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1. Introduction

Contents

1.1

POLICY GUIDLINES

1.2

GLOBAL SITUATION

1.2

SITUATION IN OMAN

1.3

REPRODUCTIVE HEALTH

1.4

GUIDELINES FOR DEALING WITH INFERTILE

COUPLES

1.5 COUNSELLING INFERTILE COUPLES

1.6 REFERRAL

2. UNDERSTANDING INFERTILITY

2.1 DEFINITION OF INFERTILITY

2.2 FACTORES AFFECTING INFERTILITY

2.3 CAUSES OF INFRTILITY FEMALE

2.4 CAUSES OF INFRTILITY MALE

3. MANAGEMENT OF FEMALE INFERTILITY

3.1 EVALUATION OF INFERTILE FEMALE

3.2 UNEXPLAINED INFERTILTIY

3.3 ASSISTED REPRODUCTIVE TECHNOLOGIES (ART)

4. MANAGEMENT OF MALE INFERTILITY

4.2

TREATMENR OF INFERTILE MALE

4.3 PREVENTION OF INFERTILITY

5. APPENDIX

INTRODUCTION:

POLICY GUIDELINES

Since children are an important part of the fulfilling family life of a couple, and because Infertility causes unhappiness, mental stress and social disadvantage to the couple, the Maternal and Child Health & Birth Spacing (MCH &BS) Program of Oman, will like to extend its services to address the needs of the infertile couples. Hence, services for the diagnosis and management of infertility will be provided all over the country as an essential and integral component of (MCH & BS) Services.

The Ministry of Health through its net work of all health centers, extended health centers and hospitals of all regions will provide range of services for infertile couples.

THE SERVICES WILL TARGET

Newly married couples over the age of 20 years that desire to

have a child but have failed after one year of regular unprotected

intercourse.

Married couples with secondary infertility that failed to have a child after two year of regular unprotected intercourse.

THESE SERVICES WILL INCLUDE

I. Counselling: Counseling will be done at all level of health care systems by providers trained in counseling skill

II. Clinical services (clinical evaluation, investigation and management): These services will be provided by trained service providers. However provision of service will vary as per the expertise and professional background of the service provider

III. Follow up:

SERVICES AT DIFFERENT LEVELS

At Primary Health Care Facility

Staff of MCHIBS area will fill in the case history, findings of clinical evaluation and preliminary investigation carried out, on the specific proforma designed for the couple.

PHC service provider will inform the client on the results of investigations, counsel the client and then refer the case to higher health care facility for further evaluation and management.

At Secondary Health Care level

Gynaecologists and dermatologists (and rologists/endocrinologist/urologists if available) of the respective Regional/other major health facilities will team up to deal with the referred cases. Team will review the case records and available investigations and develop a further management plan for the couple.

Based on the need of the infertile couple a detailed work up will be carried out by male clinician in dermatology/andrology clinic for Male partner and similarly by the gynaecologist in gynaecology/ infertility clinic for female partner. If required, consultation may also be done with endocrinologist/urologistisurgeon. All along couple will be kept informed of findings of clinical evaluation, investigations done and their results and management/procedure planned.

At Tertiary Health Care level

Referred case will be clincally re-evaluated, investgation previosly done will be reviewed, and further indicated special tests will be carried out. Information on the ART(assisted reproductive techniques) will be given to the clients. Provision of IUI (intra uterine insemination) with husband sperm will be done on the clients who are willing to avail it. ART available outside MOH will be availed by the client on her own expense.

GLOBAL SITUATION Infertility is a problem that affects men and women everywhere in the world. Although estimates of prevalence rates of infertility are not that accurate, and vary among countries and different populations within countries, world wide about 8% -12% of couples experience some form of fertility problems during their reproductive lives. 50 - 80 million of the populations globally have problem with fertility.

Despite the fact that infertility affects both men and women, yet women, particularly of developing countries, often bear the sole blame for the barren marriage.

A WHO study on 9, 000 infertile couples from 33 clinics of 25 developed and developing countries between 1980 and 1986 found that male were either the sole cause or contributory factor to infertility in more than 50% of infertile couples.

