Infertility

INFERTILITY  When pregnancy has not occurred after at least 1 year of engaging in unprotected coitus  Primary Infertility: no previous conception

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1. Secondary infertility y : with previous viable pregnancy but unable to conceive at the present Sterility : inability to conceive because of unknown condition Subfertility: lessened ability to conceive

MALE INFERTILITY FACTORS  Disturbance in spermatogenesis  Obstruction in the seminiferous tubules, ducts, or vessels preventing movement of spermatozoa  Qualitative or quantitative changes in the seminal fluid preventing sperm motility  Development of autoimmunity that immobilizes sperm  Problems in ejaculation or deposition preventing spermatozoa from being placed close enough to the woman’s cervix to allow ready penetration and fertilization 1. Inadequate Sperm Count  Sperm count is the number of sperm in a single ejaculation or in ml of semen.  Normal : 20 Million/ml or 50 Million per ejaculation

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At least 2. 50% should be motile, and 30 % in normal shape and form Spermatozoa must be produced and maintained at a temperature slightly lower than the body temperature to become normal and fully motile

2. Obstruction or Impaired Sperm Motility  May occur at any point along the pathway that spermatozoa must travel to reach the outside: the semineferous tubules, the epididymis, the vas deferens, the ejaculatory duct, or the urethra.  type of obstruction because of adhesions and occulusions that interfere with sperm transport o Mumps orchitis (testicular inflammation and scarring due to the mumps virus), o epididymitis (inflammation of the epididymis), o tubal infections (gonorrhea or ascending urethral infection)  Vasectomies develop an autoimmune reaction or form antibodies that immobilize their own sperm.  It is also conceivable that men with obstruction in the vas deferens from other causes, such as scarring after an infection, could also develop an autoimmune reaction that immobilizes sperm in the same way.  Sperm to be deposited too far from the sexual partner’s cervix to allow optimal cervical penetration. o Hypospadias (urethral opening on the ventral surface of the penis) o epispadias (urethral opening on the dorsal surface).

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obesity in a male may also interfere with effective penetration and deposition.

3. Ejaculation Problems  Psychological problems  debilitating diseases: o cerebrovascular accident o Parkinson’s disease  some medication o certain 4. antihypertensive agents - may result in erectile dysfuntion (formerly called impotence).  Solutions to the problem can include psychological or sexual counseling as well as administration of sildenafil (Viagra).  Premature ejaculation (ejaculation before penetration) FEMALE INFERTILITY FACTORS 1. ANOVULATION  absence of ovulation  genetic abnormality: o Turner’s syndrome (hypogonadism) in which there are no 5.

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ovaries to produce ova.

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hormonal imbalance: o hypothroidism that interferes with hypothalamus-pituitary-ovarian interaction. varian tumors may produce annovulation due to feedback stimulation on the pituitary. chronic or excessive exposure to x-rays or radioactive substances, general ill health, poor diet, and stress may all contribute to poor ovarian function. Stress affects the ovary by reducing hypothalamic secretion of gonadotropin-releasing hormone (GnRH), which then lowers the production of luteinizing hormone (LH) and folliclestimulating hormone (FSH). Decreased body weight or a bady/fat ration of less that 10%, as may occur in the female athletes. The most frequent cause, however, is naturally occurring variations in ovulatory patterns or polycystic ovary syndrome, a condition which the ovaries fail to respond to FSH.

2. TUBAL TRANSPORT PROBLEMS  Difficulty with tubal transport usually occurs because scarring has developed in the fallopian tubes.  Caused by chronic salpingitis (chronic pelvic inflammatory disease [PID].  It can result from a ruptured appendix or from abdominal surgery involving infection that spread to the fallopian tubes and left adhesion formation in the tubes.

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Pelvic Inflammatory Disease an infection of the pelvic organs: uterus, fallopian tubes, ovaries, and their supporting structures. Many organisms can cause PID, but chlamydia and gonorrhea are among those most frequently seen.

