Cum abordam un caz de infertilitate. Maria Cezara Muresan MD PhD Timisoara

Transcription

1 Cum abordam un caz de infertilitate Maria Cezara Muresan MD PhD Timisoara

2 Cum definim infertilitatea Care sunt cauzele infertilitatii Algoritm de diagnostic Algoritm de tratament

3 Respectarea definitiei infertilitatii Conceptia naturala - in populatia generala: 80% din cupluri concep in primul an pentru femei cu varsta < 40 ani - din cele care nu au conceput in primul an - aproximativ jumatate vor obtine sarcina - rata cumulativa de peste 90% Conditii speciale: - varsta > 35 (36/ 37) ani - existenta unei cauze de infertilitate (deja cunoscuta) sau a unor factori predispozanti - diverse neoplazii a caror tratament cauzeaza infertilitate

4 Number pregnant Rata fertilitatii functie de varsta Menken J, Trussell J, Larsen U: Age and infertility, Science 1986; 233:

5 Scaderea nr de ovocite functie de varsta cronologica Velde ER, Scheffer GL, Dorland M, et al: Developmental and endocrine aspects of normal ovarian aging. Mol Cell Endocrinol, 1998; 145: 67-73

6 PMC full text: J Hum Reprod Sci Sep-Dec; 4(3): doi: / Copyright/License Request permission to reuse << PrevFigure Quantitative (solid line) and qualitative (dotted line) decline of the ovarian follicle pool de Bruin JP, tevelde ER. Female reproductive ageing: Concepts and consequences. In: Tulandi T, Gosden RG, editors. Preservation of Fertility. London UK: Taylor and Francis; p. 3.

7 Cauzele infertilitatii - doar cauze feminine - 40 % - doar factor masculin - 20 % - cauze combinate - 20 % - infertilitate idiopatica -20%

8 Cauzele infertilitatii - cauze feminine Ovulatorii: - PCOS WHO II - Amenoreea hipotalamica WHO I - Hiperprolactinemia - Endocrinopatii - Defect faza luteala (?) Tubare / Peritoneale : - Obstructie proximala - Hidrosalpinx - Aderente peritubare - Endometrioza

9 Cauzele infertilitatii - feminine Cervicale: - mucus - anticorpi antispermatici Uterine: - Fibroame/ Adenomioza - Sinechie - Septuri/ anomalii congenitale Rezerva ovariana: -Insuficienta ovariana/ Menopauza (POF) -Scaderea rezervei (DOR) Factori masculini Cauze combinate Infertilitate idiopatica

10 Evaluarea infertilitatii Varsta anamneza istoric medical si chirurgical detalii ciclu menstrual informatii despre BTS examene paraclinice in antecedente tratamente efectuate in antecedente stil de viata, consum de medicamente

11 Documentarea ovulatiei - temperatura bazala - teste de ovulatie - foliculometrie - progesteron medio-luteal - biopsie endometriala NICE 2013

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13 Evaluarea infertilitatii Testarea permeabilitatii tubare HSG Sonohisterografie, SIS (saline infusion sonography) HyCoSy (Hysterosalpingo-contrast-sonography) Laparoscopie

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17 NICE 2013

18 Evaluarea cavitatii uterine si a miometrului ecografie - relatii despre endometru, polipi, anomalii, fibroame, adenomioza histerosalpingografie sonohisterografie histeroscopie RMN (adenomioza)

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20 Evaluarea rezervei ovariene Hormon antimullerian

21 Speroff L, Fritz MA (eds):clinical Gynecologic Endocrinology and Infertility, 7th Edition, Philadelphia:Lippincott Williams&Wilkins; 2005:

22 Utilitatea testarii rezervei ovariene

23 Alte evaluari hormonale: TSH, prolactina, hormoni tiroidieni, testosteron, SHBG, 17-OH progesteron, DHEA NICE 2013 Evaluarea mucusului cervical are o reproductibilitate redusa si o valoare predictiva pozitiva mica (ASRM) MAR test - anticorpi antispermatici

24 Evaluarea factorului masculin Anamneza, istoric/antecedente, stil de viata, examinare Spermograma - conditii de recoltare Criterii WHO -2010

25 Evaluarea factorului masculin - evaluare endocrina - ecografie - anticorpi antispermatici - teste fragmentare ADN - teste genetice Recomandari NICE 2013

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27 Algoritm de diagnostic

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29 Algoritm de diagnostic

30 Algoritm de diagnostic

31 Cui si cand recomandam proceduri ART?

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33 Inseminare intrauterina Cauze feminine (mild endometriosis) Factor masc (afectare de grad redus) Factor cervical Infertilitate idiopatica Factor masc grav afectat (donator)

34 Avantajele IUI minim invaziva costuri reduse necesitatea unui echipament minim usor de efectuat tehnica este usor de invatat acceptare de catre cuplu mai degraba decat FIV IUI in ciclu spontan IUI in ciclu stimulat CC vs FSH NICE 2013

35 IUI /FSH vs nici un tratam ESHRE IUI/FSH vs IUI/CC Unexplained infertility FSH/IUI is no better than expectant management when the prognosis is good, but has a modest effect with more than 3 years duration of infertility (Guzick et al., 1999), (Steures et al., 2006).. one additional pregnancy for every 11 cycles of FSH/IUI (95% CI: 8 16) compared with control cycles. Cochrane review - (Cantineau et al., 2007). 7 trials couples with unexplained infertility, mild male factor and mild endometriosis, pregnancy rates were higher with gonadotrophins than with antiestrogens (OR: 1.8; 95% CI: ). Meta-analysis of the remaining 6 trials couples, the 5.7% difference in pregnancy rates was not significant

36 Success rate with FSH/IUI age of the female partner duration of subfertility sperm quality tubal patency (Steures et al., 2004) around 30% of stimulated cycles remain monoovulatory (Goverde et al., 2005; van Rumste et al., 2006) up to 15% over-respond despite careful monitoring (Gleicher et al., 2000; Dickey et al., 2005) Risk of OHSS/ multiple pregnancy NICE guidelines advised against the combined use of ovarian stimulation and IUI (National Institute for Clinical Excellence, 2004 and 2013)

37 In loc de concluzii Cui si cand recomandam FIV? Varsta Durata infertilitatii Factor tubar Factor masculin Infertilitatea idiopatica Rezerva ovariana - AFC, AMH Tratamente anterioare, de ex: IUI fara obtinerea sarcinii Endometrioza Combinarea mai multor factori PCOS, cu tratamente anterioare fara sarcina Anterior tratamentelor ptr cancer

38 Va multumesc!