Understanding Subfertility: Causes, Diagnosis, and Management

University of
 
Basrah
Al-Zahraa 
Medical
 
College
Ministry of 
higher
 
Education  
and
Scientific
 
Research
GYNAECOLOGY 20th
 
EDITION by Ten Teachers
REPRODUCTIVE SYSTEM MODULE 
Session:     7
Lecture:     3
Duration : 1 hour
SUBFRTILITY
Presented by
Dr.RAYA MUSLIM AL HASSAN
Module staff:
Dr.Raya Muslim Al Hassan (module leader)           
Dr.Nada H Al Jassim
Dr.Alaa Hifthi
                                                               
Dr.Nawal Mustafa Abdulah
Dr.Marwa sadik                                                           Dr.Nehaya Mnahi Al Aubody
Academic year 2021-2022
3
rd
 year S 5
 
What is subfertility
?
 
Subfertility is the failure of conception in
a couple having regular, unprotected coitus
for  1 year
 
PRIMARY
 – Couple without a prior pregnancy
SECONDARY
 – Couple with previous pregnancy including
miscarriage/ectopic
 
75-80% of couples there will be pregnancy after 12 cycles
90-95% of couples will be pregnant after 2-3 years.
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
Causes :-
A - Female  30%
 
1- 
ovulatory disorders : -
 The
 
commonest
 
cause is polycystic
 
ovary syndrome
 
(PCOS)
Hypothalamic
 
disorders
 
e.g. Hypothalamic
 
hypogonadism) .
Pituitary disease
 
(e.g. Hyperprolactinaemia).
Endocrine abnormalities (thyroid
 
disease) .
 
2- Tubal factors :- 
 
(PID, previous surgery, endometriosis)
3- Uterine factors :- 
 
(fibroid, adhesions)
4-
Peritoneal (endometriosis).
5- 
Cervical factors .
 
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
B -
Male 30%
Compromised sperm number or
 
quality
 
is an important
 
contributor to
subfertility. ( Mainly unknown cause )  .
 
- Possible causes :-
Environmental and dietary issues.
Infections :- ( Orchitis , epididymitis )
Iatrogenic :- pelvic radiotherapy or surgery for
 
undescended
 
or
 
torted
 
testes .
Medical conditions such as diabetes .
Occupational factors :- 
 
contact with chemicals  , radiation or
heat  .
Erectile difficulties or problems with ejaculation.
Genetic : aneuploidy of sex chromosomes (Klinefelter
 
XXY most
 
commonly)
C - 
Mixed    15%
D -
Unexplained 25%
 
 
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
History & examination
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
INVESTIGATIONS
 
 
Female
Assess ovulation .
Tubal patency .
Uterine abnormality .
 
 
Male
Semen analysis .
Hormonal analysis(T,
FSH, LH) +/-Karyotyping
 
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
ASSESSING OVULATION
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
     
1)History
 (regular cycle, dysmenorrhoea, breast engorgement)
       
2)Basal body temperature chart
       3)Hormonal study
           -Serum progesterone  (mid luteal
            phase ie day 21 of 28-days cycle)
           - LH/FSH levels
           -E2, Testosterone levels – PCOS
          -Prolactin
          -Thyroid tests
          - 
Serum AMH
 
 
 
 
4) Ultrasound
 
  Assess ovulation
 
(
b
y tracking the size of follicle)
 
U/S of 
the ovary at  day
13  of cycle showing the
pre- ovulatory dominant
follicle  size of 20 mm
(normal  18-22 mm)
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
ASSESSING UTERINE/TUBAL
PROBLEMS
 
Hystero-Contrast -
Sonography (HyCoSy)
 
 
 
HSG/hysterosalpingoigr
aphy
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
Laparoscopy + dye test (chromotubation) if tubal
blockage seen in HSG
 
 
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
Laparoscopy
 
ASSESSING PERITONEAL FACTORS
 
endometriosis
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
INVESTIGATIONS (MALE)
 
Semen analysis
Needs prior appointment with
lab
Abstinence 2-4 days.
Complete collection of the
semen
Transport to lab in 1 hour
Put it in incubator 37˚c or at
room temperature.
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
TREATMENT
 
 Fertility treatment should be individualized
 
to
optimize the treatment result, Management may
be expectant, medical,
 
surgical or
 
combination of
these.
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
OVULATION INDUCTION
 
1) Normogonadotrophic anovulation (PCOS).
     Anti- oestrogens e.g Clomiphene/ Tamoxifen
     Metformin
     Gonadotrophins
2) Hypogonadotrophic hypogonadism
    Pulsatile GnRH
    Gonadotrophins with LH activity
    Bromocriptine ( for hyperprolactinaemia)
3) Laparoscopic ovarian drilling
4) Luteal phase support-progesterone
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
Peritoneal/Uterine/tubal problems
 
Endometriosis
:Laparoscopic surgical ablation/
resection of spots + adhesiolysis .
 
Uterine factors
: hysteroscopic adhesiolysis for
Asherman’s syndrome ,myomectomy for fibroid .
 