3. UTERINE PROBLEMS  Tumors such as fibromas (leiomyomas) may be a rare cause of infertility if the block the entrance of the fallopian tubes into the uterus or limit the space available on the uterine wall for effective implantation. 

Endometriosis refers to the implantation of uterine endometrium, or nodules, that have spread from the interior of the uterus to locations outside the uterus.

4. CERVICAL PROBLEMS  At the time of ovulation, the cervical mucus is thin and watery and can be easily penetrated by spermatozoa for a period of 12 to 72 hours.  If coitus is not synchronized with this time period, the cervical mucus may be too thick to allow spermatozoa to penetrate to cervix.  Infection or inflammation of the cervix (erosion) may cause so much thickening in cervical mucus that spermatozoa cannot penetrate it easily or survive in it. 5. VAGINAL PROBLEMS

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Infection of the vagina can cause the pH of the vaginal secretions to become 7. limiting or destroying the motility of spermatozoa.

acidotic,

6. UNEXPLAINED INFERTILITY FERTILITY ASSESTMENT 1. Health History  General health  Nutrition  Alcohol, drug, or tobacco use  Congenital health problems such as hypospadias or cryptorchidism  Illnesses such as mumps orchitis, urinary tract infection, or sexually transmitted diseases  Operations such as surgical repair of a hernia, which could have resulted in a blood compromise to the testes  Current illnesses, particularly endocrine illnesses or low-grade infections  Past and current occupation and work habits (e.g., does his job involve sitting at a desk all day or exposure to x-rays or other forms of radiation?)

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Document sexual practices such as: o Frequency of coitus and masturbation o Failure to achieve ejaculation o Premature ejaculation o Coital 8. positions used o Use of lubricants and past contraceptive measures, and o Existence of any children produced from a previous relationship.

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A woman should be asked about current or past reproductive tract problems, such as o Infections o her overall health  emphasizing endocrine problems such as galactorrhea (breast nipple secretions)  symptoms of thyroid dysfunction  any abdominal or pelvic operations she has had that could have compromised blood flow to pelvic organs.  frequency of using douches or intravaginal medications or sprays (which may interfere with vaginal pH)  exposure to occupational hazards such as x-rays or toxic substances  and nutrition, especially folic acid intake. o

Menstrual history should be obtained, including the following:  Age of menarche  Length, regularity, and frequency of menstrual periods  Amount of flow  Any difficulties experienced, such as dysmenorrhea or premenstrual dysphoric disorder  History of contraceptive use  History of any previous pregnancies or abortions

2. PHYSICAL ASSESSMENT  Absence of a vas deferens  presence of undescended testes  varicocele (enlargement of a testicular vein).  hydrocele (collection of fluid in the tunica vaginalis of the scrotum) is rarely associated with infertility but should be documented.  Physical assessment including breast and thyroid examination is necessary to rule out current illness. 3. FERTILITY TESTING a. Semen Analysis

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For a semen analysis, after 9. 2 to 4 days of sexual abstinence, the man ejaculates by masturbation into a clean, dry specimen jar, and the spermatozoa are examined under a microscope within 1 hour. The analysis may need to be repeated after 2 to 3 months, because spermatogenesis is an ongoing process, and 30 to 90 days is needed for new sperm to reach maturity.

b. Sperm Penetration Assay and Antisperm Antibody Testing  Sperm must be mobile enough to reach the ova. Although sperm penetration studies are rarely necessary, they may carried out to determine whether a man’s sperm, once they reach an ovum, can penetrate it effectively. Poor mobile sperm or those with poor penetration can be 10. injected into the woman’s ovum under laboratory conditions (intracytoplasmic sperm injection), bypassing the need for sperm to be fully mobile. c. Ovulation Monitoring  The least costly way to determine a woman’s ovulation pattern is to ask her to record her basal body temperature (BBT) for at least 1 month. At the time of ovulation, the basal temperature can be seen to dip slightly (about 0.5%F); it then rises to a level no higher than normal body temperature and stays at that level until 3 to 4 days before the next menstrual flow.

