Evaluation and options in Managing Subfertile Couple

Dr Edawati Dahrawi Edrus Obstetrics dan Gynaecology

Hospital Umum Sarawak

MARRIED COUPLE

Not Pregnant ?

Subfertility

Failure to conceive within 12 months ofregular sexual intercourse without any formof contraception.

Woman older than 35 years -- have notconceived during a 6-month period of trying.

Average incidence globally: 15% (varies in different population)

Conception & Subfertility

•The chances of spontaneously conceiving at any given menstrual cycle is 20%

• Main event leading to pregnancy is ovulation, fertilization & implantation THUS any event interfering with these results in subfertility

• The single most important determinant of a couple’s fertility is the age of the female partner:

• At the age of up to 25 years CCR is 60% at six months and 85% at one year

• At the age of 35 years or more the CCR is 60% at one year and 85% at two years

CCR – Cumulative Conception Rate

• About 84% of couples would conceive within one year of trying for a pregnancy

• Another 8% would conceive in the next year giving a cumulative pregnancy rate of 92% at the end of two years

NORMAL

• Female reproductive organ

• Menstrual cycle

NORMAL

• Male reproductive organ

Male spermatogenesis

Factor for Infertility

30-40%

UNEXPLAINED 5-15%

Couple does not conceive and no definite of infertility can be diagnosed after a complete

evaluationcause

FEMALE FACTOR

OVARIAN FACTOR

• Anovulation

Anovulation

• Hyperprolactinaemia

• Obesity

Ovarian Failure

• Repeated surgery on ovaries

• Chemoradiation• Primary Ovarian Failure• Pemature Menopause

TUBAL FACTOR

Endometriosis

Pelvic Inflammatory Disease (PID)

• Tubal block

• Previous tubal surgery/Ectopic pregnancy

• Uterine Factor

• Uterine Fibroid

• Adenomyosis

• Uterine Septum

• Uterine polyp

• Submucosa Fibroid

• Uterine adhesions

• Transcervical Resection

• TCRF (firbroid)• TCRP (polyp)

MALE FACTOR

NORMAL SPERM COUNT

• Parameter WHO 1999 WHO 2010• Volume 2 ml 1.5 ml• Concentration 20 million/ml 15

million/ml• Progressive motility 50% 32%• Normal forms 14% 4%

MALE FACTOR

• Oligospermia

• Asthenospermia

• Teratozoospermia

• SUPPLEMENT FOR oligoasthenoteratozoospermia

• CLOMID

• HCG and MENOPUR injection

• Azoospermia

SURGICAL MANAGEMNT FOR AZOOSPERMIA

• PERCUTANEOUS SPERM ASPIRATION (PESA)

• Testicular Biopsy (TESE/TESA)

Assessment of Subfertility Patient

Assessment of Female and Male partnerFemale – Ovulation , Tubal PatencyMale – Sperm Analysis

Investigation

FEMALE• HormoneRegular mensesD2-D5 FSH/LHD21 Progesterone

Irregular mensesD2-D5/Random FSH/LHSerum ProlactinThyroid Function Test

FEMALEPCOSTestosteroneFasting lipid profileFasting blood sugar/MOGTT

Tubal PatencyHysterosalphingogram (HSG)Laparoscopic Dye Insufflation

Female• Infective screening - Hepatitis B/C/HIV/VDRL - Rubella Ig G

Male• Semen Analysis• Infective screening - Hepatitis B/C/HIV/VDRL

HYSTEROSALPINGOGRAM (HSG)

GENERAL ADVICE

Management of Infertility

• Timed Sexual Intercourse (TSI)

• Intrauterine Insemination (IUI)

• Invitro Fertilization (IVF)/Intracytoplasmic Sperm Insemination (ICSI)

OVULATION INDUCTION

Timed SI

• Cumulative pregnancy rate 40% in 4 attempts

• May try for 3-6 cycles depends on patient age, duration of infertility and response to ovulation induction.

Suitable for• Anovulatory cycle• Patent tubes• Mild male factor

IUI

• Available in Hospital Umum Sarawak

• Success rate 10-15 %

Suitable for• Mild male factor- Sperm > 10 million /ml- Motility > 40%• Anovulation• Patent tube/tubes• Failed Times SI – 2-4

times

• IUI

IVF VS ICSI

IVF VS ICSI

IVFBlocked tubesModerate to severe endometriosisSperm count > 10 million/mlSperm motility >40%Failed IUI treatment

ICSIMale factor-moderate to severe oligospermia- Poor motility sperm- Immotile sperm- Azoospermia but sperm

available through PESA/TESE/TESA

IVF/ICSI

• IVF/ICSI stimulation

IVF stimulationTransvaginal scan (TVS)

OOCYTE RETRIEVAL (OR)

EMBRYO TRANSFER(ET)

EMBRYO TRANSFER (ET)DAY 2/3/5

Luteal Support

Post Embryo Transfer

Succcess Rate

Depends on Factor of Infertility and maternal ageFactors lower success rate1. Advanced age2. Poor responder3. Endometriosis4. Adenomyosis5. PID with Hydrosalphinx6. Male Factor

COMPLICATIONS

• OHSS• Injury to bowel ,

bladder• Injury to vessel• Puncture site

bleeding/haematoma• Pelvic Infection• Multiple Pregnancy

• Failed IVF• Miscarriage• Ectopic Pregnancy• Damage to stored

embryos• Psychological

complications• Medicolegal

complications

COMPLICATIONS

Ovarian Hyperstimulation Syndrome (OHSS)

Multiple Pregnancy

WELCOME TO KUCHING

THANK YOU