Published on March 11, 2014
SEYED MORTEZA MAHMOODI
Definition Fertility Fecundity Fecundability Incidence Prevalance
FEMALE MALE COMBINED UNKNOWN
Cervical factor infertility Uterine factor infertility Ovarian factor infertility Tubal factors Peritoneal factors Advanced Age
5%-10% Stenosis , chronic cervicitis Abnormalities of the mucus-sperm interaction Surgical procedures, infections, hypoestrogenism, and radiation therapy
PCT, Sims-Huhner Speculum examination, 1-2 mm probe IUI
2%-5% Congenital Acquired
Environmental and occupational Toxins Exercise Inadequate diet
previous pregnancies and their outcomes frequency of intercourse, use of lubricants (eg, K-Y gel) that could be spermicidal, use of vaginal douches after intercourse, and the presence of any sexual dysfunction such as anorgasmia or dyspareunia. menstrual history, frequency, and patterns since menarche. A history of weight changes, hirsutism, frontal balding, and acne should also be addressed. Ask male patients about previous semen analysis results, history of impotence, premature ejaculation, change in libido, history of testicular trauma, previous relationships, history of any previous pregnancy, and the existence of offspring from previous partners. history of sexually transmitted diseases (STDs); surgical contraception lifestyle; consumption of alcohol, tobacco, and recreational occupation; and physical activities. Ask the couple whether they are currently under medical treatment, the reason, and whether they have a history of allergies. A complete review of systems may be helpful to identify any endocrinological or immunological problem that may be associated with infertility.
Vitals height and weight to calculate the body mass index, Perform an eye examination The presence of epicanthus, lower implantation of the ears and hairline, and webbed neck gland enlargement or thyroid nodules Perform a breast examination galactorrhea. menstrual cycles. Abnormal masses
A thorough gynecologic examination should include an evaluation of hair distribution, clitoris size, Bartholin glands, labia majora and minora, and any condylomata acuminatum or other lesions that could indicate the existence of venereal disease. Bimanual examination should be performed to establish the direction of the cervix and the size and position of the uterus to exclude the presence of uterine fibroids, adnexal masses, tenderness, or pelvic nodules indicative of infection or endometriosis. The examination of the extremities is important to rule out malformation, such as shortness of the fourth finger or cubitus valgus, which can be associated with chromosomal abnormalities and other congenital defects. Examine the skin to establish the presence of acne, hypertrichosis, and hirsutism.
Postcoital test (PCT), Sims-Huhner test speculum examination HSG US Saline infusion sonography MRI Hysteroscopy Endometrial biopsy
Laparoscopy Ovulation Progesterone greater than 4 ng/mL Sonographic confirmation of follicle rupture with serial ultrasonography can also be performed. Basal body temperature charts prefer to use urinary ovulation predictor kits as they are more accurate and easier to administer Ovarian reserve
Single line Late menstrual endometrium Thick proliferative endometrium Thick secretory endometrium Posterior enhancement The uterine lining changes throughout the normal menstrual cycle
Semen analysis Volume - 2-5 mL pH level - 7.2-7.8 Sperm concentration - 20 million or greater Motility - 50%, forward progression Morphology - Normal sperm (>4%) White blood cells - Fewer than 1 million cells/µL Sperm function test the acrosome reaction test computer assessment of the sperm head, computer motility assessment hamster penetration test human sperm-zona penetration assay
Ovulation predictors Conception cap Semen collectors Collection condoms are sterile and made from silicone or polyurethane, as latex is somewhat harmful to sperm. Semen can also be collected by masturbation into a sterile container, such as a specimen cup.
In vitro fertilisation (IVF) & Embryo transfer(ET) Involves:- 1. Retrieval of pre-ovulatory oocytes from the woman. 2. In vitro fertilization by sperm. 3. Culture to 8 or 16 cell stage. 4. Transfer to the uterus.
1. Ovarian follicles stimulated 2. Mature oocytes aspirated at laproscopy 3. Oocytes placed in a petri dish to culture with capacitated sperms. 4. Cleavage monitored in fertilized egg till 6-8 cell stage 5. Embryo transferred into vagina and cervical canal
•In vivo fertilization occur within 12 hours after ovulation •In vitro fertilization is not possible after 24 hours. •Most human sperms do not survive for more than 48 hours in the female genital tract
Complications •Increased risk of multiple gestations, •Spontaneous abortions •High incidence of chromosomal and cellular abnormalities Advantages Long periods of preservation of blastocysts and embryos
Procedure Prior to any GIFT, IVF, or ICSI procedure, the woman receives hormones to stimulate development of the ovarian follicles. The fluid containing the ova is placed in a laboratory dish and observed under a microscope. The ovum is located and its stage of maturity noted. It is then carefully cultured in a special nutrient.
Approximately three hours before the procedure, a semen sample from the husband is obtained. The sperm is washed and prepared for loading into the same catheter into which several of the wife's ova will be placed. The ova are obtained by transvaginal needle aspiration (no surgical incision) via an ultrasound guide.
Sperm and ova are sequentially loaded into the catheter, which is then introduced into the patient's fallopian tube through a tiny incision in her abdomen. GAMETE INTRAFALLOPIANTRANSFER
2 cell stage 4 cell stage 6-8 cell stage Morula
Just prior to beginning the hatching process on an 8-cell embryo Assisted Hatching
Hatching a high quality 8-cell embryo A small opening is being made in the embryo's shell (zona pellucida)
The needle has been further advanced through the embryo's shell A gap in the shell is developing
A gap in the zona has been created The oolemma (egg membrane) is bulging and about to "pop"
A blastocyst starting to hatch from its shell - lower right of photo After hatching, the embryo can implant in the uterine lining Photo taken a few minutes prior to EmbryoTransfer
Intracytoplasmic sperm injection (ICSI) The injection of the sperm into the oocyte Process of supplementation of sperm fertilization potential by the direct transport of the sperm into the oocyte is termed ICSI Indications: Non satisfactory sperm motility Loss of acrosome Sperm immaturity Presence of antisperm antibodies in the woman.
Procedure: The sperm will be injected into the oocyte cytoplasm using apparatus called micromanipulator Under microscope control the oocyte will be moderately vacuum held and using an injection pipette of the diameter of 5 micrometers, the direct transport of the sperm into the oocyte is performed. 1. Oocyte holder 2. Spermatozoon expulsed from the capillary 3. Mature oocyte with the polar body 4. Injection capilary
About to inject the egg with a sperm Holding pipette on left ICSI needle on right Sperm head visible in needle at far right, just below X Polar body of egg at 7 o'clock
Needle is advanced to the left Shell of embryo has already been penetrated by needle Membrane of egg (oolemma) is stretching and is about to break Sperm head is visible at tip of needle
ICSI needle has penetrated the egg membrane A single sperm is being injected into the cytoplasm of the egg
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