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d. Ovulation Determination by Test Strip

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Various brands of commercial kits are available for assessing the upsurge of 11. occurs just before ovulation

LH that

4. TUBAL PATENCY  Tubal patency can be assessed in a number of ways. Both ultrasound and x-ray imaging can be used, not only to determine the patency of fallopian tubes but also to assess the depth and consistency of the endometrial lining. a. Sonohysterography  an ultrasound technique designed for inspecting the uterus.  The uterus filled with sterile saline, introduced through a narrow catheter inserted into the uterine cervix.  A trans-vaginal ultrasound transducer is then inserted into the vagina to inspect the uterus for abnormalities such as septal deviation or the presence of a myoma. Because this is a minimally invasive technique, it can be done at any time during menstrual cycle.

b. Hysterosalpingography (uterosalpingoggraphy)       

a radiologic examination of the fallopian tubes using a radiopaque medium, is the most frequently used method of assessing tubal patency. scheduled immediately after the menstrual flow to avoid reflux of menstrual debris up the tubes and unintentional irradiation of a growing zygote. It is contraindicated if infection of the vagina, cervix, or uterus is present (infectious organisms might be forced into the pelvic cavity). Iodine-based radiopaque material is introduced into the cervix under pressure. The radiopaque material outlines the uterus and both tubes, provided that the tubes are patent. medium is thick, it distends the uterus and tubes slightly, causing momentary painful uterine cramping. After the study, instillation of radiopaque material may be therapeutic as well as diagnostic: the pressure of the solution may actually break up adhesions as it passes through the fallopian tubes, thereby increasing their patency.

5. ADVANCED SURGICAL PROCEDURES a. Uterine Endometrial Biopsy  may be used as a test for ovulation or to reveal an endomentrial problem such as a luteal phase defect.  usually done 2 or 3 days before the expected menstrual flow (day 25 or 26 of a typical 28-day menstrual cycle).  After a paracervical block, a thin probe and biopsy forceps are introduced through the cervix.  The woman may experience mild to moderate discomfort from the maneuvering of the instruments.  There may be a moment of sharp pain as the biopsy specimen is taken from the anterior or posterior uterine wall.  Possible complications include:  Pain  excessive bleeding  infection, and  uterine perforation.  contraindicated if:

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12. pregnancy is suspected (although the chance that it would interfere with pregnancy is probably less than 10%) or  an infection such as acute PID or cervicitis is present. expect a small amount of vaginal spotting after the procedure. She should be instructed to call her primary care provider if:

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she develops a temperature greater than 1010F  large amount of bleeding, or passes clots. It is important to advise the woman to telephone the health care agency when she has her next menstrual flow.

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b. Hysteroscopy  

a visual infection of the uterus through the insertion of a hysteroscope, a thin hollow tube, through the cervix. helpful if uterine adhesions or other abnormalities were discovered on the hysterosalpingogram.

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Laparocopy

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introduction of a thin, hollow, lighted tube (a fiberoptic telescope or laparoscope) through a small incision in the abdomen, just under the umbilicus, to examine the position and state of the fallopian tubes and ovaries.

INFERTILITY MANAGEMENT CORRECTION OF THE UNDERLYING PROBLEM a. Increasing Sperm Count and Motility  If sperm are present but the total count is low, a man might be advised to abstain from coitus for 13. 7 to 10 days to increase the count.  Ligation of a varicocele (if present) and changes in lifestyle.  Sperm can be extracted by syringe from a point proximal to the blockage and used for intrauterine insemination.  If the problem appears to be that sperm are immobilized by vaginal secretions due to an immunological factor, the response can be reduced by abstinence or condom use for about 6 months. However, to avoid this prolonged time interval, washing of the sperm and intrauterine insemination may be preferred. b. Reducing the Presence of Infection  

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The infection will be treated according to the causative organism based on culture reports. Women who are prescribed mentronidazole (Flagyl) for a trichomonal infection should be cautioned that it can be teratogenic early in pregnancy and therefore should not be continued if a pregnancy is suspected.