General categories of infertility in developed & developing countries

The table 1

of infertility in developed & developing countries The table 1 Incidence of infertility may be influenced

Incidence of infertility may be influenced by:

Inaccessibility to adequate health care for childbirth and postpartum

Prevalence of sexually transmitted infections and its management

Environmental factors, affecting levels of disease transmission

Occupations of men and women of reproductive age

Exposure to chemical toxins

Nutrition and genetically determined factors.

In most developing countries, the major preventable causes of infertility are sexually transmitted infections and postpartum infection, while in most developed countries, sexually transmitted infections leading to pelvic inflammatory disease and consequently resulting in tubal block and adhesions are the cause. Tubal block alone contributes to 50% infertility in females. Similarly infection of accesory gland in males contributes to 8 12% infertility.

Over the last few years, rapid strides have been taken in the field of diagnosis and treatment of infertility. Various methods of Assisted Reproductive Technologies (ART) like Intra-uterine Insemination (IUI), Gamete Intra-Fallopian Transfer (GIFT), in Vitro Fertilization & Embryo Transfer (IVF & ET), Intra-Cytoplasmic Sperm Injection (IC SI) have greatly enhanced the chances of a successful conception further, where the sperm count is very low. In Oman currently these methods are not easily available and with exception of IUI all others will not be provided by MOH health facilities.

SITUATION IN OMAN

Accurate estimates of infertility in Oman are not known. Until late 1999, majority of infertility cases were attending infertility clinic at Royal hospital and andrology clinic at Al Nahda hospital.

Data from Royal hospital infertility clinic indicate that 50% of infertile couples are treatable, and, 35-50% contribution to infertility is due to female factors alone.

As per MOH Annual Statistical report of year 2000 the out patient attendance for male infertility was 7/10, 000 of population and for females 185/10, 000 (females of 15-49years).

History of Infertility Services in Oman:

Until 1974, only the patients history and general and pelvic examinations were carried out in the hospitals. In 1975 at Khoula hospital semen analysis, hysterosalpingography for tubal patency and dilatation & curettage for studying the secretary endometrium to confirm the ovulation were initiated in gynaecology clinic, this was followed by laparoscopic examination in 1980. In 1984 a small infertility clinic was started at Khoula Hospital and a basic proforma for the infertile couples was introduced.

Male infertility clinic was initiated in the year 1981 as a part of dermatology and genitourinary medicine clinic at Al Nahda hospital.

With the starting of the Royal hospital in 1987, a separate infertility clinic for both female and male clients was established. Investigations like hormonal profile and vaginal ultrasound examination for follicular studies for the female clients were also started on regular basis. IUI (intrauterine insemination) was initiated in 1996.

Since August 1999 the infertility clinic of Royal hospital has been shifted to Wattaya extended health centre for the female clients and to Al Nahda hospital for male clients. Currently infertility services are provided to infertile females in Gynae. Clinic daily and a special infertility clinic are run once in a week at Wattaya extended health centre. Two infertility clinics for the male infertile clients are conducted at Al Nahda hospital biweekly. These clinics cater all the cases referred from Muscat as well as referred from other regions.

Special methods of management like A.R.T. (Assisted Reproductive Technologies), GIFT (Gamete Intra-Fallopian Transfer), IVF & ET (In Vitro Fertilization & Embryo Transfer),

ICSI (Intra Cytoplasmic Sperm Injection) are not available in MOH institutions but can be availed in private sector or abroad on the clients own expense. Only IUI (Intra-Uterine Insemination) will be provided by tertiary care health facility of MOH.

To avoid misuse and duplication of investigations and for the smooth running of the programme, Ministry of Health wishes to introduce infertility services as standard practice all over the country.

This manual deals with the standard operating procedures to be followed by all the staff either working in the infertility clinic or otherwise with respect to management and treatment of infertile couples.

REPRODUCTIVE HEALTH

General Goals:

All

satisfying and fulfilling family life.

Objectives of Reproductive health Services in Oman are:

To enable married couples:

To conceive when desired

To reduce maternal morbidity

To have best possible pregnancy outcome

To remain free of reproductive disease and disability

To raise healthy children

Services contributing to optimal reproductive health and well being of Omani population that will be available and accessible in Oman are:

Preconception

Antenatal-perinatal and postnatal

Birth Spacing

married couples have optimal reproductive health and a

Child Health Services

Reproductive health strategies in Oman are:

Promote health and nutrition of pregnant and lactating mother:

Provide prenatal/preconception-counseling services to all married couple. Screen women at high risk of having congenitally anomalous babies and provide selective termination of pregnancy, wherever indicated (grossly anomalous baby).

