusts and accepts the situation. Therapeutic counselling also focuses on certain issues such as sexual and menstrual problems
Role of a Counselor
The role of counselor is to help infertile couples process their emotions and to arrive at a situation with which they feel comfortable and with which they can live a normal life. It is essential that counselling must be informal and effective and not a hindrance and waste of time. Counselors should have up-todate knowledge of infertility and assisted reproductive treatments.
BIBLIOGRAPHY Berek JS. Berek and Novak¶s Gynecology. 14th edition: Philadelphia, Lippincott Williams and wilkins. 2007 Rajan R. Postgraduate Obstetrics, Gynecology, Infertility and Clinical Endocrinology.1st edition: NewDelhi. Jaypee Bros publications; 2005 Kumar P, Malhotra N. Jeffcoat¶s principles of gynecology. 7th edition. New Delhi: Jaypee Bros Medical Publishers;2008 Mukherjee GG. Current obstetrics and gynecology. 1st edition. New Delhi: Jaypee bros medical publishers.2007. Ladewig PW, London ML, Olds SB. Maternal newborn nursing. California: Addison Wesley nursing; 2007 Pilliteri A. Maternal and child health nursing. Philadelphia: Lippincott Williams and Wilkins; 2007
Tietze C: Reproductive span and rate of conception among Hutterite women. Fertility and Sterility 1997; 8:89-97. Speroff L, Fitz M. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Lippincott Williams & Wilkins; 2004. Stenchever A. Comprehensive Gynecology. 4th ed. St. Louis, Mo: Mosby; 2001:1204-1206. http://www.asrm.org/Patients/FactSheets/CounselingFact.pdf http://www.advancedfertility.com/causes.htm http://www.ingentaconnect.com/content/repro http://www.rmany.com/diagnostic-procedures.aspx#1 http://www.fertilityfactor.com/infertility_natural_treatm ents_therapy.html