Hormone Theraphy     

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Administration of GnRH is a possibility. clomiphene citrate (Clomid, Serophene) - to stimulate ovulation. human menopausal gonadotropins (Pergonal) + to produce ovulation. human chorionic gonadotropin (hCG) Human menopausal gonadotropins (derived from postmenopausal urine) are combinations of FSH and LH. If increased prolactin levels are identified, bromocriptine (Parlodel) is added to the medication regimen to reduce prolactin levels and allow for the rise of gonadotropins. Administration of either clomiphene citrate or human menopausal gonadotropins may overstimulate an ovary, causing multiple ova to come to maturity and possibly resulting in 14. . multiple births.

d. Surgery  If a myoma (fibroid tumor) is interfering with fertility, a myomectomy, or surgical removal of the tumor, may be necessary. ASSISTED REPRODUCTIVE TECHNIQUES a. Artificial Insemination  is the instillation of sperm into the female.  The 15. sperm can be instilled into the cervix (intracervical insemination) or into the uterus (intrauterine insemination).  Either the husband’s sperm (artificial insemination by husband) or donor sperm (artificial insemination by donor or therapeutic donor insemination) can be used.

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These techniques can be used if :  the man has an inadequate sperm count, or  the woman ha a vaginal or cervical factor that interferes with sperm motility. They can also be used if the man has a known genetic disorder that he does not want transmitted to offspring or if the woman has no male partner. It is useful for men who, feeling their family was complete, underwent a vasectomy that cannot now be reserved but who now wish to have children. To prepare for artificial insemination, a woman must record her BBT, assess her cervical mucus, or use and ovulation predictor kit to predict her likely day of ovulation. On the day after ovulation, the selected sperm are delivered to her cervix using a device similar to a cervical cap or diaphragm, or they are injected directly into the uterus using a flexible catheter.

b. In Vitro Fertilization  one or more mature oocytes are removed from a woman’s ovary by laparoscopy and fertilized by exposure to sperm under laboratory conditions outside the woman’s body.  About 16. 40 hours after fertilization, the laboratory-grown fertilized ova are inserted into the woman’s uterus, where ideally one or more of them will implant and grow.  most often used for couples who have not been able to conceive because the woman has blocked or damaged fallopian tubes.  It is also used when the man has oligospermia or a low sperm count, because the controlled, concentrated conditions in the laboratory require only 1 sperm.  A donor ovum, rather than the woman’s own ovum, also can be used for the woman who does not ovulate or who carries s sex-linked disease that she does not want to pass on her children.  Before the procedure, the woman is given an ovulation-stimulating agent such as GnRH, clomiphene citrate (Clomid), or human menopausal gonadotropin (Pergonal).  Beginning about the 10th day of the menstrual cycle, the ovaries are examined daily by sonography to assess the number and size of developing ovarian follicles.  When a follicle appears to be mature, the woman is given an injection of hCG, which causes ovulation in 38 to 42 hours.  A needle is then introduced intravaginally, guided by ultrasound, and the oocyte is aspirated from its follicle.  Often, many oocytes ripen at once, and perhaps as many as 3 to 12 can be removed.  The oocytes are incubated for at least 8 hours to ensure viability.  In the meantime, the husband or donor supplies a fresh semen specimen.  The sperm cells and oocytes are mixed and allowed to incubate in a growth medium.  After fertilization of the chosen oocytes occurs, the zygotes formed almost immediately begin to divide and grow.  By 40 hours after fertilization, they will have undergone their first cell division.  The fertilized eggs are examined and, if normal, a chosen number (usually two if the woman is younger than 35 years of age; up to five if she is older than 40) are transferred back to the uterine cavity through the cervix by means of a thin catheter. c.

