Undergraduate course lectures in Gynecology prepared by dr manal behery,Faculty of medicine,Zagazig University

1. How to approach
a case of infertility
Dr Manal Behery
Assistant professor
Zagazig University
2013

2. Definitions
• Infertility = Inability of a couple practicing
frequent intercourse and not using
contraception to conceive a child
Under 35 year :No conception after one
year of unprotected intercourse
Over 35 year :No conception after 6
months of unprotected intercourse

3. Types of Infertility

Primary infertility
− Couple Has Never Produced
A pregnancy

Secondary infertility
− Woman has previously been pregnant,
regardless of the outcome, and now is
unable to conceive

4. Causes of infertility
• Tubal pathology 35%
• Male factor 35%
• Ovulatory dysfunction 15%
• Unexplained 10%
• Cervical/other 5%

5. Causes of
tubal/ Pelvic pathology
• Congenital anomalies
• Tubal occlusion
• May occur as sequelae of
– PID
– endometriosis
– abdominal/pelvic surgery
– peritonitis

6. Causes of
tubal/ Pelvic pathology
• Congenital anomalies
• Tubal occlusion
• May occur as sequelae of
– PID
– endometriosis
– abdominal/pelvic surgery
– peritonitis

7. Causes of Ovulatory Dysfunction
– polycystic ovary syndrome
– hypothalamic anovulation
– hyperprolactinemia
– premature and age-related ovarian failure
– luteal phase defect (theoretical)

8. Causes of male infertility:
– reversible conditions (varicocele, obstructive
azoospermia)
– not reversible, but viable sperm available
(ejaculatory dysfunction, inoperative obstructive
azoospermia)
– not reversible, no viable sperm (hypogonadism)
– genetic abnormalities
– testicular or pituitary cancer

9. What Can I Do?
A PRACTICAL APPROCH

10. Counsel patient!
• In normal young couples:
– 25% conceive after one month
– 70% conceive after six months
– 90% conceive by one year
• Only an additional 5%
• will conceive in an additional 6-12 months

11. Councelling

Evaluating both partners is
essential

Couple should be informed about:
− different causes of infertility
− tests and procedures required to make
a diagnosis
− various therapeutic possibilities

Couple’s interview is conducted together
as well as separately
to obtain confidential information
RichardLord

12. Possible causes of infertility

13. Start with History. . .
General and Sexual History
Obstetric and Gynecological History
What Clues Can You Find on History?

14. Step1 history:
General and Sexual History
General history
− occupation and background
− use of tobacco, alcohol and drugs
− history of abdominal surgery and earlier
diseases/infections
Sexual history
− sexual disturbances or dysfunction such as
vaginismus, dyspareunia or erectile dysfunction
− sexually transmitted infections

15. Obstetric and Gynecological History
Reproductive history
Gynecological history
Age at menarche
Menstrual periods: duration and intervals
Previous contraceptive use
Previous testing and treatment for infertility

16. Step2 : General and
Gynecological Examination
Visual evaluation and
pelvic exam for women
to rule out:
Visual evaluation and
pelvic exam for women
to rule out:
Visual evaluation and
penile exam for men
to rule out:
Visual evaluation and
penile exam for men
to rule out:
EndocrinopathyEndocrinopathy
Congenital anomaliesCongenital anomalies
Uterine hypoplasiaUterine hypoplasia
Cervical lesionsCervical lesions
DyspareuniaDyspareunia
HypogonadismHypogonadism
TumorsTumors
Epididymal cystsEpididymal cysts
CryptorchidismCryptorchidism
HydroceleHydrocele
VaricoceleVaricocele

17. Male Partner: Semen Analysis
Semen is studied for a number of factors including:
Volume (1.5 cc to 5.0 cc)
Number of sperm present
(> 20 million/ml)
Sperm motility (> 60%) and forward progression
(more than 2 on scale 1 to 4)
Morphology (> 60% normal forms)
Presence of any infection

18. Semen analysis

19. Other Tests
Urine analysis: to rule out infection
Endocrine tests: to measure
concentrations of hormones testosterone, FSH
and LH
Anti-sperm antibodies
Sperm penetration assay: to establish ability of
sperm to penetrate egg
Postcoital test (low validity):
to establish ability of sperm
to penetrate cervical mucus

20. Male partner: Evaluation:
1) Repeat semen analysis
2) Physical exam- varicocele, testicular size
3) Lab testing- testosterone, FSH, LH
4) Genetics for special cases
IUI
(intrauterine insemination)
ICSI
(intracytoplasmic sperm injection)

21. IUI VS ICSI

22. Don’t wait a year if:
– irregular menses;
intermenstrual bleeding
– h/o PID
– h/o appendicitis with
rupture
– h/o abdominal surgery
– dyspareunia
– age > 35
– male factors

23. On your first visit:
• Semen analysis
• Confirm ovulation
– basal body temperature charting
– ovulation predictor kits (detect LH surge)
– consider serum progesterone on day 21
• Labs:
– TSH and prolactin. DHEA-S if concern for PCOS.
– FSH & estradiol on cycle day 3 if >35y.
– Cervical cultures prn.

