1760089 - PowerPoint Presentation

Slide1

INFERTILITY

Presented by,

Mrs.Kavitha

Jasmine,

Asst.

Prof,

Obstetrics &

Gynecology Department,

Annammal

College Of Nursing, Kuzhithurai.

Slide2

INFERTILITY

Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus.

Slide3

TYPES

Primary Infertility

Secondary Infertility

PRIMARY INFERTILITY: It denotes those patients who have never conceived.

SECONDARY INFERTILITY: It indicates previous pregnancy but failure to conceive subsequently.

Slide4

INCIDENCE

Eighty percent of the couples achieve conception if they so

desire,within

one year of having regular intercourse with adequate frequency(4-5 times a week).Another 10 percent will achieve the objective by the end of second

year.As

such,10 percent remain infertile by the end of second year.

Slide5

FACTORS RESPONSIBLE FOR FERTILITY

Healthy spermatozoa

Motile spermatozoa

Ovulation

Tubal factor

Fertilization of

oozyte

Uterine cavity

Slide6

Slide7

CAUSES OF INFERTILITY

MALE FACTORS

Defective spermatogenesisObstruction of efferent duct system.Failureto deposit sperm high in vagina.Errors in seminal fluid.

FEMALE FACTORS

Ovarian factor.

Tubal & peritoneal factors.

Uterine factors.

Cervical factors.

Vaginal factors.

Combined factors.

Slide8

MALE REPRODUCTIVE SYSTEM

Slide9

DEFECTIVE SPERMATOGENESIS

CONGENITAL FACTORS

UNDESCENDED TESTES

KARTARGENER SYNDROME

HYPOSPADIAS

THERMAL FACTORS

INFECTION

GENERAL FACTORS

ENDOCRINE FACTORS

GENETIC FACTORS

IMMUNOLOGIC FACTORS

Slide10

CONGENITAL FACTORS:

Undescended

testes- The hormone secretion remains unaffected, but spermatogenesis is

depressed.Vas

deferens is absent in about 1-2 percent males.

Kartagener

syndrome- It is an

autosomal

disease in which there is loss of

ciliary

function and sperm motility.

Hypospadiasis

- Causes failure to deposit sperm high in vagina.

Slide11

THERMAL FACTOR:

Scrotal temperature is raised in conditions such as

varicocele,big

hydrocele

or

filariasis

. Other causes are using tight under garments or working in hot sun. In all these cases the depressed spermatogenesis may be temporary and reversible.

INFECTION:

Infections like

mumps,

bronchiectasis

bacterial or viral infection of SEMINAL VESICLE OR PROSTATE depresses sperm count.

Slide12

GENERALFACTORS:

Chronic

diseases,malnutrition

or heavy smoking reduce

spermatogenesis.Alcohol

also has the same effect.

IATROGENIC:

Radiation,cytotoxic

drugs, nitro-

furantoin,cimetidine

,

β

- blockers, anti

hypertensives,anti

convulsants

and antidepressant drugs are likely to hinder spermatogenesis

.

Slide13

OBSTRUCTION OF EFFERENT DUCTS

The efferent ducts may be obstructed by infection like tubercular ,

gonococcal

or by surgical trauma(

herniorraphy

) following vasectomy.

FAILURE TO DEPOSIT SPERM HIGH IN VAGINA

Ercetile

dysfunction, Ejaculatory defect-premature ejaculation, retrograde or absence of ejaculation.

Hypospadias

:

A developmental anomaly in the male in which the urethra opens on the underside of penis or in the perineum.

Slide14

ERRORS IN SEMINAL FLUID

1.Usually high or low

volume of ejaculate.

2.Low fructose content.

3.High prostaglandin count.

4.Undue varicosity.

Slide15

DEFECTIVE SPERMATOGENESIS

Slide16

VARICOCELE

Slide17

Slide18

OVARIAN FACTORS

ANOVULATION

OLIGOOVULATION

LUTEAL PHASE DEFECT

LUTEINISED UNRUPTURED FOLLICULAR SYNDROME

Slide19

ANOVULATION OR OLIGO-OVULATION:

Ovarian function is likely to be linked with disturbed

hypothalamo

-pituitary-ovarian axis either primary or secondary from thyroid or adrenal dysfunction.

