Management of

infertile couple
Dr. Salma Kafeel Qureshi
Consultant obstetrician & Gynecologist
MBBS (Pb), FRCOG (UK),
Sonologist, Epidural specialist (UK)
IVF specialist (Sydney Australia)
HOD Quaid-e-Azam International Hospital

Infertility
Defining infertility
A woman of reproductive age who has
not
conceived
after
1
year
of
unprotected vaginal sexual intercourse,
in the absence of any known cause of
infertility, should be offered further
clinical assessment and investigation
along with her partner.
[ NICE;new 2013]

Offer an earlier referral for

specialist
consultation
the woman is aged 36 years or over
there is a known clinical cause of
infertility or a history of predisposing
factors for infertility.

[NICE ; new 2013]

Incidence of infertility
Infertility

is a common clinical
problem. It affects 13% to 15% of
couples worldwide

Prevalence

of infertility in Pakistan is
approximately 22%
04% primary Infertility
18% secondary infertility
Neelofar S, Tazeen S:The cultural politics of gender for infertile
women in Karachi, Pakistan.InGender Studies Conference. South
Africa; 2006

Multiple Causes of InfertilityGlobal

Causes of
Infertility

Centers for Disease Control and Prevention. 2006 Assisted Reproductive Technology Success Rates: National Summary and
Fertility Clinic Reports. 2008. http://www.cdc.gov/ART/ART2006/508PDF/2006ART.pdf. Accessed April 20, 2009.

Causes of Infertility-Pakistan
Multiple factors
(male + female)

Tubal blocked; 12%

Multiple factors (male + female); 18%
Ovulatory failur; 19%
Multiple factors (female only); 11%
sexual dysfunction; 5%
Unexplained; 9%
Endometriosis;
6%
tubo-ovarian mass;
1%
Mucus hostility; 1%

R. Shaheen et al., Pakistan., vol. 42(4), pp. 389-393, 2010.

Minimal Investigation
Tests established correlation with
infertility
Semen Analysis
Mid Luteal progesterone

ovulation

diagnosis
Tubal Patency test (HSG or
Laproscopy)

History-taking
Focused

history taking -infertile

couple.
Good history is Gold standard to
investigate underlying problem
Female Partner:
Present history, menstrual history, obstetric,
contraceptive,
surgeries or serious illness, sexual history, Family history

Male Partner:
Present history, contraceptive, surgeries or serious illness,
Family history, sexual history

Focused clinical
examination
Female Partner:
Basic Investigation:
General Examination,
Abdominal Examination,
Breast Examination,
Genital Examination,
Hormonal assay,
Advanced Investigations
Transvaginal ultrasonography,
Hysterosalpingography or
Hysterosalpingocontrast-sonography
Laparoscopy
Hysteroscopy

Ultrasound of
endometrium

early follicular
triple line

luteal

Lap / Dye

A/Prof R Gyaneshwar

11

Laparoscopy

Looking inside the abdominal cavity

Ectopic

A/Prof R Gyaneshwar

13

Pelvic Infection and Tubal

Disease

A/Prof R Gyaneshwar

14

Pelvic Infection and Tubal

Disease

A/Prof R Gyaneshwar

15

Endometriosis

A/Prof R Gyaneshwar

16

Hysteroscopy

Looking inside the uterus

Hysterosalpingo-contrast-ultrasonography

Investigation of suspected tubal and uterine abnormalities:

2. Hysterosalpingo-contrast-ultrasonography
- TVS scan during which air and saline or a solution of D-galactose is
infused into the uterine cavity and observed to flow along the fallopian
tubes.
- Requires more expertise.
- Less invasive.

Focused clinical
examination
Male

Partner:
General Examination,
Semen analysis,
Anti-sperm antibodies,
Advanced Investigations
Hormonal assay,
Testicular biopsy

Male Infertility
Volume: 2-5ml
pH: 7.2-7.8
Liquefaction time: within 40 mins.
Sperm Count: -20-120 million/ml
(WHO Criteria)
Sperm motility: >50% after hour.
Sperm Morphology: >50% normal.

