active management of infertility

ActiveActive
ManagementManagement
Of InfertilityOf Infertility
• Dr Muhammad El Hennawy
• Ob/gyn Consultant
•
• Rass el barr central hospital and
dumyat specialised hospital
• Dumyatt – EGYPT
• www. mmhennawy.co.nr

• This Lecture explains my personal opinion
• In spite that this lecture contains medical
evident informations
• If you accept this lecture,
take it as a science
• If you do not accept it,
take it as a fun

• Infertility is faliure of a couple to concieve
with continous coitus without use of
contraception
for one year if (primi ) age below 35y
for two year if (multi ) age below 35y
For six monthes if age above 35y
For immediate if age above 40 y
• Delayed Conception is faliure of a couple to
concieve with continous coitus without use of
contraception
When they or one of them come to complain at any
time
(may be infertility or before it )

• most newly married couples are asked
sometimes even as soon as they have returned from the
honeymoon !
• There is a lot of pressure on couples to have a baby,
especially in traditional families, where the wife's role
is still seen to be one of perpetuating the family name
by producing heirs.
• Many couples still naively expect they will get
pregnant the very first month they try ( the result of
watching too many films , perhaps !) - and are
concerned when a pregnancy does not occur.
• All of us go through a brief interlude of doubt and
concern when we do not achieve pregnancy the very
first month we try and we start wondering about our
fertility.

Warning over delayed conception
• Women who spend a long time unsuccessfully trying for
a baby could face problem births once they do finally
become pregnant.
The finding, from Danish researchers, applies equally to
natural conceptions and those due to fertility treatment.
A total of 56,000 births were analysed - thsoe conceived
after more than a year of trying were more likely to be
born early or need caesarean section.
The study was published in the journal Human Reproduction.

The properties of the fecund male
include
1) Normal spermatogenesis and ductal system
(normal count, motility, and biologic
structure/function
2) Ability to transmit the spermatozoa to the female
vagina, through :
• - Adequate sexual drive
• - Ability to maintain an erection
• - Ability to achieve a normal ejaculation
• - Placement of ejaculate in the vaginal vault

The properties of the fecund female
include
• 1) Adequate sexual drive and sexual function to permit coitus
• 2) Functioning reproductive anatomy and physiology which includes:
- A vagina capable of receiving spermatozoa
- Normal cervical mucus to allow passage of
spermatozoa to the upper genital tract
- Ovulatory cycles
- Fallopian tubes which will function to permit the sperm and ovum
to meet and allow migration of the conceptus to the uterus
- A uterus capable of developing and sustaining the conceptus to
maturity
- Adequate hormonal status to maintain pregnancy
• 3) Normal immunologic responses to accommodate sperm, conceptus,
and fetal survival.
• 4) Adequate nutritional, chemical, and health status to maintain
nutrition and oxygenation of placenta and fetus

FERTILITY AND DURATION OF
MARRIAGE FOR
COUPLES WITHOUT
CONTRACEPTION
• 25% of pregnancies occur within 1 month
• >60% of pregnancies occur within 6 months
• 75% of pregnancies occur within 9 months

While women under age 30 have
approximately a 20 percent per month
chance of conceiving, only 5 percent of
women over age 40 will conceive
• The fertility potential of the average woman begins to
decline appreciably at the age of 35 years, and begins to
decline dramatically beyond the age of 40 years
• The biggest obstacle most women over 40 face is two-fold:
- diminishing ovarian reserve
- coupled with poor embryo quality (the phenomenon of
chromosomal aneuploidy )

the effects of paternal age on a
couple's fecundity
• They are real and may be greater than previously believed.
• After adjustment for other factors, the probability that an
ultimately fertile couple will take >12 months to conceive
nearly doubles from ~8% when the man is <25 years to
~15% when he is >35 years
• paternal age is a further factor to take into account when
deciding the prognosis for infertile couples.
• What Age Does to Sperm
• Decreased Motility
• Decreased Strength
• Decreased Potency
• Altered Genetic Make-Up

• Infertility is faliure of a couple to concieve
with continous coitus without use of
contraception
for one year if (primi ) age below 35y
for two year if (multi ) age below 35y
Six monthes if age above 35y
immediate if age above 40 y
• Delayed Conception is faliure of a couple to
concieve with continous coitus without use of
contraception
When they or one of them come to complain at any
time
(may be infertility or before it )

3 Methods Of Management
Rapid ( Active ) Or standard Or
Expectant management Of Delayed
Conception Or Infertility
1 - Rapid ( Active management) in 1 year
2 - standard management ( EBM )
3 - Expectant management in years ( old )

Expectant management Of Infertility
Infertility is always an important problem for the patient
but never an urgent one.
The general attitude is one of “let’s wait and watch” and
let “Nature take its own course”.
Since many couples and doctors know of patients who have
conceived naturally after many years of previously
fruitless marriage,
they commonly adopt this attitude
This approach was acceptable in the past, when there was
so little we could offer in any case for these couple.

