Kuliah Akbid Infertility

Infertility Problem

Gunawan Dwi Prayitno

IntroductionDefinition : Infertility is Failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology

Infertility CausesIn RSPAD-Gatot Soebroto Jakarta

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NORMALOLIGO/ASTENO/TERATOZOOSPERMIAAZOOSPERMIA

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Requisite for Succesful pregnancyOosit : ovulation ?Sperm : Concentration, motility, morphologySperm & oosit transport, fertilization, and implantation. : Psychology, organic, and immunologic compatible.

Menstrual CycleEumenorrhea : 25 31 daysPolymenorrhea : < 25 daysOligomenorrhea : > 31 daysAmenorrhea : > 3 months

Method for ovulation detection Not rutineO,2-0,5 oC

Which Investigations?!

Diagnostic tests for infertility are categorized into 3 categories.1-Testes which have an established correlation with pregnancy.2- Testes which are not consistently correlated with pregnancy.3-Testes which seem not to correlate with pregnancy.ESHRE Capri workshop 2000

Tabel 1.1 Hierarchy of evidenceLevelEvidence 1aSystematic review and meta-analysis of randomised controlled trials1bAt least one randomised controlled study without randomisation2aAt least one well-designed controlled study without randomisation2bAt least one other type of well-designed quasi-experimental study 3Well-designed non-experimental descriptive studies, such as comparative studies, correlation studies or case studies4Expert committee report or opinions and/ or clinical experienceof respected authoritis

Tabel 1.2 Stength of evidence corresponding to each level of recommendationGradeStrenght of evidenceADirectly based on level 1 evidenceBDirectly based on level 2 evidence or extrapolated recommendation from level 1 evidenceCDirectly based on level 3 evidence or extrapolated recommendation from either level 1 or 2 evidenceDDirectly based on level 4 evidence or extrapolated recommendation from either level 1, 2 or 3 evidenceGood practiceThe view of the Guideline Development GroupPoin (GPP)NICE Technology Recommendation taken from a NICE Technology AppraisalAppraisal

ESHRE Capri workshop 2000The First Category The Basic Routine Infertility InvestigationNational Guideline Clearinghouse 2000RCOG Guidelines : Grade B Recommendation 1999 Tests which have an established correlation with pregnancy are:1- Semen analysis2-Tubal patency by HSG or laparoscopy 3-Mid luteal progesterone for the diagnosis of ovulation

The Second CategoryTestes which are not consistently correlated with pregnancy as. Zona-free hamster egg penetration tests.Post coital test.Antisperm antibodies assays.

ESHRE Capri workshop 2000RCOG Guidelines : Grade B Recommendation 1999

The Third Category Includes tests which seem not to correlate with pregnancy as:Endometrial dating. Varicocele assessment. Chlamydial testing. May have a role in special situationsESHRE Capri workshop 2000

Hysteroscopy & U/S

Hysteroscopy.U/S scan of the endomerium.Are not recommended in the routine. Investigation of the infertile couple.RCOG Guidelines : Grade C Recommendation

There is no value in measuring thyroid function or prolactin in women with a regular menstrual cycle, in the absence of galactorrhoea or symptoms of thyroid disease. RCOG Guidelines : Grade B Recommendation 2001T3, T4, TSH & PL??

Day 3 (FSH) And Estradiol D3 (FSH) and (E2)estradiol for patients >35 years. because of their reduced window of fertility potential.Bloomington: Institute for Clinical Systems Improvement (ICSI); 2000 The National Guideline Clearinghouse .Modified 2002

Semen AnalysisSerial semen samples (at least two) should be assessed in the same laboratoryThe lower limit of the normal semen testing is> 20 million/mL. >50% progressive motility>30% normal formsWHO,1999

Semen Analysis In a RCT, the determination of motility characteristics as obtained by computer-assisted sperm analysis (CASA ) systems is of limited value . (Krause ,1995 ).CASA is not superior to conventional semen analysis.

RCT= Randomized control trial

Azoospermia:Testicular biopsy Testicular biopsy should be performed only in the context of a tertiary service where there are facilities for sperm recovery and cryostorageRCOG Guidelines :Grade C Recommendation

General AdviceWeight loss if BMI > 30, Women should give up smoking (B). Men should give up smoking (C)RCOG GuidelinesRegular intercourse throughout the cycle,rather than the use of temperature charts and LH detection (C)

Azoospermia:Testicular biopsy Testicular biopsy should be performed only in the context of a tertiary service where there are facilities for sperm recovery and cryostorageRCOG Guidelines :Grade C Recommendation

Treatment

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Male SubfertilityOligo/asthenospermia

Gonadotrophin is effective for treatment for male hypogonadotrophic hypogonadism.However, drug treatments are ineffective in the treatment of idiopathic male infertility.

