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Fifth stage
Gynecology
Lec-2
.د
ولدان
16/3/2016
Management of infertility
Objectives of this lecture:
1. To know the general management of infertility.
2. To know how to use clomiphene.
3. To know other drugs of ovulation induction.
4. To know the management of male infertility
5. To know the steps of IVF.
Management of infertility:
General measures:
1. Reassurance of the couples.
2. More frequent intercourse, preferably every two days.
3. Lubricants and postcoital douching should be avoided.
4.Smoking and alcohol should be stopped or reduced.
5. For the husband he should stop sauna, hot baths and not wear tight underwear, and
decrease the use of laptops as these will rise scrotal temperature and affect
spermatogenesis.
Treatment of female infertility:
Ovulatory factors: for induction of ovulation:
Treatment of WHO class 1: Hypogonadotropic hypogonadal anovulation:
Reversing the lifestyle factors that contribute to the anovulation (low weight, heavy
exercise) should be attempted before considering intervention with medications.
Gonadotrophin therapy (FSH)
Dose 75-150 IU/day.
Side effects:
Ovarian hyperstimulation syndrome – is a potentially life-threatening complication of
ovulation induction.
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Its most severe manifestations include massive ovarian enlargement and multiple cysts,
hemoconcentration, and third-space accumulation of fluid; these changes may be
complicated by renal failure, hypovolemic shock, thromboembolic episodes, acute
respiratory distress syndrome, and death.
GnRH analogue can also be used for this group.
Treatment of WHO class II: normogonadotrophic normoestrogenic anovulation:
clomiphene citrate: It is derivative related to diethylstilbestrol have mixed estrogenic and
antiestrogenic effects. It binds to hypothalamic estrogen receptors, thereby blocking the
negative feedback effect of circulating estrogen.
It acts as an antiestrogen in the uterus, cervix, and vagina and impairs endometrial receptivity
and decreases implantation efficiency.
Elevated concentrations of circulating follicle stimulating hormone (FSH) and luteinizing
hormone (LH) result from clomiphene treatment.
These findings may explain the low pregnancy rates observed in clomiphene-induced
ovulatory cycles.
It also decreases the quality and quantity of cervical mucus making it less penetrable by
sperms.
Contraindications include liver disease and the presence of ovarian cysts.
Treatment is initially begun at a dose of 50 mg daily for five days; from the second day of the
cycle. If ovulation does not occur in the first cycle of treatment, the dose is increased to 100
mg. Thereafter, dosage is increased by increments of 50 mg to a maximum daily dose of 250
mg until ovulation is achieved, at which point the woman should attempt to conceive for four
to six months.
Monitoring:
The response to treatment can be monitored with:
1. a basal body temperature chart.
2. Mid luteal serum progesterone level.
3. endometrial biopsy.
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4. Monitoring the follicle size with ultrasound (enlargement followed by collapse suggests
ovulation).
5. determining the ovulatory LH surge by urinary LH kits or serum LH measurements.
Side effects of clomiphene:
1. Ovarian enlargement and cysts.
2. Multiple gestation.
3. Hot flashes.
4. Visual symptoms, such as blurring and/or scotomata.
5. Iatrogenic luteal phase defect.
Supplementary treatments – These drugs can be used with clomephene:
1. HCG (single dose 10,000 IU IM) may be added to the regimen. It is given when
transvaginal ultrasonography (TVS) shows that the leading follicle has reached 18 to 20
mm in diameter.
2. Bromocriptin has also been tried in women with normal serum prolactin and no
galactorrhea who have failed clomiphene therapy.
3. Weight loss (5 to 10 percent) alone or in combination with exercise in obese patient.
4. Metformin for patients with PCOS.
5. Dexamethsone.
Tamoxifin and FSH can also be used in this group.
Laparoscopic treatment for PCOS, including electrocautery (also known as diathermy), laser
"drilling," and multiple biopsy. The risks are those of anesthesia, injury to the bowel, bladder,
and major blood vessels, infection, and postoperative adhesion formation and early
menapause.
Treatment of hyperprolactinemic anovulation
Treated by dopamine agonist (bromocriptine) start with 1.25 mg at bedtime, increasing at
three- to five-day intervals to a maximum of 10 mg/day.
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Treatment of Hypergonadotropic hypoestrogenic anovulation:
10 to 30 percent of cases of anovulation. The primary causes are premature ovarian failure.
Most of these women have amenorrhea; they usually do not respond to therapy for
anovulation.
Treatment of tubal factor:
by laparoscopic tubal surgery.
Types of tubal surgery;
1. Adhesolysis.
2. Treatment of distal tubal occlusion.
a. Fimbrioplasty.
b. Terminal salpingostomy.
3.Treatment of proximal tubal occlusion: Tubocornual anastomosis performed by
laparotomy.
4. Tubal anastomosis: Indications for tubal anastomosis include reversal of sterilization,
midtubal block secondary to pathology, tubal occlusion from ectopic pregnancy.
Invitro fertilization and embryo transfer (IVF_ET):
Indications:
1. Tubal blockage.
2. Cervical hostility.
3. Unexpained infertility.
4. Endometriosis.
5. Male factor infertility.
Treatment of Male Infertility:
Treatment of defective sperm formation is not all that encouraging. Empirical therapy
includes use of vitamin E, B12, Folic acid, small doses of thyroid extracts and supplements
containing Zinc preparations. Other medications are also used. Another options that can be
tried is hormone replacement therapy.
Surgery may be indicated in some cases of anatomical defects or obstructions.
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Artificial Insemination Homologus: in cases of hypospadias, premature ejaculation,
impotence, the husband's semen is collected by masturbation and is deposited in the upper
part of the vagina.
Intra-Uterine Insemination: the semen is processed to eliminate the debris and dead sperms.
Good-grade motile sperms are then transferred into the uterine cavity by use of a catheter
designed for this purpose.
Intra-Cytoplasmic Sperm injection: in cases of severe absense of sperm formation.
women with non-tubal factor infertility are offered three to six cycles of superovulation and
intrauterine insemination (IUI) before proceeding to IVF. A reasonable course when
counseling younger women who are potential candidates for IVF is to wait for a total of two
years of unprotected intercourse or conventional treatment. A shorter period is generally
used in older women, in whom ovarian failure (menopause) could occur at any time.
IVF-ET includes:
1. Superovulation by injection of FSH.
2. Monitoring of the response by ultrasound scans and blood tests.
3. Egg retrieval with the help of a needle under local or general anesthesia.
4. Preparation of a suspension of motile sperm.
5. Approximation of female and male gametes and fertilization in the laboratory.
6. Transfer of the resulting embryo (s) into the uterus of the woman.