Failure to conceive of 1 year of unprotected sexual Menarche, succeeding menstruation, interval contact meaning the couple is not practicing any between the cycle (28 , 28 – 32, 32 – 35) artificial or natural form of family planning IMPT to know: interval of the cycles to be able to IF >35: investigation should begin AFTER 6 months predict when ovulation will occur. o In 28 day cycle: Expected ovulation D14 nd Classification: because the 2 half of the cycle is more 1. Primary - Never had any pregnancy constant due to lifespan of Corpus luteum. 2. Secondary – Had been pregnant either abnormal or o In 35 day cycle: Expected ovulation D21 normal as G1P0 (0010) or G1P1 (1001) As long as the woman got pregnant regardless of the Past Personal History outcome of the pregnancy labeled as GRAVIDITY. Especially for the male, ask for childhood diseases particularly "MUMPS ORCHITIS" Regardless of whether it is primary or secondary, it will follow a similar pattern. Past Medical History: Previous abdominal & pelvic surgeries History Taking: (appendectomy, ovarian surgery, laparoscopy): First visit: Ideally should be a couple, Assess risk for adhesions (Peritoneal factor) First part: Investigative: who is at fault? First explain: Physiology Physical Exam: IMPT: Correct attitude of the couple – PATIENCE Aside from pelvic examination, is there any particular The past history may give inkling, like if the organ needed to check? menstrual history is very erratic chances are the woman in anovulatory. Even if by menstrual history, Breasts: I know she is anovulatory, I cannot give outright Breast changes During Menses anovulatory drugs. Why? I will make her ovulate but Breast changes are affected by which hormone is if her tubes are obstructed, ovulation is useless. predominant. Right after the menstrual cycle the breast are non-tender & less engorged. But as you General Data: go to the secretory phase, with the effects of E + P, Age breasts become fuller & tender. Female: Fertility rate by age 30 goes down by 50% That’s why during PE, do not examine the breast Male: Perhaps on the 60’s related to erectile pre-menstrual. Take note when was the LMP? dysfunction, esp. if diabetic becoming impotent Example: LMP - June 25. Today - July 23 Perhaps in a Occupation: Male (Hot Seats, OFW – gone for day or so, she is expected to get her period. If she several years) has OVULATORY cycles, you will expect to feel more engorged tender breast. HPI: IMPT: PREMENSTRUAL gives inkling that her cycles It’s not about how long have you been married but are OVULATORY. how long have you been together? How long have you indulge in sexual activity? Thyroid Gland: What do you do to try to get pregnant? HYPO/ HYPERTHYROIDISM Ask for PMH, Signs & Symptoms Sexual Hx: Frequency of sexual contact. The normal average There are 3 basic work-up for infertility: should be 2 – 3x/week due to the 72 hours lifespan 1. Male Factor: Semen Analysis of the sperm inside the uterine cavity for continuous 2. Tubal Factor: Test for Tubal Patency supply of sperm. It must be per week because you 3. Ovarian Factor: Documentation of Ovulation are actually given a day to get pregnant in a month (time the woman ovulates). So if you have contact MALE FACTOR (Semen Analysis): day before ovulation, the sperm is expected to live Male Factor: 40% cause of infertility (Dr. PPP & PGH) th until the day of ovulation. 