Abnormal Semen
Parameters.
Oligospermia:

- sperm count <20

million/ml
Mild: -10-20 million/ml
Moderate: -5-10million/ml
Severe: -<5 million/ml.
Azoospermia: - Absence of single
sperm in ejaculate.
Asthenospermia: -Sperm motility
<50%
Teratospermia: - <4% normal
sperms associated with poor fertility

Building burdeninfertility
Quacks
Hakeems
Dayaa
Inexperienced

practitioners

Treatment Options for

Infertile couple
Female Partner
Non-Invasive Treatment
Counseling
Induction of Ovulation,
Intra-uterine Insemination (IUI)
Invasive Treatment
Tubal surgery,
In-vitro Fertilization (IVF) and Embryo
transfer(ET),
GIFT, ZIFT

Treatment Options for

Infertile couple
Male Partner
Non-Invasive Treatment
Counselling, Intra-uterine
Insemination (IUI)
Invasive Treatment
Surgical restoration of duct
patency,
Intra-cytoplasmic Sperm
Injection (ICSI) PGD.
TESE, PESE, TESA, MESA.

Ovarian Stimulation
Young

Patient
Minimal Stimulation
CC or letrozole
Poor responder or poor ovarian
reserve/Age >35 years
(melatonin, DHEA EXCEL)
Inj. LH/ FSH 75IU
PolyCysticOvaries (PCO)
Diane-35/androgen
Lezra
Inj. rFSH 75IU

OVULATION DISORDERS
WHO Classification

Group 1 (10%) Hypothalamic pituitary failure

low gonadotrophins - low oestrogen

Group 2 (85%) polycystic ovaries

two of the following three criteria
-presence of at least 10 follicles measuring 29 mm in
diameter and/or
-clinical and/or biochemical hyperandrogenism
-oligo- and/or anovulation

Group 3 (5%) Ovarian failure

high gonadotrophins - low oestrogen

Clomiphene Citrate

Dose:
50-100 mg./day.
starting day 2,3,4 or 5 for 5 days.
Monitoring confirm ovulation:
ultrasound
LH kits, LH serum levels
day 21 progesterone.

CC Pathways

hCG vs. LH monitoring

If

normoovulatory LH monitoring is
preferred

If

ovulatory dysfunction: hCG is

preferred

Meta-analysis by Kosmos et al, 2007

Anovulatory cycles
Clomiphene

citrate (all doses) was associated with

an increased pregnancy rate per treatment cycle

If

still anovulatory after 6 months of continuous use

the case is considered clomiphene resistant

Meta-analysis by Hughes et al, 2011

The Aromatase Inhibitors

Letrozole (LEZRA 2.5 mg)

effective

in
anovulatory infertility.
It has the following
advantages:
1- It reduce E2 level.
2- It avoids the
unfavorable effects
on the endometrium
frequently seen with
CC

CC or low-dose FSH for the first-line treatment of

infertile women with PCOS:

Pregnancies and live births are achieved more

effectively and faster after OI with low-dose FSH
than with CC.

This result has to be balanced by convenience

and cost in favour of CC.

FSH may be an appropriate first-line treatment

for some women with PCOS and anovulatory
infertility, particularly older patients.

Homburg et al, 2012

Metformin
The

addition of metformin in the CCresistant patient is highly effective in

achieving ovulation induction.

Meta-analysis by Siebert et al, 2013

Prolactin Reducing
Medications
- For Hyperprolactinaemia associated
infertility.
Causes:

Pituitary adenoma (prolactinoma).

Hyperactive lactotrophs.
Medications: tranquilizers, hallucinogens, painkillers,
alcohol,..

Diseases of the kidney or thyroid gland.

Dopamine agonist:

- Bromocriptine.

- Quinagolide.
- Cabergoline

Gonadotropins :
Indications
Indications:
-Failure to respond to antiestrogen
therapy
At least 3 cycles of C.C. and no ovulation
Dose: 0-200mg/day for 7 days.
At least 6 Ovulatory cycles and not conceived.

-Side effects to antiestrogen therapy

irrespective of ovulation
-Two or more miscarriage after C.
therapy.

CC /Letrozole
+Gonadotropins
_________________________________
D2_____________D6__________D10
Clomiphene Citrate
Inj. hMG
(HMG Massone)

_________________________________
D2_____________D6__________D10
Letrozole (LEZRA)
Inj. hMG
(HMG Massone)

Hypothalamus
Hypothalamus
GnRH
Travels via
portal blood

Positive
feedback exerted
4
by large in
estrogen
output.

Anterior pituitary

LH surge
FSH

LH

Ruptured
follicle

3Slightly

elevated
estrogen
and rising
inhibin
levels.

Progesterone
Estrogen
Inhibin
8

Thecal
cells
Granulosa
cells
Inhibin

Androgens

Convert
androgens to 2
estrogens
Early and midfollicular phases

Mature follicle

Corpus luteum
Ovulated
secondary
oocyte
Late follicular and
luteal phases

LH and FSH Theca &

Granulosa cell

Thank you