Thus, the disturbance may result in

anovulation

, or even

amenorrhoea.As

there is no ovulation, there is no corpus

luteum

formation.

Slide20

LUTEAL PHASE DEFECT(LFD):

In this condition there is inadequate growth and functioning of corpus

luteum

. There is inadequate progesterone

secretion.The

life span of corpus

luteum

is reduced to 10

days.As

a

result,there

is inadequate

secretory

changes in the

endometrium

which hinders implantation Drug induced

ovulation,decreased

level of FSH and LH, elevated

prolactin,subclinical

hypothyroidism,older

women,pelvic

endometriosis,dysfunctional

uterine bleeding are the important causes.

Slide21

LUTEINISE UNRUPTURED FOLLICULAR SYNDROME

(

trappedovum

):

In this condition the ovum is trapped inside the follicle which gets

luteinized.The

causes may be associated with pelvic endometriosis or with

hyperprolactineamia

.

Slide22

CERVICAL FACTORS

OVARIAN & TUBAL FACTORS

Slide23

Tubal factors:

Are responsible for about 30-40 percent cases of female infertility. It is due to obstruction in the tube due to;

1.Peritubal adhesions

2.Endosalpingeal damage

3.Previous tubal surgery or sterilization

4.Salpingitis

5.Tubal endometriosis

6.Polyps or mucous debris in the tubal lumen

7.Tubal spasm

Peritoneal causes:

Minimal endometriosis,

dyspareunia

, abnormal peritoneal fluid are the peritoneal factors.

Slide24

Uterine factors:

The

endometrium

must be sufficiently receptive enough for effective

nidation

and growth of fertilized

ovum.The

possible factors that hinders

nidation

are:-

1.Uterine

hypoplasia

2.Inadequate

secretory

endometrium

3.Fibroid uterus

4.Congenital malformation of the uterus

Cervical factors:

Congenital elongation of

cervix,second

degree uterine

prolapse,acute

retroverted

uterus,abnormal

composition of cervical mucous.

Slide25

Vaginal factors:

It includes;

1.Atresia vagina

2.Transevrse vaginal septum

3.

Septate

vagina

4. Narrow

introitus

Slide26

COMBINED FACTORS

Apareunia

And

Dyspareunia

Anxiety And Apprehension

Use Of Lubricants During Intercourse Which Are Spermicidal

Immunologic Factors

Slide27

Combined factors:

These include the presence of factors both in male and female partners causing infertility.

General factors:

Advanced age of wife beyond 35 is related but spermatogenesis continues throughout life although ageing reduces the fertility in males.

Infrequent intercourse, lack of knowledge of coital technique and timing of coitus to utilize the fertile period are common even among the literate couples.

Apareunia

and

dyspareunia

Anxiety and apprehension

Use of lubricants during intercourse which may be spermicidal.

Slide28

INVESTIGATIONS OF INFERTILITY

OBJECTIVES ;

1.To detect the etiological factors.

2.To rectify the abnormality in an attempt to improve the fertility.

3.To give assurance with explanation to the couples, if no abnormality is detected.

Slide29

INVESTIGATION IN MALES

History collection:

Age, duration of

marriage,history

of previous

marriage,and

proven fertility if

any,are

to be noted.

A general medical history should be taken with special reference to sexually transmitted

diseases,mumps

orchitis

after puberty, diabetes,& recurrent chest infection.

Relevant surgeries such as

herniorrhaphy

, surgeries on testes or genital area are to be enquired.

Occupational history should be directed towards exposure to excessive heat or

radiation.Social

habits,particularly

heavy smoking and alcohol is to be collected.

Slide30

Examination:

A full physical examination is to be performed to determine the general health condition.

Examination of reproductive system includes inspection and palpation of genitalia.

Presence of

varicocele

should be elicited in upright position.

Slide31

VARICOCELE

Slide32

A.Routine

Investigations

include urine and blood examination including postprandial sugar.

B.Seminal

Fluid Analysis

: This should be the first step in investigation because if some gross are detected like absence of

sperm,the

couple should be

counselled

for the need of assisted reproductive therapy.

C.Collection

:

Collection of semen is done by masturbation failing which by coitus

interruptus.The

semen is collected in a clean wide mouthed

jar.The

sample must be send to lab as early as possible so that examination is conducted

witnin

2 hours.