25% (Katz Book 6 Ed) Mumps – Adults: Swelling of Testes Problem: Dyspareunia (Sx: Endometriosis) Infections – STD: Testes, vas deferens, epididymis After sexual contact the seminal fluid has nowhere Diabetes – Affects the nerves to go except to come out from the vagina on the Exposure to radiation & chemotherapeutic agents premise the sperm cells have already migrated into the uterine cavity & perhaps into the fallopian tube. st 1 thing to do: Semen Analysis (volume, sperm The seminal fluid is not expected to go inside the count, motility & morphology) cervix. Table 41-4 Lower Fifth Percentile Values in Fertile Men OFW: be discrete in asking questions. Have you had Parameter Value Problems a child with another or STID? Semen volume (mL) 1.5 Sperm concentration (million/mL) 15 Total number (million/ejaculate) 39 Oligo/Azoospermia Total motility (%) 40 Asthenospermia Progressive motility (%) 32 Normal forms (%) 4 Teratospermia Requirement: 2- 3 days of abstinence (natural: OVARIAN FACTOR (Documentation of Ovulation) sexual contact & artificial: masturbation) Presumptive Evidences of Ovulation: GOOD: 30 M, 50% motile 1. Menstrual History NOT GOOD: 50 M, 10% motile To know if the cycle is ovulatory: Start by Menstrual Hx If abnormal: REFER to URO (Infertility Specialist) If the cycles are regular, periodic & predictable, http://www.rrc.com/docs/Testing_Male-Fact.pdf these are usually preceded with PREMENSTRUAL Book: MOLIMINA which predicts the impending ovulation & Best to examine within 2 hours subsequent menstruation. Liquefaction: 15 – 20 minutes after ejaculation Premenstrual Molimina: are the symptoms, Sperm morphology: Kruger Criteria sensations, feelings, & observations, such as bloating, headaches, nausea, ovulatory pain, & TUBAL FACTOR (Tubal Patency): breast tenderness that many women experience History needed for tubal patency: previous during the premenstrual phase of their cycles. operation like appendectomy (formation of adhesions) or endometriosis (peritubal adhesions) 2. Changes in Cervical Mucus: Spinnbarkeit & Ferning PID, Thyroid Fever, TB Salphingitis There are certain predictors of ovulation. Looking back at physiology: Test for Tubal patency: 1. Hysterosalphingography, a radiologic procedure by introduction (injection under fluoroscopy) of contrast material (black dye) through the cervix, fill up the uterus, traverse to the tube & out to the pelvic cavity Done a week AFTER menstruation Give prophylactic antibiotics at time of HSG: Doxycycline 100mg BID for 3 days (will last for 4 days) http://www.rrc.com/docs/hsg.pdf
2. Sonohysterogram or sonohysterography: inject
saline to the cervix, filling up the endometrial cavity. What will you see will be the turbulence due to the exit of saline through the tube After menstruation there will be a rise in estrogen in UTZ: Fluid in the cul de sac FOLLICULAR PHASE under the effect of FSH. The follicles will start producing Estrogen causing 3. Laparoscopy + Chromotubation proliferation of endometrium. Because of the peak Chromotubation is very similar to hysterogram in E just before the menses (D12-D13) there will be except the dye is a colored dye usually methylene CHANGES IN THE CERVICAL MUCUS. The cervical mucus blue (need to have a vision of pelvic cavity directly) will undergo 2 changes: Can also be: Laparotomy + Chromotubation- Open Spinnbarkeit reaction Ferning test abdomen
Among the 3 tests for tubal patency, the most basic
test used is HSG. But if patient is OLDER: Age 35 – 36, do a more aggressive work up, proceed straightforward to L + C to be able demonstrate peri-tubal adhesions & outright lyse Pre- Mucus is clear, watery & easily Estrogen the adhesions. ovulatory stretched Post- Mucus is whitish/ opaque, can Progesterone Other Notes: ovulatory break, beaded If tubes are patent: IUI If you notice these changes, then most likely you If tubes are not patent: Microsurgery, Salphingectomy, IVF might be having ovulatory cycles so this is the time to schedule for contact. These will not tell that a woman, she is going to TREATMENT: ovulate. It will only tell the presence of high E level If the 3 basic work–ups results are normal, the treatment that will be the trigger for the secretion of LH. may simply start by telling the couple when the RIGHT Remember, ovulation is the effect of LH surge. time to have contact is/ TIMING of sexual contact.