Provide quality services to the pregnant women to go through

the pregnancy, delivery and post partum period safely and have a

healthy baby.

Provide promotive, preventive and curative service to children under the age of five years.

Provide information and access to safe, effective, suitable

and affordable methods of birth spacing as per clients choices for regulating fertility.

Prevent all complications and consequent morbidity that can result due to reproduction.

Prevent mortality in women associated with pregnancy and childbirth.

Provision of information and services for infertility to married couples.

Promote and enhance service utilization of all the services related to reproductive health by mass awareness.

Specific goal of Infertility Services in Oman:

Through provision of infertility service MOH clinics of

Sultanate of Oman will make an effort to improve the fertility

status of married infertile couples.

Provide infertility services as an integral part of Maternal and Child and Birth Spacing

Program free of cost in MOH Clinics within the available resource.

GUIDELINES FOR DEALING WITH INFERTILE COUPLES

Before initiating a detailed evaluation of infertile couple, all available records of previous investigation and management will be reviewed.

The parent institute will first book any case of infertility.

Trained service providers will do clinical assessment, preliminary investigation and counseling before referring the case to higher health care facility.

On first visit, at Primary health care facility, a female client with primary/secondary infertility will be evaluated when the husband semen analysis is first found normal and or acceptable.

In situation where male partner has children from previous or current other wife/s

All cases will be referred to a secondary health care level for further Specialized investigations

At the secondary health care level a special clinics for

infertility will run in both Gy & Ob dept for females and dermatology dept. for males. As per the indication, the case may further be referred for management by other expertise like

endocrinologist, surgeons, urologist

Specific day/s will be fixed in all health institutions to provide infertility services.

etc.

At secondary health care facility, a combined male/female

infertility clinic is advised to run at the same time and place when possible.

Couple will be kept well informed on the investigation and management plans and the results.

Referral to tertiary health care facility is allowed when

investigation/management are not available at secondary health care facilities.

Tertiary level, Infertility clinic for the female clients is at Wattaya extended health centre And for male clients is at dermatology/andrology clinic at Al-Nahdha Hospital.

Infertility clinics at Wattaya extended health centre and

dermatology/andrology clinic at AI-Nahdha hospital will treat the referred cases of Muscat as well as referrals from other regions.

If despite all investigations no cause of infertility has been

found or if the cause is not treatable, the couple will be briefed on the outcome of fertility assessment, reassured and counseled, given information on the availability of IUI in MOH and other ART method that can be availed in private clinic/abroad on clients own expense.

WHO WILL RECEIVE INFERTILITY SERVICES

All couples desirous of having children who either have:

Primary infertility, i.e. who have never conceived despite regular

unprotected intercourse for one year, will be registered in infertility

clinic and will be evaluated and treated.

Secondary infertility i.e. who have previously conceived but are

subsequently unable to conceive within 2 years, despite exposure to regular unprotected intercourse following abortion or full term normal delivery, will be registered, evaluated and treated in infertility clinic.

Couples in the age group 15-20 years will be physically examined, reassured and explained on

The fertile period of menstrual cycle and at the most, non invasive tests like semen analysis and

Hormonal profile may be carried out.

Despite all investigations and treatment some women may fail to conceive, such women will be dealt with compassionately and explained that no further work up is required.

WHO WILL PROVIDE INFERTILITY SERVICES

All trained health personnel having knowledge about the causes, investigations and management of infertility will provide infertility services, they all should acquire training on inter personal communication.

WHAT DO INFERTILITY SERVICES WILL INVOLVE:

History taking and Counseling

Trained nurses/midwifes, doctors working in MCH/BS clinic/Infertility clinic at all level of health care system will be involved in obtaining case history and doing counseling.

Physical Examination

Trained female doctors at all level of health care system, working in gynae/birth spacing/infertility clinic will do physical examination of female client. Trained male doctors in dermatology! anthology! infertility clinic will do physical examination of male client.

Routine investigation

Female staff nurse/doctors at PHC facility will get semen analysis done for male and haemogram, random blood sugar, VDRL Test, urine routine test for female client.

Special investigation

For female client:

Gynaecological infertility team will do/order hormonal profile, mid luteal serum progesterone, ultra-sonography & hysterosalpingography and do post coital test for the couple if indicated.