RCOG Guidelines : Grade B Recommendation

Male Subfertility

IUI offers couples with male subfertility benefit over timed intercourse, both in natural cycles and in cycles with COH. Mild ovarian hyperstimulation with gonadotrophins is advised in cases with less severe semen defects (motile sperm concentration > 10 million). Cohlen et al., January 1999 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.Oligo/asthenospermia

Male Subfertility

Intrauterine insemination with or without ovarian stimulation is an effective treatment where the man has abnormalities of semen quality, but it has to be remembered that the pregnancy rates even after treatment remain very low (A) Cohlen et al., January 1999 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.Oligo/asthenospermia

Varicocele Varicocele treatment should be offered when all of the following are present:A varicocele is palpable.The couple has documented infertility.The female has normal fertility or potentially correctable infertility.The male partner has one or more abnormal semen parameters .Baltimore (MD): American Urological Association, Inc.; 2001 Apr. 9 p. [15 :National Guideline Clearinghouse modified 2002

Obstructive Azoospermia

Vasectomy reversal and surgical correction of epididymal blockage (microsurgical)can be considered in cases of obstructive azoospermia . It needs Expert hands. RCOG Guidelines : Grade B Recommendation

ICSIIntracytoplasmic sperm injection (ICSI) is indicated inSevere deficits in semen quality Obstructive azoospermia . Non-obstructive azoospermia . Previous IVF cycle with failed or very poor fertilisation. RCOG Guidelines : Grade A Recommendation

Ovulation DisordersClomiphene C. is an effective treatment for anovulation in appropriately selected women.(A)(Mild to moderate WHO type 1 T type 2 dysfunction)Up to 12 cycles of treatment should be considered (B). RCOG Guidelines

Ovulation DisordersFSH and hMG are both effective for ovulation induction in women with clomiphene resistant polycystic ovarian syndrome. RCOG Guidelines : Grade A Recommendation

Ovulation DisordersThere is no advantage in routinely using GRh analogues in conjunction with gonadotrophins for ovulation induction in women with clomiphene-resistant PCOSRCOG Guidelines : Grade A Recommendation

Hyperprolactinaemia

Dopamine agonists are effective treatment for women with anovulation due to hyperprolactinaemia RCOG Guidelines : Grade A Recommendation

Laparoscopic ovarian drilling with either diathermy or laser is an effective treatment for anovulation in women with clomiphene-resistant PCOS PCO:Laparoscopic Drilling"

RCOG Guidelines : Grade A

PCO:Laparoscopic Drilling"

There is insufficient evidence of a difference in pregnancy rates between :Laparoscopic ovarian drilling after 6-12 m follow up & Gonadotrophins 3-6 cycles .Multiple pregnancy are considerably reduced after laparoscopic drilling. .

Farquhar et al., August 2001 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.

Endometriosis :Minimal &Mild Surgical ablation of minimal And mild endometriosis improves fertility in subfertile womenRCOG Guidelines : Grade A Recommendation

Endometriosis : Mild. Also , ovarian stimulation with IUI is more effective for them than either no treatment or IUI alone.

RCOG Guidelines : Grade A Recommendation

Endometriosis :Moderate to Severe

Endometriosis :Moderate to Severe Surgical treatment may improve fertility but controlled studies and comparisons with assisted reproduction techniques are required (B).RCOG Guidelines : Grade B Recommendation

Endometriosis-associated infertility Hormonal therapy for ovulation suppression cannot be recommended as a standard therapy for endometriosis-associated infertility. So drug treatments dont improve conception rate.

Hughes et al., 1996 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.RCOG Guidelines : Grade A Recommendation

Microsurgical Tubal Surgery Microsurgical tubal surgery may be appropriate for : Mild distal tubal disease ( Laparoscopy). Proximal tubal obstruction, or Reanastomosis to reverse sterilization . If pregnancy has not occurred within 12 m of surgery, IVF should be discussed.RCOG Guidelines : Grade B Recommendation

Microsurgical Tubal SurgeryMild distal tubal diseaseMicro scissor Cutting fimbrial bandCutting fimbrio-omental bandDissection of fimbriae adherent to the uterus

Tubal Catheterization Where proximal tubal obstruction is suspected, and there are no other tubal abnormalities, a tubal catheterisation procedure may be attempted RCOG Guidelines : Grade B Recommendation

Tubal CatheterizationBilateral Cornual BlockAmorphous materialR. OvaryR. fimbriaCornual catheterization

Moderate to Severe Distal tubal Disease

. IVF should be considered as the first line treatment for moderate to severe distal tubal disease RCOG Guidelines : Grade B Recommendation

Hydrosalpinges & IVF,Johnson et al., March 2002(Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment

Unexplained InfertilityExpectant management (no treatment) for up to three years of trying should be considered, taking into consideration the woman's age. RCOG Guidelines : GradeC Recommendation

Unexplained InfertilityThe effective treatment for unexplained infertility is ovarian stimulation in conjunction with IUI . If failed IVF is recommended. RCOG Guidelines : Grade A Recommendation

TERIMA KASIH

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