Understanding Understanding Infertility Infertility Basic Sciences Basic Sciences A/Prof R Gyaneshwar A/Prof R Gyaneshwar FRANZCOG, MH.Ed FRANZCOG, MH.Ed Clinical Director of Obstetrics & Clinical Director of Obstetrics & Gynaecology Gynaecology Liverpool Health Service Liverpool Health Service Conjoint Associate Professor Conjoint Associate Professor University of New South Wales University of New South Wales
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Understanding Infertility Basic Sciences A/Prof R Gyaneshwar FRANZCOG, MH.Ed Clinical Director of Obstetrics & Gynaecology Liverpool Health Service Conjoint.
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Basic SciencesBasic SciencesA/Prof R GyaneshwarA/Prof R GyaneshwarFRANZCOG, MH.EdFRANZCOG, MH.Ed
Clinical Director of Obstetrics & GynaecologyClinical Director of Obstetrics & GynaecologyLiverpool Health ServiceLiverpool Health Service
Conjoint Associate ProfessorConjoint Associate ProfessorUniversity of New South WalesUniversity of New South Wales
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AcknowledgementAcknowledgement
Dr Antony Lighten – Dr Antony Lighten – IVF AustraliaIVF Australia
Dr Derek Lok – Dr Derek Lok – Sydney IVFSydney IVF
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Reproductive PhysiologyReproductive Physiology
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Endometriosis
Fibroids
Blocked or damaged Fallopian tubes eg
Ectopic pregnancy
Failure of Ovulation
Polycystic Ovarian
Syndrome
Miscarriage
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Causes of InfertilityCauses of Infertility
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The Causes of Infertility and The Causes of Infertility and their Approximate Frequency their Approximate Frequency (adapted from Hull et al 1985)(adapted from Hull et al 1985)
CausesCauses Frequency %Frequency %
Sperm defects or dysfunctionSperm defects or dysfunction 3030
Ovulation failureOvulation failure (amenorrhoea or oligomenorrhoea)(amenorrhoea or oligomenorrhoea) 2525
WHO Type 1:WHO Type 1: HypogonadotrophicHypogonadotrophicNearly everyone conceivesNearly everyone conceives
AnovulationAnovulation WHO Type 2:WHO Type 2: NormogonadotrophicNormogonadotrophicMost women conceiveMost women conceive
Ovarian failureOvarian failure WHO Type 3:WHO Type 3: HypergonadotrophicHypergonadotrophicConception remote chance Conception remote chance without donated oocyteswithout donated oocytes
Monthly fecundity rate 6.1 (laparoscopic surgery) vs 3.2 (diagnostic laparoscopy) per 100 person month
The Canadian Collaborative Group on Endometriosis 1997 NEJM 337:217
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HysteroscopyHysteroscopy
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Septate uterusSeptate uterus
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Congenital AnomaliesCongenital Anomalies
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Failure of sperm production
Blocked/absent vas deferens
Low sperm numbers and/or poor sperm movement
High numbers of abnormal shaped sperm
Antisperm antibodies
Erectile dysfunction
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Male FactorMale Factor
Primary Testicular DiseasePrimary Testicular Disease Most common cause of male factor infertilityMost common cause of male factor infertility AetiologyAetiology
Semen Analysis Semen Analysis (WHO 1999)(WHO 1999) 3 days of abstinence, collection technique, 72 3 days of abstinence, collection technique, 72
days for sperm to be ejaculateddays for sperm to be ejaculated Vol > 1 mlVol > 1 ml Concentration > 20 x 10Concentration > 20 x 106 6 / mL/ mL Motility > 50%Motility > 50% Morphology Morphology (WHO Strict Criteria 99)(WHO Strict Criteria 99) > > 15% 15%
normalnormal Note:Note: SA best performed in andrology lab; If SA best performed in andrology lab; If
abnormalabnormal always repeatalways repeat
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Sperm Count Variation in a Sperm Count Variation in a Healthy ManHealthy Man
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Important ConceptsImportant Concepts
AgeAge Duration of infertilityDuration of infertility Primary versus secondary infertilityPrimary versus secondary infertility Multiple causes of infertilityMultiple causes of infertility Sub-fertility versus sterilitySub-fertility versus sterility
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HistoryHistory DurationDuration Previous pregnanciesPrevious pregnancies Wt / Ht / BMIWt / Ht / BMI Full menstrual historyFull menstrual history Androgenising signsAndrogenising signs Pelvic painPelvic pain Previous investigationsPrevious investigations Past medical historyPast medical history Past surgical historyPast surgical history Medications / cigarettes / alcoholMedications / cigarettes / alcohol
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HistoryHistory Previous paternitiesPrevious paternities Sexual dysfunctionSexual dysfunction Mumps / STDMumps / STD TraumaTrauma Undescended testesUndescended testes Previous investigationsPrevious investigations Past medical historyPast medical history Past surgical historyPast surgical history Medications / cigarettes/ alcoholMedications / cigarettes/ alcohol
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RANZCOG Statement RANZCOG Statement C-Obs 3 March 2004C-Obs 3 March 2004
Tests recommended at the first antenatal visit of Tests recommended at the first antenatal visit of each pregnancy:each pregnancy:
Blood group and antibody screenBlood group and antibody screen Full blood examinationFull blood examination Rubella Antibody statusRubella Antibody status Syphilis serologySyphilis serology Hepatitis B serologyHepatitis B serology Midstream urine examination by culture: Midstream urine examination by culture: eg dipslideeg dipslide HIV serologyHIV serology Hepatitis C serologyHepatitis C serology Cervical cytologyCervical cytology
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Prognostic FactorsPrognostic Factors
AgeAge Duration of infertilityDuration of infertility Primary versus secondary infertilityPrimary versus secondary infertility Multiple causes of infertilityMultiple causes of infertility Sub-fertility versus sterilitySub-fertility versus sterility
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Duration of InfertilityDuration of Infertility
The longer the duration of infertility, the The longer the duration of infertility, the greater the likelihood of a cause of greater the likelihood of a cause of infertility; infertility; ie the less likely that the situation ie the less likely that the situation is due to bad luckis due to bad luck
Treatment is more successful in patients Treatment is more successful in patients where a specific treatable cause is foundwhere a specific treatable cause is found
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PrognosisPrognosis
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Effect of Multiple Minor Effect of Multiple Minor AbnormalitiesAbnormalities
Luteal ProgesteroneLuteal Progesterone 7 days prior to estimated date of period if regular7 days prior to estimated date of period if regular If irregular, start 7 days prior to shortest cycle date If irregular, start 7 days prior to shortest cycle date
and repeat every 5-7 days till next period arrivesand repeat every 5-7 days till next period arrives