Tubal factors: 
 Laparoscopic tubal surgery or IVF .
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
Treatment of male subfertlity
 
According to the cause
 
 
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
Intra-uterine insemination(IUI): injection of
activated semen inside the uterus by a catheter
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
 
University of
 
Basrah
Al-Zahraa 
Medical
 
College
 
Ministry of 
higher
 
Education  
and
Scientific
 
Research
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Subfertility is defined as the failure to conceive after one year of regular, unprotected intercourse. Causes include ovulatory disorders, tubal factors, uterine factors, male factors, and unexplained factors. Diagnosis involves assessing ovulation, tubal patency, uterine abnormalities, and semen analysis. Management strategies depend on the underlying cause and may include medical interventions, lifestyle changes, and assisted reproductive technologies.


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  1. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Academic year 2021-2022 3rd year S 5 REPRODUCTIVE SYSTEM MODULE Session: 7 Lecture: 3 Duration : 1 hour SUBFRTILITY Presented by Dr.RAYA MUSLIM AL HASSAN Module staff: Dr.Raya Muslim Al Hassan (module leader) Dr.Nada H Al Jassim Dr.Alaa Hifthi Dr.Nawal Mustafa Abdulah Dr.Marwa sadik Dr.Nehaya Mnahi Al Aubody GYNAECOLOGY 20th EDITION by Ten Teachers

  2. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College What is subfertility? Subfertility is the failure of conception in a couple having regular, unprotected coitus for 1 year PRIMARY Couple without a prior pregnancy SECONDARY Couple with previous pregnancy including miscarriage/ectopic 75-80% of couples there will be pregnancy after 12 cycles 90-95% of couples will be pregnant after 2-3 years.

  3. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Causes :- A - Female 30% 1- ovulatory disorders : - The commonest cause is polycystic ovary syndrome (PCOS) Hypothalamic disorders e.g. Hypothalamic hypogonadism) . Pituitary disease (e.g. Hyperprolactinaemia). Endocrine abnormalities (thyroid disease) . 2- Tubal factors :- (PID, previous surgery, endometriosis) 3- Uterine factors :- (fibroid, adhesions) 4-Peritoneal (endometriosis). 5- Cervical factors .

  4. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College B -Male 30% Compromised sperm number or quality is an important contributor to subfertility. ( Mainly unknown cause ) . - Possible causes :- Environmental and dietary issues. Infections :- ( Orchitis , epididymitis ) Iatrogenic :- pelvic radiotherapy or surgery for undescended torted testes . Medical conditions such as diabetes . Occupational factors :- contact with chemicals , radiation or heat . Erectile difficulties or problems with ejaculation. Genetic : aneuploidy of sex chromosomes (Klinefelter XXY most commonly) C - Mixed 15% D -Unexplained 25% or

  5. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College History & examination

  6. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College INVESTIGATIONS Female Assess ovulation . Tubal patency . Uterine abnormality . Male Semen analysis . Hormonal analysis(T, FSH, LH) +/-Karyotyping

  7. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College ASSESSING OVULATION 1)History (regular cycle, dysmenorrhoea, breast engorgement) 2)Basal body temperature chart 3)Hormonal study -Serum progesterone (mid luteal phase ie day 21 of 28-days cycle) - LH/FSH levels -E2, Testosterone levels PCOS -Prolactin -Thyroid tests - Serum AMH

  8. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College 4) Ultrasound Assess ovulation (by tracking the size of follicle) U/S of the ovary at day 13 of cycle showing the pre- ovulatory dominant follicle size of 20 mm (normal 18-22 mm)

  9. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College ASSESSING UTERINE/TUBAL PROBLEMS Hystero-Contrast - Sonography (HyCoSy) HSG/hysterosalpingoigr aphy

  10. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Laparoscopy + dye test (chromotubation) if tubal blockage seen in HSG

  11. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College ASSESSING PERITONEAL FACTORS Laparoscopy endometriosis

  12. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College INVESTIGATIONS (MALE) Semen analysis Needs prior appointment with lab Abstinence 2-4 days. Complete collection of the semen Transport to lab in 1 hour Put it in incubator 37 c or at room temperature.

  13. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College

  14. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College TREATMENT Fertility treatment should be individualized to optimize the treatment result, Management may be expectant, medical, surgical or combination of these.

  15. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College OVULATION INDUCTION 1) Normogonadotrophic anovulation (PCOS). Anti- oestrogens e.g Clomiphene/ Tamoxifen Metformin Gonadotrophins 2) Hypogonadotrophic hypogonadism Pulsatile GnRH Gonadotrophins with LH activity Bromocriptine ( for hyperprolactinaemia) 3) Laparoscopic ovarian drilling 4) Luteal phase support-progesterone

  16. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Peritoneal/Uterine/tubal problems Endometriosis:Laparoscopic surgical ablation/ resection of spots + adhesiolysis . Uterine factors: hysteroscopic adhesiolysis for Asherman s syndrome ,myomectomy for fibroid . Tubal factors: Laparoscopic tubal surgery or IVF .

  17. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Treatment of male subfertlity According to the cause

  18. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College Intra-uterine insemination(IUI): injection of activated semen inside the uterus by a catheter

  19. Ministry of higher Education and Scientific Research University of Basrah Al-Zahraa Medical College

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