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INFERTILITY PowerPoint Presentation

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Description : Check out this medical presentation on Obstetrics & Gynecology, which is titled "INFERTILITY", to know about assessment and treatment of patients with fertility problems.

Tags : Obstetrics, Gynecology, INFERTILITY, assessment, treatment, fertility problems

Published on : Jul 18, 2021 | Views : 9158 | Downloads : 85

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Slide 1-

INFERTILITY Assessment and treatment of patients with fertility problems Dr Nitu Raje-Ghatge
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Why learn about it? Its in the curriculum ! Infertility – primary/ secondary Investigations eg hormone tests Knowledge of subfertility secondary care investigations Primary care management Knowledge of specialist treatments and surgical procedures
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Why learn about it.. Expectations from secondary care services! Inappropriate timing of referrals (early/late) Incomplete /inadequate investigations
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What is infertility? NICE: Failure to conceive after regular UPSI for 2 years in the absence of reproductive pathology. P.S NICE suggests offer clinical investigations if failure to conceive after 1 year of UPSI. GP NOTEBOOK: Infertility is the failure of conception in a couple having regular, unprotected coitus for 1 year, provided that normal intercourse is occurring not less than twice weekly.
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Natural conception rates: 80% of couples will be pregnant after 12 cycles. 50% of remaining will conceive during a 2nd year ( hence cumulative rate 90%) 50% in the following 4 years.
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PRIMARY/SECONDARY INFERTILITY PRIMARY – Couple without a prior pregnancy SECONDARY – Couple with previous pregnancy including miscarriage/ectopic.
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Etiology: Male factors Female factors Unexplained -20% Mixed – 15%
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Male Account for 25% Hypogonadotrophic hypogonadism Obstructive azoospermia Surgery Erectile dysfunction Anatomical - Hypospadias - Undescended/ maldescended testis
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Female Peritoneal factors 40%, - Endometriosis. Tubal blockage 20%.
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Etiology (female) Ovulatory dysfunction 15-20% - Hypothalamic/hypogonadotrophic hypogonadism - Hypothalamic pituitary dysfunction (PCOS) - Ovarian failure Uterine cavity abnormalities - Asherman's syndrome - Uterine fibroids. Cervical hostility 5-10%, - Infection - Female sperm antibodies.
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Fertility may be impaired in poorly controlled diabetes.
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History taking (female) Symptoms (past or present) - P I D / STD, - dysparenuria - galactorrhoea, - thyroid symptoms Obstetric history
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History taking (female) Menstrual history - irregularities Surgical history – D & C, abdominal/pelvic surgery Contraception - IUCDs Cervical smear
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History taking (male) Symptoms h/o genital tract infection e.g. mumps orchitis, prostatitis Surgical history - Hernia repair - Testicular surgery for torsion/ undescended /maldescended testis - Prostate surgery
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History taking (male) Trauma to the male genital or inguinal region Occupational history - exposure to lead, cadmium Drug history - Sulphasalazine – impairs spermatogenesis - Phenothiazines/ typical antipsychotics/ metoclopramide increase prolactin levels - Immunosuppresants
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IN BOTH Smoking Alcohol intake Psychological factors
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EXAMINATION General health and nutritional status BMI <19 (F) > 29.(M/F) SSC
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Female: Hirsuitism, galactorrhoea Bimanual examination - adnexal masses (tubo/ovarian, ovarian cyst) - tenderness (PID/ endometriosis) - Uterine fibroids
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Male Hypospadias Size and consistency of each testicle and epididymis; Presence of varicocele or hernia; Size of prostate. Gynaecomastia
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Now what?? Investigate Or Refer
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Early referral if.. Female Age >35 years Amenorrhoea/ oligo menorrhoea PID Abnormal pelvic exam Male Undescended testes Previous genital pathology Previous urogenital surgery In Both Prior treatment for cancer HIV, Hep B, Hep C
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Investigations Primary care Female Assess ovulation. Other hormonal tests Tests for PID Male Sperm analysis Secondary care Tubal patency Uterine abnormality
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Assessing ovulation Do if regular cycles with > 1 year of infertility irregular cycles 1) Serum progesterone 2) LH/FSH levels
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INVESTIGATIONS (Female) 1) Serum progesterone (mid luteal phase ie day 21 of 28 week cycle) Timing is important!!! Regular cycles - 7 days before next MP Irregular cycles - day 28/35 wk then weekly till menstruation occurs
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Interpretation of test
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Assessing ovulation 2) LH/FSH levels High levels – poor ovarian function High LH compared to FSH -PCOS
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Other hormonal tests E2, Testosterone levels – PCOS Prolactin ONLY if - ovulation problems - galactorrhoea, - pituitary problem.
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Other hormonal tests Thyroid tests - only with symptoms/ signs Other androgen profile (DHEAS, Androstenedione, SBHG) – as per etiology
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Tests for PID HVS Chlamydia screening
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Don’t forget!! Rubella status - check immunity - Vaccinate if non immune, avoid conception for 3 months
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Cervical hostility Post coital test - no longer recommended by NICE Mucus invasion test - doubtful significance
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Investigations (Male) Semen analysis Needs prior appointment with lab Abstinence for atleast 3 days Transport to lab in 30- 60 min Repeat abnormal test in next 3 months, earlier if gross abnormality
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Semen analysis- interpretation (WHO values) Volume 2 mls or more Sperm concentration - 20 million/ml Sperm morphology - atleast 30% normal Sperm number - 40 million/ ejaculate Sperm motility – 50% Vitality – 75% WBC - <1 million/ml Anti sperm antibody tests- not recommended by NICE
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Investigations in secondary care
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Tests for uterine/tubal problems HSG/hystero salpingo-contrast USG Laparoscopy + dye test Done only when ovulation tests/Sperm tests normal. Choice of tests depends upon co morbidities
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Management in primary care Principles of care Couple centred management Access to evidence based information Counselling (third person) Contact with fertility support groups Specialist teams
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Positive approach Reassure about cumulative pregnancy rates
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Management in primary care Lifestyle changes - Weight reduction, BMI 19-29 - Smoking cessation- offer support groups - Alcohol reduction <1-2 units/week for women <3-4 units/week for men - S I every 2-3 days - Information about OTC/ recreational drugs
Slide 39-

