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Lab Session 3 - Infertility

The document outlines standard operating procedures for evaluating and treating infertility in Oman, including conducting diagnostic workups, offering treatment options such as ovulation induction drugs and intrauterine insemination, and providing referrals to specialty clinics or IVF centers if initial treatments are unsuccessful. Guidelines are provided for screening infertility patients, investigating causes of infertility for both male and female partners, and determining appropriate treatment pathways.

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Meme 1234
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35 views28 pages

Lab Session 3 - Infertility

The document outlines standard operating procedures for evaluating and treating infertility in Oman, including conducting diagnostic workups, offering treatment options such as ovulation induction drugs and intrauterine insemination, and providing referrals to specialty clinics or IVF centers if initial treatments are unsuccessful. Guidelines are provided for screening infertility patients, investigating causes of infertility for both male and female partners, and determining appropriate treatment pathways.

Uploaded by

Meme 1234
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Lab Session 3: Subfertility

(1 hr)

Ms. Marina
Learning Objective

1. Demonstrate an
understanding of
the infertility
standard operating
procedures in
Oman
Review: Definition and classification
❑Primary infertility

❑Secondary infertility
THE MINISTRY OF HEALTH
SPECIALTY - POLYCLINIC

Basic Services for Infertility

1. Educate on infertility causes and prevention


2. 2. Conduct
Conduct appropriate
appropriate diagnostic
diagnostic workup
investigations
and “work-up”

3. Offer information and treatment options

4. Provide referral and resources for


counseling and emotional support
AL WATTAYA OBS/GYN
POLYCLINIC
Guidelines for Screening Infertility Couple
Choice of Patients:
❑Primary infertility – married and living with husband for 1
year or more
❑Secondary – infertility more than 3 years
❑Secondary infertility less than 3 children with same
husband
❑Patient with major medical problems e.g. complicated
diabetes, cardiac diseases should be referred to to the
specialty clinic for clearance to conceive
AL WATTAYA OBS/GYN
POLYCLINIC
Guidelines for Screening Infertility Couple
Investigations:
❑Primary infertility – married and living with husband for 1
year or more
❑Secondary – infertility more than 3 years
❑Secondary infertility less than 3 children with same
husband
❑Patient with major medical problems e.g. complicated
diabetes, cardiac diseases should be referred to to the
specialty clinic for clearance to conceive
Fertility “Work-up”

Male Factor
Causes and Investigations
If cycles are regular
•Serum progesterone (Day 21)
•If > 30 mmol/L –ovulation occurring
•If < 30 mmol/L – suggestive of
anovulation

If cycles are irregular /amenorrhea


Assessment of of associated with Galactorrhea
ovulation • Do LH, FSH, TFT, Prolactin levels

If hirsuitism is present
• Do serum testosterone
•If > 5 mmol/L – do DHEAS and 17
OH progesterone
What does the thyroid gland do?
❑ Every cell in the body
depends upon thyroid
hormones for regulation
of the body's
metabolism, blood
calcium levels, energy
production, fat
metabolism, oxygen
utilization, balance of ❑ The thyroid gland is located near
the front of the throat, just below the
other hormones &
voice box & just above the collar
weight maintenance. bones.
How does hypothyroidism affect fertility?
❑ Anovulatory cycles – not releasing an egg / ovulating. This
makes pregnancy impossible.
❑ Luteal Phase Problems – with a short second half of the
menstrual cycle a fertilized egg can't implant securely and ends
up leaving the body at the same time that menstruation would
occur (very early miscarriage) & is often mistaken as a regular
period.
❑ High Prolactin Levels – due to elevated levels of Thyroid
Releasing Hormone (TRH) and low levels of Thyroxine (T4)
resulting in irregular ovulation or no ovulation.
❑ Other Hormonal Imbalances – reduced sex hormone binding
globulin (SHBG), estrogen dominance, progesterone
deficiency, all of which interfere with proper reproductive
hormone balance.
Dehydroepiandrosterone Sulfate
(DHEAS)
❑ In women, concentrations of DHEAS are often measured,
along with other hormones such as FSH, LH, prolactin,
estrogen, and testosterone, to help diagnose polycystic
ovarian syndrome (PCOS) and to help rule out other causes of
infertility, lack of menstrual period (amenorrhea), and presence
of excess facial and body hair (hirsutism).