Slide33

INDEPTH EVALUATION:

These are needed for the cases of –a)

Azoospermia

b)

Oligospermia

c)Low volume ejaculate d)Problems of sexual potency etc.

.SERUM FSH,LH, TESTOSTERONE,PROLACTIN & TSH: Testicular

hypogonadotropic

hypogonadism.Elevated

prolactin

due to pituitary adenoma may cause impotency.

.FRUCTOSE CONTENT IN SEMINAL FLUID: Its absence suggest congenital absence of seminal vesicle or portion of

ductal

system or both.

.TESTICULAR BIOPSY: It is done to differentiate primary testicular failure from obstruction as a course of

azoospermia

or severe

oligospermia.The

biopsy material is to be sent in

Bouin’s

solution.

Slide34

Transrectal

Ultrasound(TRUS):

is done to visualize the seminal vesicles, prostate and ejaculatory duct obstruction.

Indications of TRUS are-

Azoospermia

or

oligospermia

, abnormal digital examination, ejaculatory duct abnormality and genital abnormality like

hypospadias

.

Vasogram

: is a radiographic study done to evaluate the ejaculatory duct

obstruction.It

is mostly replaced by TRUS.

karyotype

analysis

: This is done in case with

azoospermia

or severe

oligospermia

and raised

FSH.Klinefelter’s

syndrome (XXY) is the commonest.

Slide35

VASOGRAM

Slide36

INVESTIGATION IN FEMALES

HISTORY COLLECTION

EXAMINATIONS

SPECIAL INVESTIGATIONS

-

INDIRECT DIAGNOSIS OF OVULATION

-DIRECT DIAGNOSIS OF OVULATION

Slide37

DIAGNOSIS OF OVULATION

1.Direct method

2.Indirect method

Indirect

method includes collection of menstrual history, Basal body temperature, Cervical mucous

study,endometrial

pH and hormone study.

Direct

method

includes

Laparoscopy

Dilatation &

Insufflation

Test

Hysterosalphingography

Laparoscopy &

Chromopertubation

Sonohysterosalphingography

Slide38

LAPAROSCOPY;

Laparoscopic visualization of recent corpus

luteum

or detection of ovum from the aspirated peritoneal fluid from the pouch of

douglas

is the only direct evidence of ovulation.

The scope of diagnostic laparoscopy has been

widened.It

is an invasive

investigation,so

this is done after male factor and

ovulatory

functions have been

fonud

normal or corrected.

The indications of its use are;

a.Abnormal

HSG findings.

b.Failure

to conceive after reasonable period(6 months) even with normal HSG.

c.Unexplained

infertility.

d.Age

above 35 years.

Slide39

INDICATIONS FOR LAPAROSCOPY IN INFERTILITY

Diagnostic

- Age above 35 years.

- Abnormal HSG.

- Failure to conceive after reasonable

period with normal HSG.

- Unexplained infertility.

Operative Gift &

Zift

Procedures.

-Ovarian diathermy

-Reconstructive tubal surgery.

- Fulguration of

endometriotic

implants.

Slide40

PROTOCOLS:

A double puncture technique is to be

applied.All

the pelvic organs are to be properly

visualized,of

particular importance is to note the

fimbrial

end of fallopian tubes and their relation with the

ovaries.Proper

documentation with the aid of diagram is mandatory.

Advantages Over

Hsg

:

It can precisely diagnose

peritubal

adhesions,pelvic

endometriosis or evidence of

ovulation.Chromopertubation

with

methylene

blue cannot only reveal patency of the tube but the nature of tubal motility.

Drawbacks:

It is more invasive than

HSG.It

cannot detect abnormality in the uterine cavity or lumen of tube.

When to be done?

It is preferably done in the

secretory

phase.Recent

corpus

luteum

may be visualized and endometrial biopsy can be taken in the same setting.

Slide41

LAPAROSCOPY

Slide42

LAPAROSCOPY

Slide43

INSTUMENTS USED IN LAPAROSCOPY

Slide44

DILATATIONAND INSUFFLATION TEST(RUBIN’S TEST)

Principle:

The underlying principle lies with the fact that cervical canal is in continuity with the peritoneal cavity through the

tubes.As

such entry of air or CO

2

into the peritoneal cavity when pushed

transcervically

under pressure gives evidence of tubal patency.