For male clients:

Dermatologist/andrologistlurologist/infertility team wills do/order hormonal profile, ultra sonography

Highly specialized investigations

Laparoscopy, androgen studies and other special investigations indicated will be carried out by gynaecologistldermatologist/andrologistlurologistlendocrinologistli nfertility team at tertiary care level.

Note: Tests like endometrial biopsy, testicular biopsy, antisperm antibodies, scrotal thermo-graphy, Doppler echography and imaging of pituitary region are not done routinely. The respective experts when indicated will only do them at tertiary health care facility as per feasibility and availability.

WHERE AND WHAT SERVICES WILL BE PROVIDED

All MOH institutions with trained female/male service providers will provide infertility services as per the availability of expertise and laboratory back up.

AT PRIMARY HEALTH CARE LEVEL

In MCH/IBS Clinics:

History taking of couple and confirming that the attending couple fits in the criteria of

infertility as per the protocol of MOH.

Physical examination of female client

Semen analysis

First line investigation of female client

Counseling on fertile period

Review of investigations and referral of couple to higher level for further management

AT

In Infertility Clinic: (Team of doctors: gynaecologist and dermatologist/anthologist)

Review of case

History taking of couple

Physical examination of female client by gynaecologist.

Physical examination of male client by dermatologist/andrologist.

Discussion on the investigation and management plan.

Based on the treatable cause of infertility in either or both the partners, female clients will be

Treated by gynaecologist and male clients by male dermatologist /andrologist

Counseling the couple.

Reference to tertiary care level if cause couldnt be treated at secondary health care level.

Antenatal care for those that conceive after infertility management.

AT TERTIARY CARE LEVEL

In Infertility Clinic: (Team of doctors: gynaecology/ dennatologist /andrologist/endocrinologist/Urologist)

Review of history and investigation

Repeat clinical evaluation if needed

Do special Investigations and treat as per the cause.

Counsel

SECONDARY HEALTH CARE LEVEL

Provision of Intra-uterine Insemination (IUI) where ever indicated

Give informationladvise on other assisted reproductive techniques (ART) where ever indicated as per infertility work up out come that could be availed by the couple on their own expense in Private hospitals in the country or abroad

COUNSELING INFERTILE COUPLES

The counselors who have been trained in interpersonal communication (IPC) skills and have interest and knowledge about causes, investigations and management of infertility will do counseling.

Before evaluating any infertile couple, it is important to explain to them that full work up may require few months and several visits by them. During the course of investigations they might have to go to higher health care facilities that has specialists and laboratory back up, hence, their cooperation and patience will be needed all through out, and appreciated.

All couples should be explained:

That Infertility is a shared concern, evaluating both partners is mandatory and problem Could lie with any of the partner.

On how to recognize the fertile period of menstrual cycle. How to track the number of days in the menstrual cycle, monitor the appearance and texture of her mucus, which becomes clear, watery and copious at the time of ovulation.

How often to have intercourse and the timing of intercourse i.e.,

intercourse should take place three days preceding ovulation and one day after it (between day 11-17 of a 28 days menstrual cycle).

On the kind of investigations/procedures planned/carried out and their outcomes.

Due to social taboo a woman may feel guilty and responsible for

not being able to bear children. Explain to her and her husband that infertility can be contributed by either of them, or by both of them. Reassure them that as a physician you will do your best to help them.

Where cause of infertility is not amenable, or if all available

methods of infertility treatment have failed, counselors should help the clients to cope with the bad news. Explain to the couple that no

further investigations or treatment are required and further visits to any of the clinics should be discouraged.

Ensure that the client knows that birth spacing methods used, do not cause infertility.

Some hormonal oral, injectable contraceptives and implants can

delay fertility by a few months but fertility eventually will return.

Barrier methods protect against STIs, therefore can protect against tubal infertility.

IUCDs are also safe and effective method of birth spacing and do

not cause any pelvic infection by themselves or contribute to infertility but may accelerate ascending infections in those women that are at high risk of STIs and increase the risk of tubal infertility. Such women should use barrier methods and should receive adequate treatment for the STIs and pelvic infections.

REFERRAL

Proper communication between the primary, secondary and tertiary centres is of utmost importance To ensure the best and optimum utilization of time, efforts and resources.