24. Ovulation

25. Basal body temprature

26. Ovulation Predictor Kits

27. Salivary Estrogen: TCI
Ovulation Tester- 92% accurate

28. Add Saliva Sample

31. Non-Ovulatory Saliva Pattern

32. High Estrogen/ Ovulatory
Saliva Pattern

33. Approach to Ovulation Disorders
• Evaluate- Hypothyroidism
Prolactin Disorder
Hyperandrogenism- PCOS
Weight loss/ weight gain
• Induce Ovulation
Clomid (clomiphene citrate)

34. Three months later
• Hysterosalpingogram
– evaluates tubal patency and uterine cavity shape
– noninvasive but involves a tenaculum
– performed by radiology with gynecology supervision
– diagnostic and therapeutic

35. Hysterosalpingogram

36. HSG: Unilateral Blocked Tube

37. HSG: bilateral tubal block

38. HSG: Hydrosalpinx

39. Diagram shows the appropriate steps in an imaging evaluation for fallopian tube
abnormalities.
©2009 by

40. Other Tests
Laparoscopy
− to evaluate for pelvic disease,
− such as endometriosis
− check patency of fallopian tubes
Hysteroscopy
− to evaluate condition of uterine
− cavity (polyps, fibroids)

41. Sorry, no data for...
• Post coital test
• endometrial biopsy
• immune testing for antisperm
antibodies
• routine cervical cultures

42. Traditional Infertility Evaluation
1) Semen Analysis
2) Hysterosalpingogram (HSG)
3) Documentation of Ovulation
4) Post-coital Exam
5) Diagnostic Laparoscopy

43. Current Infertility Evalution
1) Semen Analysis
2) Hysterosalpingogram (HSG)
3) Documentation of Ovulation
4) Ovarian Reserve Testing

44. Ovarian Reserve Testing
Day #3 FSH (<10 mIU/ml) and estradiol (<80 pg/ml)
-Correlates with the functional status of the ovaries and
the quality of the oocytes
- FSH >15 only 5% success with IVF
- High estradiol level increases risk of cancelling IVF
cycle

45. Treatment Possibilities:
Female Infertility
Ovulation disordersOvulation disorders Ovulation-inducing drugsOvulation-inducing drugs
HyperprolactinemiaHyperprolactinemia Prolactin-suppressing
drugs
Prolactin-suppressing
drugs
Uterine and tubal
abnormalities
Uterine and tubal
abnormalities Surgical proceduresSurgical procedures
Cervical mucus problemsCervical mucus problems Intrauterine inseminationIntrauterine insemination
EndometriosisEndometriosis Suppressing hormones
or surgical procedure
Suppressing hormones
or surgical procedure

46. Case 1
• A 24 year old couple comes to see you. They have been
trying to get pregnant for 8 months.
– What questions do you ask?

47. Case 1
• The woman tells you she has never been pregnant. She
has a regular 28 day cycle and bleeds for 4 days each
month. Her medical history is unremarkable except she
“got really sick” when she was 16 and had “nasty stuff
coming from down there”
– what do you do next?

48. Case 2
• A 35 year old woman and her 31 year old male partner
come to see you. They have been trying to get pregnant
for 6 months.
– What do you ask?

49. Case 2
• She says her periods have been irregular since she went
off the pill a year ago. She has never been pregnant. He
has fathered a child by another woman several years
ago.
– What do you look for on exam?
– What lab tests do you order today?
– Do you give them homework?

50. Case 2
• They come back 3 months later with BBT charts showing
no discernable pattern. Lab tests, including semen
analysis, were all normal.
– What is the diagnosis?
– What do you do next?

51. Case 2
• You begin discussion of clomiphene. They want to know
the side effects, and if this means they’ll have sextuplets
and get a free house like the folks on TV.
– What do you tell them?
– How do you administer the clomiphene?

52. Case 2
• They come back in one month. She feels “like a total
bitch - excuse me, doctor” on the clomiphene. She is not
pregnant. BBT charting shows a mid-cycle temperature
rise.
– What happens next?

53. Case 3
 A 31-year-old G1 P1 woman presents with a
history of infertility of 2-year duration.
 Manarche at 12 years and occurs at28-day
intervals.
 A biphasic basal body temperature chart is
recorded.
 She denies sexually transmitted diseases,
 hysterosalpingogram shows patent tubes and a
normal uterine cavity.
 Her husband is 34 years old and his semen
analysis is normal.