When to be done? It should be done in the post menstrual phase

atleast

2 days stopping of menstrual bleeding.

LIMITATION:

It should not be done in the presence of pelvic infection.

OBSERVATIONS:

The patency of the tube is confirmed by:

1.Fall in pressure when raised above 120mm hg.

2.Hissing sound heard on auscultation on

eithr

iliac

fossa

.

3.Shoulder pain experienced by the patient.

Drawbacks:

In about one third of cases it gives a false negative findings due to corneal

spasm.It

also cannot identify the side and site of block in the tube.

Slide45

HYSTEROSALPINGOGRAPHY

Slide46

HYSTEROSALPHINGOGRAPHY

Principle:

The principle is

sams

as that of

insufflation

test,instead

of air or CO

2

,dye is instilled

transcervically

.

When to be done? 2 days after stopping of menstrual bleeding.

Advantages:

It has got many advantages over insufflations

test.It

can precisely detect the side and site of block in the

tube.It

can reveal any abnormality in the uterus like congenital

anomalies,fibroid

etc.

Slide47

HYSTEROSCOPY

Slide48

CHROMOPERTUBATION

Slide49

SONOHYSTEROSALPHINGOGRAPHY

Normal saline is pushed within the uterine cavity with a

paediatric

Foley

catheter.The

catheter balloon is inflated at the level of cervix to prevent fluid leak.USG of the uterus and

fallopie

tube is

done.Ultrasound

can follow the fluid through the tubes up to the peritoneal cavity and in the pouch of Douglas.

Advantages:

It is a non-invasive method .

It can detect uterine abnormality and polyps.

Tubal Pathology could be detected.

There is no radiation

exposture

.

Slide50

PREVENTION OF INFERTILITY

Assurance To The Couples

Body Weight Should Be Adequate

Smoking & Alcoholism Is Prevented

Managing Coital Problems

Slide51

1.ASSURANCE:

The infertile couples remains psychologically disturbed right from the beginning, more so as the investigations

proceeds.The

couple in such cases should be tactfully handled to minimize

psychologic

upset.

When minor defects are detected in both the husband and the

wife,each

of which alone could not cause infertility but in

combination,they

significantly reduce the fertility

potential.As

such,the

faults should be treated simultaneously and not one

afer

the other.

2.BODY WEIGHT:

Overweight or underweight of any partner should be adequately dealt with to obtain an optimal

weight.Body

mass of index of 20-24 is optimum.

Slide52

3.SMOKING AND ALCOHOL

:

Excess smoking or alcohol consumption is to be avoided.

4.COITAL PROBLEMS

:

The coital problems must be carefully evaluated by intelligent

interrogation.Advice

to have intercourse during the

midcycle

too often gives a result early enough even prior to

investigation.Using

LH test

kit,one

can detect LH surge in urine by getting a deep blue

colour

of

dipstick.The

test should be performed daily between day 12 to day 16 of a regular

cycle.Timed

intercourse over24-36 hours after the

colour

change reasonably succeeds in

conception.Minor

psychosexual problems should be corrected accordingly.

Slide53

TREATMENT OF MALE INFERTILITY

The treatment of male is indicated in:

1.Extreme

oligospermia

2.Azoospermia

3.Low volume ejaculate

4.Impotency

Slide54

GENERAL MEASURES:

Reduction of weight in obese.

Avoidance of

alchohol

and heavy smoking.

Avoidance of tight and warm undergarments.

Avoidance of occupation that may elevate testicular temperature.

Use of vitamins E,C,D,B

12

and folic acid as antioxidants to improve spermatogenesis.

Medications that interfere with spermatogenesis must be avoided like

nitrofurantoin,cimetidine,antihypertensives,anticonvulsants

&

anyidepressants

.

Slide55

SURGICAL MEASURES

When the patient is found to be

azoospermic

and yet testicular biopsy shows normal spermatogenesis, obstruction of vas must be suspected. This should be corrected by microsurgery-

Vaso

Epididymostomy

or

Vasovasostomy

.

The presence of

varicocele

is corrected by high ligation of spermatic vein and the

hydrocele

by

surgey

.

Orchidopexy

in

undescended

testes should be done between 2-3 years of age to have adequate spermatogenesis in later life.