3. Biphasic Basal Body Temperature IF Ovarian Factor: Anovulation
Not used anymore PCOS (Rotterdam Criteria 2/3: Infertility, O O After menses: 36.8 C - 36.9 C Hyperandrogenism, Chronic Anovulation) After ovulation: rise due to thermogenic effect of Thyroid, Hyperprolactinemia PROGESTERONE, TX: Induction of ovulation, Ovulatory drugs O If the woman will have her menses: DROP in C If the woman will be pregnant: continuous rise 1. Clomiphene Citrate (ANTI-ESTROGEN) because of the progesterone coming from the Most popular drug to induce ovulation Corpus Luteum & eventually to be taken over Family of Tamoxifen by the placenta Works if there is ENOUGH Estrogen Presence of Biphasic rise in temperature will tell Will not work IF lacks E2 most likely she has ovulatory cycle Easy to administer:, 50 mg - 150 mg taken on D3 - Use: Ovulation thermometer which only have 36 - D7 of the cycle per orem (worth: P280) O 38 C. As soon as the patient wakes up, sticks it Do an UTZ to monitor the response under the tongue & document daily (D1 to Last Day Hypothalamus of menses) •GnRH Documentation of Ovulation: 4. Serial Follicular Monitoring Pituitary Most practical (Sonographic) •FSH & LH In a patient with a regular cycle, try to look at the ovary starting D12. UTZ will tell if there is a dominant follicle which measures: 16 mm to 18.5 Ovarian mm at D14. Then if at D16: < 10 mm, that will tell •Estrogen & Progesterone that the woman must have ovulated. If you know at what diameter the follicle will rupture, you’ll be able to predict when she is going Pituitary Glands will produce the gonadotropic to ovulate. A dominant follicle measuring 18 - 22 hormones: FSH & LH which will act on the ovaries mm will most likely ovulate. for the stimulation & development of the follicles. Take note of: These follicles would produce E. i. ↓ in Size of the Dominant Follicle Too much E would trigger the Negative Feedback ii. Presence of the Fluid in the Cul de sac because mechanism to stop the production of FSH. with the extrusion of the egg from the ovary, there will be a leakage of the antrum folliculi Clomiphene Citrate Stimulation: that will stay in the cul de sac. No negative feedback mechanism iii. Change in the Endometrial Lining. If the woman Level of E will not be increase due to the anti- ovulated in D14 – 15, by D16 observe the estrogenic effect. So the hypothalamus cannot changes in the endometrial lining from sense the level of E & will keep producing GnRH, Proliferative to SECRETORY PHASE. increasing both FSH & LH. Result: ↑ in the # of follicles ↑ chance of 5. Endometrial biopsy ovulation The presence of secretory endometrium telling that Drawback: Multi-fetal Pregnancy, Twinning a woman had ovulated because a woman will never have a secretory endometrium in the absence of 2. Gonadotropins progesterone. Given if with Pituitary Failure Exogenous FSH & LH O 6. Serum progesterone assay 1 indicated: HYPOGONADOTROPIC (Lack FSH & LH) ↑ Progesterone: woman must have ovulated Administer: Parenteral (IM/SC), No oral preparation In practice, cannot be given to any general GYNE but Most will use serial follicular monitoring to only the infertility specialist because the problem is determine whether ovulation has taken place or not. development of OVARIAN HYPERSTIMULATION SYNDROME wherein the ovaries grow in size. Ovulation Usually drugs for those who will undergo IVF TVS: Antral Follicle Count (>5 follicle/ ovary) SE: Multi-fetal pregnancy, TWINNING AMH – Most sensitive, secreted by granulosa ↑ Age: ↑ FSH ↓ AMH Other Notes: LH Level: Urine Kit Metformin – An Adjunct Insulin Sensitizer GnRH – Given if Hypothalamus is not working Unexplained infertility/ Idiopathic PCOS – oral/injectable Last Resort: Surgery IVF IF Normal Basic work – ups Do Laparoscopy + Chromopertubation: Check for Lesions Among the factors in infertility, the easiest factor to TX: Clomiphene, IUI, IVF (IF >35: do IVF Right Away) treat is the OVARIAN factor. IF Turner's Syndrome (Ovarian Agenesis) Treatment: Can get pregnant but not of her own The only way is to change your husband Does not have primordial follicles (atrophied) Try to lower the antibodies in the female by abstinence or use condoms IF Tubal Factor: Nowadays, the sperms will no longer be deposited IF Distal tubal obstruction in the vagina but directly into the endometrial cavity TX: Tubal Plastic Surgery (Micro) called INTRAUTERINE INSEMINATION (IUI) – the Salphingostomy (Ostomy: opening) seminal fluid collected will have to go to a Try to open the fimbriae by invert the end of the processing called: sperm wash or sperm swim up tube (Like a bulb becoming a flower) which means trying to clear the seminal fluid of debris & will only collect best sperm cells. This is If with HSG, you see part of the tube is part of ART. normal but it ends in the middle (obstruction) TX: Supplement HSG + Laparoscopy & do anastomosis UTERINE FACTOR Presence of polyp, submucous myoma IVF: Remember after fertilization, in a few days the egg Nowadays. IVF discovered primarily for a patient will go down into the endometrium which is now whose tubes are obstructed. going to termed as the DECIDUA for implantation. In Vitro (Outside), Layman: Test Tube Baby Sometimes this endometrial lining is not fertile for Success Rate: 30% chance to be able to get implantation If this endometrium is not suitable for pregnancy implantation, no pregnancy will happen. Test: Endometrial Biopsy Procedure: Most common problem as a Luteal Phase Defect. 1. Ovarian Hyperstimulation - to produce a lot of eggs 2. Oocyte Retrieval PERITONEAL FACTOR Via UTZ – try to get an egg from the ovary then The ability of the distal end of the tube to pick up place in the TT or petri dish with sperm (the seminal the egg. The distal end of the tube has fimbriae fluid will have to undergo sperm washing or sperm (finger like projections), when the woman ovulates swim –up) & make them fertilized on their own this fimbriae will detect that there is an egg 3. Fertilization available for pick-up. So at the time of ovulation this 4. Embryo Transfer – Back into the endometrium fimbriae will keep on moving, trying to pick the egg termed as TUBAL PICK-UP MECHJANISM ICSI: Intra-cytoplasmic Sperm Injection So if there is anything here (adhesions) that the tube If there is failure of IVF cannot move, that egg will not find its place inside the fallopian tube Cryopreservation Do the fertilization directly by introducing the sperm When will you suspect? In patients with into the cytoplasm of the egg Endometriosis (adhesions around the tube) or previous PID This may be also the option if the problem is the CASE 9 peritoneal factor. A lot of patients with 31 year old, married G1P1 (1001), vendor, wants to be endometriosis do IVF to attain pregnancy. st pregnant. She has been married for 3 years. Her 1 child was with another partner. Her husband is a 33 y/o, truck driver. He OTHER FACTORS: also has a 10 y/o child with a previous partner. She has regular CERVICAL FACTOR menses. PMH: 2008 – diagnosed with PID, treated as an Character of Cervical Mucus outpatient. PPE: Speculum: cervix pink, smooth. IE: cervix – IF maybe laden with macrophages because of an firm, long, closed; uterus – normal size: adnexa – no mass/ infection in the lower genital tract, this may be tenderness hostile to the sperm. It will kill the sperm & none Category: Secondary Infertility would swim – up the endometrium. Possible Cause: PID Sometimes the cervical factor is being alluded as the Factors involved: cause of a woman who seems to be normal after Tubal: Obstructed tube from intraluminal infection evaluating the 3 basic factors (Male, Tubal & Peritoneal: Adhesions from the distal end of the Ovarian). We may think of the wife developing tube antibodies against the sperms of the husband Test: Laparoscopy Look into the pelvic cavity Test: Post-coital Test (SIM HUHNER'S TEST) The tubes may be patent but if they don’t move, No longer used that egg will never find its place in the tube. Ask the couple to have contact at 7 am, by 10 am Only after knowing the cause that you will be ready retrieval of some seminal fluid from the vagina & to treat the patient, otherwise you’ll fail. placed in a slide. Check whether there are still Work-ups motile sperms present Do Semen analysis (sperm count changes every 72 IF all the sperms are dead, most likely the cervical days) factor is involved. Do HSG. Additional Notes from Dr. Dee 2013 (KQ ) For those who will be under Dr. PPP, please hide this. She likes to browse thru your reviewer if she sees it on your table
(Palgrave Studies in Animals and Literature) Wendy Woodward, Susan McHugh (Eds.) - Indigenous Creatures, Native Knowledges, and The Arts - Animal Studies in Modern Worlds-Palgrave Macmillan (2017)
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