INFERTILITY

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					INFERTILITY
Definition Inability to concieve after 1 yr of unprotected intercourse Primary or Secondary

Fecundity – probability of achieving pregnancy in single cycle - 20 – 25 %

Initial visit – male partner is a must. History – menstrual cycles , pelvic pain dyspareunia Risk Factors – PID, pelvic surgery , IUD, exposure to DES. Pituitary, thyroid, adrenal functions Occupational exposures. Emotional factor

Causes of infertility
Relative prevalence of causes: Male factor - 25 – 40% Female - 40 – 55% Both - 10% Unexplained – 10% Absolute infertility – cong abnormal gametes absent uterus

Semen Analysis
Volume – 2 ml Sperm concentration - > 20 million Motility - > 50% Morphology - > 30% normal forms Azoospermia – complete absence of sperms Oligospermia – less than 20 million of normal sperms

Causes of Male infertility
Psychosexual Varicocele Obstruction of vas deferens Post vasectomy Klinefelters syndrome Chemotherapy Ejaculatory failure Irradiation

Female Infertility
Aging of the oocyte - decline in fertility Begins in early 30s and accelerates by 40s. Disorders of ovulation 30- 40% Tests for ovulation – LH surge – 34-36 hrs BBT – 0.5F Midluteal serum progesterone Ultrasound

Fern test – sodium chloride in cervical mucus due to estrogen

Endometrial biopsy Tubal factor – 30-40% Damage due to surgery
Peritubal adhesions – laparoscopy, HSG

Uterine factor - congenital anomalies of the uterus DES exposure Fibroids Ashermann’s syndrome LPD – develpomental delay of > 2 days

ART
Artificial insemination Invitro fertilisation Intra cytoplasmic sperm injection- ICSI GIFT ZIFT Donor oocytes Cryopreserved embryos

FIBROIDS
5-20% of reproductive age group Benign neoplasms derived from smooth muscle cell rests Etiology – estrogen , GH , HPL but estrogen is significant Rare before puberty and after menopause Associated with endometrial hyperplasia, carcinoma, DUB

Myomas increase during pregnancy and OCPs

Anatomy – well circumscribed, pseudocapsule, firm, radial blood supply , degeneration Location – subserous , submucous , intramural uterine and extrauterine

Degenerations – Atrophy Calcareous Red degeneration Sarcomatous Hyaline Fatty

SYMPTOMS
Asymptomatic – 50% Commonly in nulliparous Menstrual disorders – menorrhagia, dysmenorrhoea Infertility Pain – torsion, haemorrhage , dysmenorrhoea Pressure symptoms Abdominal lump

Signs – general examn – anemia Systemic examination – PA – Abdominal lump arising from the pelvis, lower border not felt. well defined margins, smooth or bossy surface Speculum examination Bimanual examn – mass moves with the cervix, not felt separate

Differential diagnosis
Pregnancy Pelvic kidney Ectopic pregnancy Endometrial Adenomyosis carcinoma Chronic PID Benign or malignant ovarian tumor Bicornuate uterus Haematometra

Investigations
Haemoglobin Blood group Ultrasound – number , location , size , follow up Hysterosalpingography – 6-11 day, location and tubal patency Hysterography Dilatation and curretage – D&C Laparoscopy

CT Scan , MRI Intravenous pyelography – broad ligament fibroid

Management
Asymptomatic – observe for 6 months, Indications for surgery – Infertility Symptomatic Rapid growth Nature of growth not known

Medical – iron for anemia, RU486 – mifeprestone – 50mg daily for 3 months Danazol – 600-800mg daily for 3-6 mths GnRH analogues – 6 months – decreased vascularity, amenorrhoea Surgery – Myomectomy Hysterectomy

Fibroid Uterus (Leiomyoma)

Ultrasonography

Hysterosalpingogram

Fibroid Uterus per-operative

Surgical specimen

THANK YOU


				
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posted:9/26/2008
language:English
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