Slide56

IMPOTENCY

Psychosexual treatment may be of help Hyper

prolactinaemia

needs further investigation and

treatment.For

erectile dysfunction

SILDENAFIL (25-100 mg) or TADALAFIL(10-20mg) is currently advised. A single dose is given orally one hour before sexual

activity.In

unresponsive

cases,artificial

insemination is to be adopted.

ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

(FOR MALE INFERTILITY)

Prospect of male infertility has improved significantly with the treatment available for infertile males.

Slide57

MANAGEMENT OF FEMALE INFERTILITY

GENERAL MEASURES

PHARMACOLOGICAL MANAGEMENT

SURGICAL MANAGEMENT

Slide58

TREATMENT FOR ANOVULATION

Anovulation

is a common factor for female infertility. It may be present in otherwise normal menstrual cycle or may be associated with

oligomenorrhoea

or

amenorrhoea

.

INDUCTION OF OVULATION

1.General Measures

2.Pharmacological Management

3.Surgical Management

GENERAL MEASURES:

-Psychotherapy to improve the emotional stability.

-Reduction of weight in obesity as in PCOS cases is essential to have a good response of drug therapy in induction of ovulation.

Slide59

PHARMACOLOGICAL MANAGEMENT:

1.CLOMIPHENE CITRATE:

Patient selection:

Normogonadotrophic-normoprolactinaemic

patients who are having normal cycles with absent or infrequent ovulation.

PCOS cases with

oligomennorhoea

or

amenorrhoea

Hypothalamic

amenorrhoea

following stress or using oral contraceptive pills.

Dose:

Clomiphene

citrate is

simple,safe

and at the same time cost-

effective.Initial

dose of 50mg

daily.Dose

can be increased to a maximum of 250 mg daily if ovulation is not induced by lower

dose.The

actual starting day of its administration in the follicular phase varies between day 2 and day5 and therapy is given for 5

days.Ovulation

is expected to occur about 5-7 days after the last day of

therapy.Therapy

for 6 cycle is generally given

Slide60

Mechanism of action of

clomiphene

citrate:

Clomiphene

citrate is an anti-

oestogenic

drug.It

blocks the

oestrogen

receptors of

hypothalamus.This

results in increased

GnRH

pulse amplitude causing increased

gonadotropin

secretion from the pituitary.

Side effects:

1.Hot flushes

2.Nausea

3.Vomiting

4.Headache

5.Visual disturbances

6.Ovarian

hyperstimulation

Couple Instructions:

The couple is

adviced

to have sexual intercourse as per following guidelines

:

Daily or on alternative days beginning 5-7days after the last dose of

clomiphene

therapy.

Several times for 24-48 hours after the

colour

change in urine when tested by LH kit.

Number of times over 24-36 following

hCG

administration.

Slide61

2.GONADOTROPHINS:

Indications:

Hypogonadotrophic

hypogonadism

Clomiphene

failed or resistant cases

Unexplained infertility

Dose schedule:

Dose schedule starts with a minimal dose of 75 IU IM/day.

Follicular stimulation is started at any time from 2-5 days of the cycle and is continued for 7-10 days depending on the response.

Follicular growth is monitored with serum

estradiol

estimation and follicular number and size are measured by

transvaginal

sonography

.

Serum

oestradiol

level of 500-1500 pg/ml and maximum follicular diameter of 18-20mm are optimum.

When this optimum level is obtained,5000-10000IU of

hCG

is administered IM to induce ovulation.

Ovulation is expected to occur approximately 36 hours after

hCG

administration.

Slide62

Side effects of

gonadotrophin

therapy:

Primary ovulation failure with raised serum FSH.

Uncontrolled thyroid and adrenal dysfunction.

Sex hormone dependent

tumour

in the body

.

Slide63

SURGICAL MANAGEMENT

Laparoscopic Ovarian Drilling

Wedge Resection

Surgery Of Pituitary

Prolactinomas

Surgical Removal Of Ovarian And Adrenal

Tumours

Tubal Surgery

Slide64

1.Laproscopic ovarian drilling(LOD) or laser

vapourisation

:

This is done by multiple puncture of the cysts in polycystic ovarian syndrome by diathermy or

laser.It

reduces systemic and

intraovarian

androgen

levels.This

procedure is helpful in

clomiphene

resistant,hyperandrogenic

anovulatory

women.The

woman ovulates spontaneously following LOD.