Management in primary care Pre conceptual advice - Folic acid supplementation - Rubella status - Cervical screening Management of erectile dysfunction - psychosexual couselling - drugs
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Management in secondary care Depends upon the etiology..
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Hypogonadotrophic hypogonadism Pulsatile GnRH Gonadotrophins with LH activity Bromocriptine ( for hyperprolactinaemia)
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Ovarian dysfunction ( hypothalamic dysfunction) 1) Anti- oestrogens eg Clomiphene/ Tamoxifen - 1st line - use for atleast 12 months if ovulating - initiated in secondary care - under USG guidance ( to adjust dose) - shared care when dose established - S/E risk of multiple pregnancy, OHSS
Slide 43-

Ovulatory dysfunction- treatment 2) Metformin - not licensed for ovulatory disorders in UK - used 2nd line with Clomiphene in - anovulatory women with PCOD + BMI >25 + no response to CC
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Others… 3) Gonadotrophins 4) Luteal phase support – - progesterone, - clomiphene 5) Laparoscopic ovarian drilling
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Peritoneal problems (endometriosis) Laparoscopic surgical ablation/ resection of endometriosis + adhesiolysis If ovarian endometriomas, laparoscopic cystectomy
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Uterine/ tubal factors Tubal factors: - Laparoscopic tubal surgery/ tubal microsurgery - Salpingography + tubal catheteristion - Hysteroscopic tubal cannulation Uterine factors - hysteroscopic adhesiolysis - myomectomy
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Assisted reproduction techniques Intra uterine insemination (IUI)
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In vitrio fertilisation Intracytoplasmic sperm injection (ICSI) Donor insemination Oocyte donation
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ACON at CRH Satellite IVF unit Counselling, monitoring and most of treatment , except egg retrieval and embryo transfer.
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Central unit Clarendon Wing, LGI SJUH, Leeds CARE, Manchester
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Questions…..zzzz??