Female Infertility

ETIOLOGY:

• The causes of female infertility are attributed to 

Dyspareunia and vaginal causes.:

• Fixed retroversion with prolapsed ovaries
• Inflamed adnexal disease 
• Pelvic endometriosis: due to Immobility of tubes, Anovulation & Tubal block
• These conditions are often associated with blocked fallopian tubes

Congenital defects in the genital tract:

• Absent or septate vagina
• Hypoplasia
• Absent uterus

Infection in the lower genital tract:

• Chlamydial cervicitis( sperm fragmentation, block tubes by PID)
• Cervical mucus: Assessed by the postcoital test
• Leucocytes in the mucus: infection( cervicitis.)
• Cultures for gonorrhoea, Chlamydia trachomatis and Ureaplasma urealyticum
• Treatment:Antibiotics, electrocautery/cryocautery

Nonmotile, nonprogressively motile sperms:

• Sperm antibodies
• Examine: patient’s serum and cervical mucus
• Treatment:IUI, IVF or GIFT technique

Cervical Factors:

• Position of the cervix
• Patency of the cervical canal
• Alkalinity of Cervical mucus
• Ciliated endocervical cells
• Treatment:IUI, Condom for 3 month, Gamete Intrafallopian transfer, antibiotics ,Corticosteroids 
• Complication: 
• Cervical fibroid impacted in pouch of Douglas : May lead tourinary retention

Uterine causes:

• Hypoplasia, malformed uterus and incompetent os
• Asherman’s syndrome
• Pelvic tuberculosis, blockage of tubes and endometrial TB(asymptomatic clinicaly)
• Uterine fibroid:Dyschrony between the glandular and stromal growth
• Cornual fibroid
• Submucous fibroid 
• Cervical fibroid
• Tubal factors:Tubal blockage, peritubal adhesions & fimbrial end blockage can be caused by:
• Salpingitis(MC)
• Gonorrhoea infection
• Chlamydial infections
• Puerperal infections

Ovaries:

• Nonovulation-endocrine disorders, PCOD(amenorrhea, hirsuitism and obesity ), corpus luteal phase defects,Resistant ovarian syndrome
• Peri-ovarian adhesion
• Luteinized unruptured follicular (LUF) syndrome
• Duphaston (dydrogesterone) is effective in corpus LPD
• Complication:Ovarian hyperstimulation(FSH/LH therapy)
• Peritoneal causes—adhesions, endometriosis.
• Chronic ill health—especially thyroid dysfunction.
• Hormonal—pituitary gland dysfunction, hyperprolactinaemia and hypothalamic disorders.

INVESTIGATIONS:

• To test  ovarian reserve, FSH is measured

Tests for Tubal Patency:

• Done in the preovulatory phase

Hysterosalpingography (HSG):

• Visualization of uterine cavity and the fallopian tubes
• Material used:Foley catheter, Rubin cannula Leech-Wilkinson cannula for insufflation
• Performed between the end of the menstrual period and ovulation (usually the ninth or tenth day of the cycle)
• Blockage of tube:
  
• fibrotic block (stricture)
• inspissated amorphous material plugging the lumen
• Bilateral cornual block with extravasation of the dye: tubercular salpingitis

Laparoscopic chromotubation:

• Laparoscopic and dye test are done doing secretory phase of the cycle for finding out the tubal factors of infertility

Indications for laparoscopy:

• HSG showing abnormal findings.
• Prior to planning tuboplasty.
• Prior to IUI.
• Prior to induction of ovulation.
• Removal of hydrosalpinx prior to IVF.
• PCOD to puncture the cysts
• Suspected cases of endometriosis: biopsy for infertility is taken on 23 to 26 day

Sonosalpingography (SSG):

• AUB
• Amenorrhoea due to Asherman’s syndrome
• Part of infertility investigation
• Repeat pregnancy losses for uterine anomalies
• Prior to IVF
• Preovulatory phase as in HSG

Hysteroscopy and falloscopy:

• Interstitial end of the fallopian tube is studied by falloscopy
• Mucus plug or inspissated material can be flushed
• Polypus can be removed
• Ampullary and fimbrial salpingoscopy
• Study the mucosa of the fallopian tube in deciding between tubal microsurgery and IVF

Gold standard in the investigation of tubal infertility:

• Laparoscopy is now combined with hysteroscopy as a comprehensive one-stop infertility work up, to detect the cause of infertility and treat the cause in one go.

Fertiloscopy:

• Diagnosis of pelvic pathology and testing of tubal patency
• Therapeutic

• Medical treatment:
• Both Bromocriptine and cabergoline can be used for infertility treatment of a female with increased prolactin levels as both decrease prolactin levels, however, cabergoline is better tolerated.

Tuboplasty:

• Tubal microsurgery:In tubal blockage.
• Laparoscopic tubal adhesiolysis, fimbrioplasty and tubal surgery
• IVF (in vitro fertilization) and ET (embryo transfer):
• Women in whom tuboplasty fails
• Bilateral tubal block at cornua
• MAF (micro-assisted fertilisation): If IVF fails

Balloon tuboplasty and cannulation:

• Only breaks flimsy adhesions and dislodges plugs

Tubal cannulation:

• If tubal blockage is due to flimsy adhesions

Medial end tubal blockage:

• Tubal cannulation
• Balloon tuboplasty
• IVF
• Surgery—tuboplasty

Lateral end block:

• Fimbrioplasty
• Salpingostomy
• Adhesiolysis of external adhesions

Exam Question

• Lady with infertility with bilateral tubal block at cornua : best method of management is IVF
• Treatment for Cervical infertility can be Condom for 3 month, Gamete Intrafallopian transfer IUI
• Salpingitis, PID & Submucosal myomata are cause of infertility
• LH, GnRh and Clomiphene are used in treatment of  infertility
• Endometrial biopsy for infertility is taken on 23 to 26 day
• In endometriosis, cause of infertility is  Immobility of tubes, Anovulation & Tubal block
• A woman treated for infertility, presents with 6 week amenorrhea with urinary retention. The most likely etiology is impacted Cervical Fibroid
• For  infertility without significant clinical problem, most likely diagnosis is  T.B. endometrium
• Laparoscopic and dye test are done doing secretory phase of the cycle for finding out the tubal factors of infertility.
• To test  ovarian reserve, FSH is measured
•  MOST common cause of ovarian hyperstimulation FSH/LH therapy
• PCOS shows oligomenorrhoea, infertility and hirsuitism
• Both Bromocriptine and cabergoline can be used as both decrease prolactin levels, however, cabergoline is better tolerated.
• Gold standard investigations for female infertility is Laparoscopy and hysteroscopy