2.Wedge resection:

This is not commonly done these days. Bilateral wedge resection of the ovaries is done in PCOS cases where

clomiphene

citrate fails to induce

ovulation.It

induces adhesions.

3.Surgery for pituitary

prolactinomas

.

4.Surgical removal of

virilising

or other functioning ovarian or adrenal

tumours

.

5.Tubal surgery

Slide65

TUBAL SURGERY

Indications for tubal surgery:

1.Peritubal adhesions

2.Proximal tubal block

3.Distal tubal block

4.Mid tubal block

Guidelines for tubal surgery:

Tubal surgery may be considered in young women after previous tubal sterilization or in women with mild disease at the distal tubal segment.

Tubal surgery may be tried for mild proximal tubal block.

Preoperative assessment and planning for surgery has to be done by HSG or laparoscopy.

Prior counseling of the couples about the hazards of surgery and prospect of future pregnancy should be done.

IVF is considered as the best treatment option for any complicated tubal occlusive disease.

Salphingectomy

should be done before IVF when

hydrosalpines

are present.

Slide66

Methods of tubal surgery:

Tuboplasty

is the name given to finer surgery on the tubes to restore the anatomy and physiology as far as practicable.

The operation can be done by conventional methods or by microsurgical techniques which may be employed following

laparotomy

.

Microsurgical techniques gives better results due to minimal tissue handling and

damage,perfect

haemostasis

and minimal adhesions.

Slide67

TUBOPLASTY

OPERATIONS

Salphingo-ovariolysis

Separation or division of adhesions.

Fimbrioplasty

Separation of fimbrial adhesions to open up the abdominal ostium.

Salphingostomy

Creates a new opening in the completely occluded tube.It is called terminal or cuff at the abdominal ostium.

Tubotubal

Anastomosis

When the segment of the diseased tube is resected following tubectomy,an end to end anastomosis is done.

Tubocornual

Anastomosis

When there is corneal block, the remaining healthy tube is anastomosed to the patent interstitial part of the tube.

Slide68

ADJUVANT THERAPY

Adjuvant procedures to improve the result of tubal surgery include prophylactic

antibiotics,use

of adhesion prevention devices(

intercede,seprafilm

) and postoperative

hydrotubation

.

Hydrotubation

:

Hydrotubation

is the procedure to flush the tubal lumen by medicated fluids passed

transcervically

through a

cannula

. The fluid contains antibiotics and hydrocortisone(Gentamicin-80mg and

dexamethasone

4mg in 10ml distilled water). It should be done in postmenstrual phase.

Slide69

SALPHINGO OVARIOLYSIS

Slide70

TUBO TUBAL ANASTOMOSIS

Slide71

TUBOCORNUAL ANASTOMOSIS

Slide72

ARTIFICIAL INSEMINATION

1.IUI- Intrauterine Insemination

2.Fallopian Tube Sperm Perfusion

1.INTRA UTERINE INSEMINATION

IUI may be either AIH(artificial insemination husband) or AID(artificial insemination donor).Husband’s sperm is commonly

used.The

purpose of IUI is to bypass the

endocervical

canal which is abnormal and to place increased concentration of mobile sperms as close to the fallopian tubes.

INDICATIONS FOR IUI:

1.Hostile cervical sperm

2.Cervical

stenosis

3.Oligospermia

4.Immune factor (Male & Female)

5.Male factor-impotency or anatomical defects

6.Unexplained infertility

Slide73

Washing,centrifuge

and swim-up methods are commonly

used.About

0.3ml of washed and concentrated sperm is injected through a flexible polyethylene catheter within the uterine cavity around the time of

ovulation.Washing

in culture media removes the proteins and prostaglandins from the semen that may cause uterine cramps or anaphylactic reactions.

The processed motile sperm for insemination should be

atleast

1 million. Fertilizing capacity of spermatozoa is 24-48 hours. The procedure may be repeated 2-3 times over a period of 2-3 days.

TIMING OF IUI:

Spontaneous cycles: IUI likely on day 12 and 14.

Clomiphene

Citrate induced cycles: IUI at 5-7 days after completion of cycles.