When a couple or one of them come to me
complaining of delayed coneption
of any time
• I explain to them or one of them that there is 2
methods of management
1 - Rapid ( Active management) in 1 year
2 - standard management
and I let them to choose after my explaination

Standard Management Of Infertility

Rapid ( Active ) management Of Delayed
Conception Or Infertility
• It is worthwhile drawing an analogy to the current
management of labour and childbirth.
• In older days, when no drugs were available, doctors
were often forced to wait and watch.
• They could do little to intervene and it was common for
labours to last for over 2-3 days often resulting in
stillbirths and even maternal deaths.
• With the advent of drugs like oxytocin and
prostaglandins, all that has changed!
• Obstetricians now take an active approach to provide a
favourable outcome in a quicker time frame.

• Today, unfortunately, the investigation and
management of infertility still leaves a lot to be desired.
• It is often slow, time-consuming and costly. The
infertile couples are seldom seen together.
• Investigations are performed in a piecemeal fashion
rather than as part of an overall strategy.
• Doctors are also keen to “do something” and repeated
curettages and laparoscopies (done unnecessarily) are a
common feature in the medical history of these hapless
couples.
• Also, myomectomies may be performed for small
fibroids; ovarian cystectomy and wedge resections done
for simple ovarian cysts which should have been left well
alone; as well as “uterine ventrisuspension” when all else
fails.
• These procedures commonly induce adhesions and
damage a previously normal pelvis.

• Both patient and doctor suffer from the inefficient
treatment of this problem.
• The doctor feels inadequate and unable to help his
patient, and trust between the doctor and patient breaks
down.
• The temptation to try many empirical, possibly useless
medical treatments is considerable; and patients often
end up spending large sums of monies at the hands of
quacks and “spiritual healers”.
• This is why taking an active success-oriented approach
to infertility is important today.
• The couple must be seen together and treated as a unit.
The workup to establish a diagnosis should be completed
in 1 months.
• The timing of the procedures is important, and we have
found the following strategy cost-effective.

Why active is preferable !!
Active Versus Standard And Expectant Management
• 1. Couples today marry at an older age.
Their biological time clock is running out
and we often need to accelerate events
we cannot sit back and wait and watch.
• 2. Effective treatment is available today to enhance
Nature’s efficiency
(or rather its inefficiency in the case of these
couples).
This treatment must be judiciously employed, to give
couples their best chance.

Age-related decline in fertility
• A decrease in the number and health of the eggs to
be ovulated.
• A decrease in sperm counts.
• A decrease in the frequency of intercourse.
• The presence of other medical and gynecologic
conditions, such as endometriosis, which may
interfere with conception.

• in less than 15 - 30 days ! They just need to make 3
visits to the clinic, thus saving a lot of time, money
and energy.
• a detailed medical history from the couple, and also
performs a physical examination for both of them, to
determine if this can provide clues as to the cause of
the problem.

Investigations
Start at the time which they come in it and regulate other times to end
all these investigation in 15 - 30 days
• Semen analysis (during the wife’s menstrual period)
• FSH, LH, TSH, Prolactin Blood Tests ( at third day from beginning
of cycle)
• Hysterosalpingogram ( at Fifth - seventh day from beginning of
cycle)
• Vaginal Ultrasound For Ovulation Monitoring And Assessing
Endometrial Thickeness And Texture ( at eleventh - sixteenth day
from beginning of cycle)
• Serum Progesterone Level For Ovulation ( at twenty-one day from
beginning of cycle)

Some doctors will perform further testing
during the rest of the month, though we
rarely do these tests in our own practise
• They include: ultrasound scans for ovulation monitoring
between Day 11-16 ; and the scan results can be used for
timing the PCT (postcoital test) as well, during which time
the cervical mucus is assessed also.
. Some doctors will also performed a laparoscopy in the same
month (Day 20-25) ; and combine it with an endometrial
biopsy , if desired

Treatment
• All these ttt takes only one year
• Timed intercourse, 6 cycles;
• Intrauterine insemination (IUI)- 4
cycles;
• Superovulation with HMG plus IUI -3
cycles;
• then IVF or GIFT. Don’t waste time!
As a rule of thumb, if a treatment is
going to work, it should work in 4
cycles.

• While no one can predict what the out-come
of treatment is going to be for any infertile
couple,
• at the end of it all,
• they should at least have the satisfaction of
knowing that they tried everything that was
possible.

What is your Opinion???
1 - Rapid ( Active management)
2-standard management
3 - Expectant management

active management of infertility

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