Gamete Intrafallopian Transfer

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In gamete intrafallopian transfer (GIFT) procedures, ova are obtained from ovaries exactly as in IVF. Instead of waiting for fertilization to occur in the laboratory, however, both ova and sperm are instilled within a matter of hours, using a laparoscopic technique, into the open end of a patent fallopian tube. Fertilization then occurs in the tube, and the zygote moves to the 17. uterus for implantation. This procedure has a pregnancy rate equal to that of IVF. The procedure is contraindicated if the woman’s fallopian tubes are blocked, because this could lead to ectopic (tubal) pregnancy.

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d. Zygote Intrafallopian Transfer  

Zygote intrafallopian transfer (ZIFT) involves oocyte retrieval by transvaginal, ultrasoundguided aspiration, followed by culture and insemination of the oocytes in the laboratory. Within 24 hours, the fertilized eggs are transferred by laparoscopic technique into the end of a waiting fallopian tube.

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ZIFT differs from GIFT in that fertilization takes place outside the body, allowing health care providers to be certain that fertilization has occurred before the growing structure is reintroduced. As in GIFT, a woman must have one functioning fallopian tube for the technique to be successful, because the zygotes are implanted into the fimbriated end of a tube rather than into the uterus.

e. Surrogate Embryo Transfer

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an assisted reproductive technique for a woman who does not 18. ovulate. involves use of an oocyte that has been donated by a friend or relative or provided by an anonymous donor. The menstrual cycles of the donor and recipient are synchronized by administration of gonadotropic hormones. At the time of ovulation, the donor’s ovum is removed by a transvaginal, ultrasound-guided procedure. The oocyte is then fertilized by the recipient woman’s male partner’s sperm (or donor sperm) and placed in the recipient woman’s uterus by embryonic transfer. Once pregnancy occurs, it progresses the same as an unassisted pregnancy.

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Preimplantation Genetic Diagnosis

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The individual retrieval of oocytes and their fertilization under laboratory conditions has led to close inspection and recognition of differences in sperm and oocytes. Before the oocytes is fertilized, the 19. DNA of both sperm and oocytes can be examined for specific genetic characteristics or other abnormalities.

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ALTERNATIVES TO CHILDBIRTH a. Surrogate Mothers  a woman who agrees to carry a 20. pregnancy to term for an infertile couple. b. Adoption 

Adoption, once a ready alternative for infertile couples, is still a viable alternative, although today there are fewer children available for adoption from official agencies than formerly.

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Child-Free Living An alternative lifestyle available to both fertile and infertile couples. Have advantages for a couple in that it allows time for both to pursue careers. Can be as fulfilling as having children, because it allows a couple more time to help other people and to contribute to society through personal accomplishments.

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Coverage of final examination: Intrapartal Complications  Problems with the force of labor o Hypotonic Uterine Contractions o Hypertonic Uterine Contraction o Precipitate labor o Uterine Rupture o Inversion of the Uterus 

Problems with the Passager o Proplapse of the Umbilical Cord o Multiple Gestation o Malpresentation

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Problems with the Passageway o Inlet Contraction

Outlet contraction Trial Labor

Therapeutic Management of the Problems or Potential Problems in Labor and Deliver  Induction and Augmentation of labor  Vacuum-Assisted Delivery  Forceps Delivery  Caesarian Birth Infertility  Male Infertility Factors o Inadequate Sperm Count o Obstruction or Impaired Sperm Motility o Ejaculation problems  Female Infertility Factors

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o Anovulation o Tubal Transport Problems o Uterine Problems o Cervical Problems o Vaginal Problems Fertility Assessment

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Infertility Management o Increasing Sperm Count and Motility o Hormone Therapy o Surgery o Artificial Insemination o Alternatives to Childbirth