Urinary LH detection: IUI done in 24 hours after

colour

change

.

Slide74

COLLECTION OF SEMEN FOR IUI:

1.The total number of days since last ejaculation should be no longer than 4-5

days.Sperm

cells are made and replaced rapidly after each ejaculation.

2.Collect the semen using sterile

techniques.Bacterias

that are normally found in the skin can contaminate the specimen.

3.Masturbation is the preferred method of

collection.It

ensures the cleanest possible sample.

4.Donot have intercourse for 2-3 days before the day of collection.

5.Your appointment of sperm collection will be 70-90 minutes before the insemination.

7.The specimen must reach the lab within 30 minutes after collection of specimen.

8.Only containers distributed by the ANDROLOGY LABORATORY must be used for collection.

Slide75

PREPARATION FOR IUI:

1.PREPARING THE SEMEN SAMPLE: The semen should be washed in a way that separates a highly active normal sperm from lower quality sperm.

2.MONITORING FOR OVULATION: Ovulation can be calculated using basal body

temperature,LH

kits and trans vaginal ultrasound.

3.DETERMINIG OPTIMAL TIMING: Most IUIs are done after one or two days of detecting ovulation.

ADVANTAGES OF IUI:

IUI is the least

invasive,effective,simple,cheap

and first line assisted conception treatment method for infertility couples.

Woman’s

cervicel

mucus can sometimes kill the

sperm,preventing

the sperm from reaching the

egg.Here

IUI is the effective method.

IUI helps to deliver much more motile sperms to the fallopian tubes at the critical times around ovulation.

IUI is cost effective and simplest method in advanced infertility treatment.

Slide76

DISADVANTAGES OF IUI:

High risk of generating OHSS-Ovarian Hyper Stimulation Syndrome.

Stimulated ovarian cycle in IUI can cause multiple pregnancy.

Ovarian cysts as the side effect of stimulated ovarian cycle.

Possibility of using wrong semen samples.

Noninfective

salphingitis

and allergic

rection

can occur.

70-80 percent chance for abortion or ectopic pregnancy.

AFTER CARE OF IUI:

Patient should be kept in Foot end elevated position after the procedure.

She should be

adviced

to take rest for 10-20 minutes following the procedure.

Vital signs should be monitored immediately after the procedure.

Complete

bedrest

for 4-5 days after IUI.

No exercise

exept

light walking for 2 weeks after IUI.

Intake lot of protein rich foods like

eggs,soya,chicken

products

ie

atleast

75gm of protein per day.

Keep a positive frame of mind and pray to GOD to help you at this time.

After

IUI,keep

your stomach

coverted

and protected from wind for

atleast

2 weeks since the womb needs to stay warm to aid conception.

Slide77

INTRA UTERINE INSEMINATION

Slide78

INDICATIONS OF IUI

Hostile Cervical Sperm

Cervical

Stenosis

Oligospermia

Immune Factor

Male Impotency And Anatomical Defects

Unexplained Infertility

Slide79

ASSISTED REPRODUCTIVE TECHNOLOGY(ART)

ART encompasses all the procedures that

involve manipulation of

gamates

and embryos

outside the body for the treatment of infertility.

Slide80

PRINCIPAL STEPS IN ART

REGULATION USING

Gnrh

AGONIST.

Controlled Ovarian

Hyperstimulation

.

Monitoring Of Follicular Growth.

Oocyte

Retrieval.

Fertilization

Invitro

.

Transfer Of

Gamrates

Or Embryo.

Luteal

Support With Progesterone

.

Slide81

DIFFERENT METHODS OFART:

IVF-ET: In Vitro

Fertilisation

and Embryo Transfer

GIFT: Gamate Intra Fallopian Transfer

ZIFT: Zygote Intra Fallopian Transfer

POST: Peritoneal

Oozyte

& Sperm Transfer

SUZI:

Subzonal

Insemination

ICSI: Intra

Cytoplasmic

Sperm Injection

Slide82

INVITRO FERTILISATION AND EMBRYO TRANSFER(IVF-ET)

The field of reproductive medicine has changed for ever with the birth of Louise Brown in 1978 by IVF-

ET.Patrick

Steptoe and Robert Edwards of England are remembered for their revolutionary work.