54. ➤ What is the most likely etiology of
the infertility?
• ➤ Most likely etiology: Endometriosis
(peritoneal factor).
• What further support the diagnosis ?
• if the patient complained of the three
Ds of endometriosis (dysmenorrhea,
dyspareunia, anddyschezia), then the
examiner would be pointed toward the
peritoneal factor.

55. • A 22-year-old G0 P0 woman complains of irregular
menses every 30 to 65 days. The semen analysis is
normal. The hysterosalpingogram is normal. Which
of the following is the most likely treatment for this
patient?
• A. Laparoscopy
• B. Intrauterine insemination
• C. In vitro fertilization
• D. Clomiphene citrate

56. • A 26-year-old G0 P0 woman has regular menses
every 28 days. The semen analysis is normal
• . The patient had a postcoital test revealing motile
sperm and stretchy watery cervical mucus. She has
been treated for chlamydial infection in the past.
• Which of the following is the most likely etiology
of her infertility?
• A. Peritoneal factor
• B. Male factor
• C. Cervical factor
• D. Uterine and tubal factor
• E. Ovulatory factor

57. • A 28-year-old G1 P1 woman complains of
painful menses and pain with intercourse. She
has menses every month and denies a history
of STD
• Which of the following tests would most
likely identify the etiology of the infertility?
• A. Semen analysis
• B. Laparoscopy
• C. Basal body temperature chart
• D. Hysterosalpingogram
• E. Progesterone assay

58. • A 34-year-old infertile woman is noted to
have evidence of blocked fallopian tubes by
HSG
• Which of the following is the best next
step for this patient?
• A. FSH therapy
• B. Clomiphene citrate therapy
• C. Laparoscopy
• D. Intrauterine insemination

59. Case 4
A 37-year-old female and her 37-year-old
husband present with the complaint of a
possible fertility problem. The couple has been
married for 2 years.
The patient has a 4-year-old daughter from a
previous relationship.
The patient used birth control pills until one-and-
a- half-years-ago
. The couple has been trying to conceive since
then and report a high degree of stress related
to their lack of success.

60. Case cont’
 The patient reports good health and no
problems in conceiving her previous pregnancy
or in the vaginal delivery of her daughter.
 She reports that her periods were regular on the
birth control pill, but have been irregular since
she discontinued taking them.
 She reports having periods every 5-7 weeks.
 Past history is remarkable only for mild
depression. Imipramine 150 mg qhs for the last
8 months is her only medication

61. Case cont’
 has no history of STDs, abnormal Paps, smoking,
alcohol or other drugs. She has had no surgery.
 The patient’s partner also reports good health and
reports no problems with erection, ejaculation or
pain with intercourse.
 He has had no prior urogenital infections or
exposure to STDs
 . He has had unprotected sex prior to his current
relationship, but has not knowingly conceived.
 He has no medical problems or past surgery

62. Case cont’;
He works as a long-distance truck driver and is
on the road 2-3 weeks each month.
He smokes a pack of cigarettes a day since age
18 and drinks 2-3 cans of beer 3-4 times a week
when he’s not driving.
He occasionally uses amphetamines to stay
awake while driving at night. The couple has
vaginal intercourse 3-5 times per week when he
is at home.

63. Physical exam
 The patient is 5’9” and weighs 130 pounds.
 Breast exam reveals no tenderness or masses,
but bilateral galactorrhea on compression of the
areola.
 Pelvic exam reveals normal genitalia, a well-
estrogenized vaginal vault mucosa and cervical
mucus consistent with the proliferative phase.
 The uterus is anteflexed and normal in size
without masses or tenderness.

64. Patient Laboratory
• Results Normal Values
• TSH 2.1 mIU/ml 0.5-4.0 mIU/ml
• Free T4 1.1 ng/dl 0.8-1.8 ng/dl
• Prolactin 60 ng/ml <20 ng/ml
• FSH 6 mIU/ml 5-25 mIU/ml
• LH 4 mIU/ml 5-25 mIU/ml
• Basal body temperature chart shows a monophasic
temperature graph.

65. Partner
• Semen analysis revealed 2 cc of semen, 4 million per
mL, 30% normal forms and 20% motility.

66. Management
• The patient’s major infertility factor is anovulation;
• the most likely cause is hyperprolactinemia from
imipramine.
• The prolactin level is elevated, consistent with drug-
induced hyperprolactinemia.
• The patient was instructed, in conjunction with her
therapist, to taper off the imipramine.
• Her follow-up basal body temperature chart was
biphasic, consistent with ovulatory cycles.
•

67. Management cont’
 The patient’s partner, however, has a semen
analysis that is consistent with oligospermia.
The couple was given their options of:
 1) In Vitro fertilization with ISCI;
 2) artificial insemination with partner’s sperm;
 3) artificial insemination with donor sperm;
 or 4) adoption

68. thank you