Infertility
د. نجمه محمودكلية الطبجامعة بغدادفرع النسائية والتوليدTreatment of female infertility
Ovulation induction :-The term superovulation is applied when used in women who may be already ovulating but irregularly. Before starting induction of ovulation , SFA should be performed. Medications used for ovulation induction are :-1) Clomiphene citrate : - Clomiphene citrate (CC) is the initial treatment for most anovulatory infertile women. CC is a nonsteroidal agent that demonstrates both estrogenic & non –oestrogenic properties.CC block oestradiol receptors, As a result, Gonadotropin-releasing hormone (GnRH) secretion is improved and stimulates pituitary gonadotropin release. The resulting increase in follicle-stimulating hormone (FSH), in turn, drives ovarian follicular activity. Clomiphene citrate is administered orally, typically starting on the second to sixth day after the onset of spontaneous or progestin induced menses.
Treatment typically begins with a single 50mg tablet daily for 5 consecutive days. Doses are increased by 50-mg in subsequent cycles up to 150 mg until ovulation is induced. CC prescribed up to 6 months. 2) Tamoxifen :- Is a similar drug , has antiestrogenic properties given in 20-40 mg from day 2-6 of menstrual cycle . 3) Gonadotrophin therapy :- In individuals, who are often classified as "clomiphene resistant", the next step is traditionally the administration of
exogenous gonadotrophin preparations via injections ,like FSH (urinary or recombinent) & human menopausal gonadotrophin (hMG) preparations which extracted and purified from the urine of postmenopausal women, and their active components are both FSH and LH.these given by SC or IM route in early follicular phase , these drugs need close monitering of follicular maturation by serial USS , ovulatory trigger with hCG may be required , if more than 3 follicle s are mature , hCG is withheld & the couple are asked to avoid pregnancy in that cycle.
Complication of fertility drugs
1) Ovarian Hyperstimulation Syndrome:- Ovarian hyperstimulation syndrome (OHSS) is a clinical symptom complex associated with ovarian enlargement resulting from exogenous gonadotrophin therapy. Symptoms may include abdominal pain and distension, ascites, gastrointestinal problems, respiratory compromise, oliguria, hemoconcentration, and thromboembolism.USS picture for OHSS
These symptoms may develop during ovulation induction or in early pregnancies that were conceived through exogenous ovarian stimulation. The etiology of OHSS is complex, but hCG, either exogenous or endogenous (derived from a resulting pregnancy), is believed to be an early contributing factor. Development of OHSS involves increased vascular permeability with loss of fluid, protein, and electrolytes into the peritoneal cavity, and leads to hemoconcentration.
Increased capillary permeability is felt to result from vasoactive substances produced by the corpus luteum. Vascular endothelial growth factor (VEGF) is believed to play a major role ,and angiotensin II may also be involved. Hypercoagulability may be related to hyperviscosity following hemoconcentration or may be secondary to the high estrogen levels present with a resulting increase in coagulation factors. Predisposing factors for OHSS include **multifollicular ovaries such as with PCOS, **young age, **high estradiol levels, and ***pregnancy.
Diagnosis of OHSS :- Uss can show enlarged ovaries with ascitis. OHSS is life threatening condition can complicate up to 5% of cycles with ovarian stimulation , it can present in mild, moderate Or severe form. 2) Multiple gestation. ## Ovarian drilling :- laparoscopic ovarian drilling (LOD) is an alternative in women resistant to medical therapies.
During LOD, electrosurgical coagulation, laser vaporization may be used to create multiple perforations in the ovarian surface and stroma, The mechanism of action with LOD is thought to be similar to that of ovarian wedge resection. Both procedures may destroy ovarian androgen-producing tissue and reduce peripheral conversion of androgens to estrogens. Specifically, a fall in serum levels of androgens and LH, and an increase in FSH levels have been demonstrated after ovarian drilling
Laprascopic ovarian drilling
Treatment of anovulation due to hyperprolactinemia :-Dopamine agonists are the primary treatment of hyperprolactinemia ,as bromocriptine it is administered in a daily dose of 1.25 -7.5 mg Cabergoline given twice weekly. Surgical therapies should only be considered with prolactin-secreting adenomas resistant to medical therapy. Cabergoline is more effective & better tolerated than bromocriptine which cause GIT side effect.
Hypothalamic anovulation:-
This condition is diagnosed with gonadotrophin assessment & oestrogen deficiency, FSH & LH levels are below 5 U/L. MRI of pitutary & hypothalamus is useful to rule out pitutary tumors , hypothalamic anovulation can be effectively treated with GnRH administered with an infusion pump either SC or IV ,if the pt is not competent in using the pump, gonadotrophin therapy is indicated.INTRAUTERINE INSEMINATION:-
This technique processes semen and separates motile, morphologically normal spermatozoa from dead sperm, leukocytes, and seminal plasma. This highly motile fraction is then inserted transcervically via a flexible catheter near the anticipated time of ovulation. Intrauterine insemination can be performed with or without superovulation and is appropriate therapy for treatment of #cervical factors, #mild and moderate male factors, and # unexplained infertility.Treatment of tubal disease
1) Tubal surgery :- is only indicated in grade 1 & 2, it aim to restore normal anatomy ,the outcome of tubal surgery is influenced by the expertise of the surgeon, facilities avaialable & the extent of tubal damage . With the increasing availability & success of assisted conception technologies, the role of tubal surgery is diminishing. Salpingo-ovariolysis Fimbrial surgery SalpingoneostomyTreatment of male infertility:-
Male infertility has varied causes and may include abnormalities of semen volume such as aspermia and hypospermia or of sperm number such as azoospermia and oligospermia. Additionally, motility may be limited, termed asthenospermia, or sperm structure may be abnormal, teratozoospermia. Accordingly, therapy should be planned only after thorough evaluation.Anejaculation may be related to psychogenic factors, organic erectile dysfunction, orimpaired parasympathetic sacralspinal reflex. Appropriate treatments depend on the cause and may include psychologicalcounseling or erectile dysfunction treatment with sildenafil citrate (Viagra) ,in men withretrograde ejaculation, The administration of oral pseudoephedrine or other α-adrenergic agent to aid bladder neck closure iswarranted. However, if drugs are ineffective, then IUI may be performed using sperm processed from avoided postejaculatory urine specimen..
In azospermia testicular sperm extraction (TESE) may be performed in conjunction with intracytoplasmic sperm injection (ICSI). hypogonadotropic hypogonadism is best treated with injections of FSH and hCG. In asthenospermia,expectant management may be considered,especially if the duration of infertility is short, and maternal age is less than 35 years,for treatment, IUI and ICSI are preferred. Antioxident therapy (vit E & C) & the use of AB in the presence of infection help to improve fertility.
In men with antisperm AB , systemic steroid can be used. In men with varicocele , varicocele ligation is done for symptomatic pt , but improvement in fertility following surgery is not confirmed Assissted conception techniques:- These techniques include:- In vitro fertilization (IVF). Intracytoplasmic sperm injection (ICSI). Donor insemination(DI). Gamete intrafallopian transfer (GIFT). zygote intrafallopian transfer (ZIFT).
Subzonal insemination (SUZI). testicular sperm aspiration (TESA). Percutanous sperm aspiration (PESA). Microepididymal sperm aspiration (MESA).
IVF