❑ DHEAS levels may be ordered with other hormones to


investigate and diagnose the cause of the development of
masculine physical characteristics (virilization) in young girls
and early (precocious) puberty in young boys.
Causes and Investigations (con’t)
If ovulating
• Do pelvic assessment with
Laparoscopy and dye
hydrotubation if indicated

Assessment of If uterine pathology is


suspected
of tubal factor • Do HSG/Hysteroscopy

If patient is suspected with


tubal disease
• Do laparoscopy +
Hydrotubation before
commencing any treatment
Hydrotubation
❑ A medical procedure in which a liquid-medicine filled tube is
injected through the cervix into the uterus and fallopian tubes.
❑ The method that transfuses the methylene blue or saline from
cervix into the uterine cavity. When it flows into the fallopian
tube, it can make a diagnosis of tubal occlusion at the same
time, with a certain pressure of the liquid, the obstruction then can
be restored.
Causes and Investigations (con’t)
If patient has anovulatory
cycles
• For induction of ovulation for 6
months, without evaluating
Assessment of tubal factor
of tubal factor
If no conception after 6 cycles
of induction of ovulation then
proceed with laparoscopy +
ovarian drilling if indicated
Laparoscopy and Ovarian Drilling
Laparoscopy and Ovarian Drilling
❑ Laparoscopic ovarian drilling is a surgical treatment
that can trigger ovulation in women who have
polycystic ovary syndrome (PCOS).

❑ Electrocautery or a laser is used to destroy parts of the


ovaries that would temporarily destroy certain portion
of the ovary to help decrease excess amounts of
androgen.

❑ The woman may start ovulating again, but for a short


period. Once healing takes place, the usual pattern of
menstruation will resume
Causes and Investigations (con’t)

Assessment of Semen analysis should be


of male factor advised on the first visit
Sperm/ Semen Analysis
It is the basic analysis done for men to detect some
abnormalities which affects fertility.
- Test for number and motility of sperm
The following are necessary to teach by health care workers:
❑ Tell the client to avoid smoking, alcohol intake and drugs
before taking the laboratory exam.
❑ The client needs to have 2-4 days of abstinence and collect
the specimen as close as possible to usual sexual activity.
❑ Transport within an hour after collection
❑ Maintain at body temperature
Exam may be repeated 1-3 months
Review: Box 8.3 (pp. 176) (Pilliterri) as reference
Treatments

Male Factor
Treatments for Female Infertility
• Maintain normal body weight
• Clomiphene
• Metformin
• Gonadotropin therapies
• Laparoscopic ovarian drilling
Ovulation-Inducing Drugs:
Clomiphene
❑Chemically stimulates pituitary gland to produce
hormones that trigger ovulation process
❑Numerous side effects
❑May not be appropriate for patients with:
❑ Large fibroid tumors
❑ Ovarian cysts
❑ Liver problems
Ovulation-Inducing Drugs:
Clomiphene
Guidelines for Prescription:
To be given by registrar only
❑Start with 100mg orally daily from D2 to D6
❑Ovulation is checked with D21 (for serum progesterone )
❑If serum progesterone is <30 mmol/L increase the dose in
subsequent cycle (maximum dose 200mg)
❑Advise the patient to have intercourse every other day from D10
for at least 1 week and to maintain menstrual calendar
❑If patient fails to conceive after 3 cycles of ovulatory dose of
Clomiphene, offer another 3 cycles which can be combined with
Follicular study + IUI (Intrauterine insemination)
❑If no conception by 6 months, then refer the patient to special
infertility clinic (Saturday appointment)
Treatments for Female Infertility
(continued)

• Intrauterine insemination
• With or without salpingectomy
• Protubation
• Tuboplasty (tubal ligation
reversal)
Indications for intra-uterine
insemination
❑Oligo-asthenospermia (decreased sperm
motility)
❑Unexplained infertility
❑Presence of sperm antibodies
❑Cervical mucus problems (too acidic)
Refer to special infertility clinic
Guidelines for referral:
❑Severe endometriosis
❑Unexplained infertility
❑Male factor severe
oligospermia
❑Failed to conceive with IUI
Refer to IVF Center
Guidelines for referral:

❑If patient has bilateral


tubal disease/block
Conclusion
THERE IS NO ONE RULE TO TREAT INFERTILITY
• It usually takes a while for most couple. Infertility should be
evaluated after one year of unprotected intercourse.
• History and Physical examination usually will help to
identify the etiology.
• If patients fail the initial therapies then the proper referral
should be made to a reproductive specialist.
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