INFERTILITY CAUSES. Basic evaluation of the female
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- Gillian Harrell
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2 INFERTILITY Infertility is the inability to conceive after 12 months of unprotected intercourse. There are multiple causes of infertility and a systematic way to evaluate the condition. Let s look at some of the causes. CAUSES Infertility is related to female factor in 33% cases Male factor in 20% cases Both male and female factor in 39% cases Unexplained in 8% of cases As far as evaluation is concerned, there are different ways to go about it keeping the goals of the couple in mind. Evaluation goals The infertility evaluation serves to 1. Determine the aetiology of infertility as expediently as possible, 2. Offer recommended treatment protocol to the couple, 3. Determine expected success rate and approximate cost for therapy 4. Educate the couple about their specific disorder and available alternatives. This serves to To identify potentially correctable conditions. To identify irreversible conditions that may be amenable to assisted reproduction (ART). To identify irreversible conditions those are not amenable to assisted reproduction (ART) and counsel for third party reproduction. When it comes to evaluation of infertility, it is very important for the couple to undergo it together as a unit. This makes for a healthy dynamic and encourages the mindset of taking on challenges together. Basic evaluation of the female As far as medical history is concerned, it plays a big part in evaluating the condition. It s important for you to give a complete account of your medical and other relevant history to the doctor. 1 of 10
3 History Present history The current problem/complaint, age, number of years of marriage, occupation, smoking, alcohol, and caffeine consumption. Menstrual history For age of menarche, cycle characteristics and any associated symptoms like painful menstruation or intermenstrual spotting and also history of primary or secondary amenorrhoea Obstetric history Previous pregnancies, if any, and their outcome, recurrent pregnancy loss, induced abortion, post-abortive infection or puerperal sepsis. Contraceptive history: Previous use of any contraceptive method, particularly intrauterine system, and associated problems. Sexual history Coital frequency, timing in relation to the cycle, use of vaginal lubricant, vaginal douching, loss of libido, and painful coitus. Past history Treatment for pelvic infection, tuberculosis, appendicectomy, laparotomy, caesarean sections, and cervical conisation. Family history Family history of consanguinity, diabetes mellitus, hypertension, twins delivery, and breast cancer. General history should focus on weight changes and on endocrine diseases that could interfere with gonadal functions like hypothyroidism. Physical Examination Here are some tests that one must take in the evaluation process. General Examination Vital signs (especially blood pressure), body height and weight (BMI) for over or under weights. Examination should also include the thyroid gland, secondary sexual characters, any excessive hair with/without acne on face or chest, and acanthosis nigricans. Breast Examination To evaluate its development and to exclude any pathology or presence of occult galactorrhoea. Abdominal Examination For any pathological and surgical scars. Genital Examination: Local examination followed by per-vaginal (PV) examination. 2 of 10
4 Investigations Tests on women are performed to evaluate three principles axes: ovaries, tubes, and uterus. Ovaries Ovarian function and reserve are examined by hormonal tests and ultrasonography. Hormonal Tests Day 2-Day 5 - FSH, LH, E2 Other endocrine tests: AMH, TSH, Prolactin (Independent of Menstrual cycle) Pelvic ultrasonography It provides information about the uterus, the ovaries, and to a certain extent the fallopian tubes, especially of the presence of hydrosalpinx. Measurement of antral follicle count (AFC) in early follicular phase indicates the patient s ovarian reserve. AFC is a direct ovarian reserve marker. Fallopian Tubes Tubal assessment is required to diagnose tubal infertility. When IVF is indicated (severe sperm abnormality, known severe endometriosis, women of advanced maternal age), tubal patency does not need to be verified. Different methods to assess tubal patency are hysterosalpingography (HSG), hysterosalpingo-contrast-sonography (HyCoSy), and laparoscopy with chromotubation. HSG HSG is the radiographic evaluation of the fallopian tubes. Radiography images are obtained intermittently after injection of oil-based or water-soluble contrast media. HSG should be performed between menstrual day 6 to 11 to ensure the absence of pregnancy and facilitate maximum uterine visibility with a thin proliferative phase endometrium. Uterine cavity, Fallopian tube architecture, hydrosalpinx, tubal phimosis, and peritoneal spillage are assessed. Laparoscopy Laparoscopy with chromopertubation has been considered as the gold standard for evaluating tubal patency. Laparoscopy is indicated when there is evidence or strong suspicion of endometriosis, pelvic/adnexal adhesions, or significant tubal disease requiring treatment. 3 of 10
5 Uterus Intrauterine lesions including endometrial polyps, submucosal myomas, adhesions, or uterine septum can interfere with spontaneous fertility and compromise pregnancy rates in assisted reproduction. Two-dimensional US is the first test to screen a suspected intrauterine abnormality. Other tests include SHS for polyp or intrauterine myoma assessment and 3D-US or MRI for Mullerian anomalies. Hysteroscopy remains the gold standard for evaluation of the uterine cavity. Evaluation Techniques of Female Infertility History Female Uterine anomaly? FSH, E2, Proesterone, AMH, TSH, Prolactin. Pelvic Sonography incl. AFC Ovulation Disorder? 3D-US or MRI Hysteroscopy Tube Tests? Not Required for IVF Tube Test HSG 4 of 10
6 Evaluation Of Ovulation Disorder Irregular menses Ovarian reserve test FSH, E2, AMH, AFC FSH, E2, Progesterone TSH, Prolactin, Adrogens High FSH, Low E2 Normal FSH and E2 High androgens Polycystic ovaries Abnormal TSH or High prolactin Other tests normal Normal or low FSH, Normal or low E2, High or normal prolactin, other tests normal POF PCOS after exclusion of -Congenital adrenal Hyperplasia -Androgen secreting Tumor-Cushing syndrome Thyroid dysfunction Hyperprolactinemia Hypogonadotrophic Hypogonadism Infertility is a common issue faced by men and women the world over. If you or your partner suffer from it, it is very important for both of you to tackle the issue like a team. There are plenty of treatment and corrective measures available that help you get over your condition if not bypass it. 5 of 10
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