INDICATIONS OF IVF:

Tubal disease

Unexplained infertility

Endometriosis

Male factor infertility

Cervical hostility

Failed ovulation induction

Ovarian failure

Woman with normal ovaries but no functional uterus.

Woman with genetic risk

Slide83

PATIENT SELECTION:

Age less than 35 years.

Presence of ovarian reserve (serum FSH < 10 IU/L)

Husband –normal

seminogram

Couple must be screen negative for HIV and hepatitis.

Normal uterine cavity as evaluated by

hystreroscopy

.

PRINCIPAL STEPS OF AN ART CYCLE:

1.Regulation using

GnRH

agonist.

2.Controlled ovarian

hyperstimulation

.

3.Monitoring of follicular growth.

4.Oocyte retrieval.

5.Fertilisation

invitro

(IVF,ICSI GIFT)

6.Transfer of

gamates

or embryos.

7.Luteal support with progesterone

.

Slide84

IN VITRO FERTILIZATION

Slide85

IVF-ET

Slide86

TEST TUBE BABY-DISAMBIGUATION

Slide87

GAMATE INTRA FALLOPIAN TRANSFER-(GIFT)

Slide88

GAMATE INTRA FALLOPIAN TRANSFER

GIFT was described by Asch and colleagues in 1984.

It is a more invasive and expensive procedure than IVF but the result seems better than

IVF.In

this procedure both sperm and unfertilized

oocyte

are transferred into fallopian

tubes.Fertilisation

is then achieved in vivo.

Slide89

GIFT

Slide90

ZYGOTE INTRA FALLOPIAN TRANSFER

ZIFT was first described by

Devroey

et al, in 1986. The placement of the zygote (following one day of in vitro fertilization) into the fallopian tube can be done either through the abdominal

ostium

by laparoscopy or through the uterine

ostium

under ultrasonic guidance.

This technique is a suitable alternative of GIFT when defect lies in the male factor or in cases of failed GIFT.

Slide91

ZIFT

Slide92

ZIFT

Slide93

INTRA CYTOPLASMIC SPERM INJECTION

ICSI was first described by Van

Steirteghem

and colleagues in 1992.

Indications:

1.Severe

oligospermia

(less than 5million sperm/ml)

2.Presence of sperm antibodies

3.Obstruction of efferent duct system

4.Congenital absence of vas

5.Failure of fertilization in IVF

Technique:

One single

spermotozoan

or even a

spermatid

is injected directly into the cytoplasm of an

oocyte

by

miropuncture

of the

zona

pellucida.This

procedure is carried out under a high quality inverted operating microscope Micropipette is used to hold the

oocyte

while the

spermatozoan

is deposited inside the

ooplasm

by an injecting pipette.

Slide94

INTRA CYTOPLASMIC SPERM INJECTION

Slide95

INTRA CYTOPLASMIC SPERM INJECTION

Slide96

HAZARDS OF ART

Most of the ART are associated with increased chromosomal abnormalities of the

offsprings

.

Increased number of pregnancy

loss,multiple

pregnancy and ectopic pregnancy have been observed.

Perinatal

mortality and morbidity are high.

Psychological stress and anxiety of the couple are severe.

Slide97

Role Of Nurse

Midwife In Infertility Management

Slide98

Nurse midwife comes from a variety of training

backgrounds,but

the

vasy

majority have previous experience in women’s health care.

Nurses have to work diligently to help the specialist execute treatment plans and play an important role in supporting the patients through the complex journey of infertility treatment.

Slide99

The nurse will aid the patient in scheduling various investigations like Ovarian reserve testing ,

Hysterosalphingogram

, & Semen

analysis.Infertility

testing and treatment involves specific timing

aroumd

the menstrual

cycle.For

some patients this may be

unpredictable,So

it requires efficient and effective action from the nurse.

Slide100

The nurse have to instruct the couples about schedules far taking the

medicines.Should

provide teaching on self subcutaneous and intramuscular

injection.For

many patients this is the first time they have had to give self

injections.Nurses

do an outstanding job at making sure

thattreatment

plans are effectively delivered.

Slide101

The diagnosis and treatment of infertility involves significant stress that is comparable to being diagnosed with

cancer.Added

to this stress is the cost of the

treatment.In

the end an empathetic nursing team will work under stressful condition to ensure that patients are compassionately and effectively cared for.