REFERRAL FROM PRIMARY TO SECONDARY HEALTH CARE LEVEL:

Couple will be referred to secondary health care facility after having:

Taken the detailed male and female clienf s history. Completing clinical examination of the female client (if female doctor is available).

Getting semen analysis done.

Carrying out routine blood and urine tests.

REFERRAL FROM SECONDARY TO TERTIARY HEALTH CARE LEVEL:

Couples will be referred to tertiary health care facility after having:

FOR FEMALE CLIENT:

Done clinical re-evaluation to confirm the findings and review of investigations.

Pelvic ultra-sonography.

Assessing hormonal profile: serum follicular stimulating hormone, leutinizing hormone,

prolactin, mid luteal progesterone and thyroid function tests (T3, T4 & TSH if indicated)

Evaluating tubal patency by laparoscopylhysterosalpingogram (if facility available).

Given a trial of 6 months of induction of ovulation with clomiphene citrate and failed.

Doing endometrial biopsy if indicated (Suspected case of genital tuberculosis).

FOR MALE CLIENT:

Doing semen analysis, if needs repetition.

Assessing hormonal profile serum follicular stimulating hormone,

leutinizing hormone, prolactin (If gynaecomastia is present), and

thyroid function tests (T3, T4 & TSH).

Doing ultra-sonography.

Carrying out following tests if indicated and if facility & expertise are available

Anti sperm antibodies (Immunobead test).

Serum estradiol and serum testosterone.

Doppler test.

Scrotal thermography.

Testicular biopsy.

INDICATIONS FOR REFERRAL TO THE TERTIARY LEVEL:

FEMALE:

Repeated abnormal post coital test (minimum twice).

Endocrine disorders, Hyperandrogenemia, Hypogonadotropic hypogonadism.

High prolactin levels with/without adenoma.

Previous ectopic pregnancy.

Amenorrhoea.

Primary ovarian failure.

Tubal block.

. Failure of clomiphene citrate therapy x 6 cycles.

History of prior urogenital surgery.

Genital malformations.

Unexplained infertility (> 18 months).

MALE:

History of testicular mal-descent.

Previous history of genital pathology including orchitis, varicocele, STI.

Any urogenital surgery.

Any abnormality on physical examination.

Any endocrine disorder.

Severe oligozoospermia /asthenozoospermia/azoospermia.

UNDERSTANDING INFERTILITY DEFINITION OF INFERTILITY Infertility is defined as ‘ inability of a couple to

UNDERSTANDING INFERTILITY

DEFINITION OF INFERTILITY

Infertility is defined as inability of a couple to achieve conception after a year of regular unprotected intercourse.

This means either a womans inability to conceive and bear child or a mans inability to impregnate a woman.

Most couples that are evaluated are sub-fertile rathei than sterile. Data from some countries

Have shown that as high as 38 % couple conceive before the treatment was begun and another

27% before the treatment was completed.

PRIMARY INFERTILITY:

A couple that has never conceived despite unprotected regular intercourse for at least 12 months.

S1 INFERTILITY:

The couple has previously conceived but is subsequently unable to conceive within 12 months after delivery or abortion despite exposure to regular unprotected intercourse

PRIMARY MALE INFERTILITY: when man has never impregnated a woman.

SECONDARY MALE INFERTILITY: when man has impregnated a woman, irrespective of whether she is his present partner are not, and irrespective of the outcome of the pregnancy.

PRIMARY FEMALE INFERTILITY: when woman has never been pregnant.

SECONDARY FEMALE INFERTILITY: a woman has been previously pregnant but not necessarily by the same partner, irrespective of pregnancy outcome.

PREGNANCY WASTAGE:

The woman is able to conceive but unable to produce a live birth (unable to carry the fetus to a viable age).

SUB FERTILITY:

The couple has difficulty in conceiving jointly because both partners may have reduced fecundity.

PROBABILITY OF PREGNANCY:

In normal fertile population there are 20% chances of pregnancy happening in each cycle. 95% of couples will get pregnant by 13 cycle.

DURATION OF INVOLUNTARY INFERTILITY:

Longer the duration of infertility less is the chance of pregnancy. Couples with duration of less than 3 years of infertility stand a better chance of pregnancy

FACTORS AFFECTING FERTILITY

AGE OF WOMAN:

After late 30s there is slight decline in fertility and some women may take longer to conceive.

AGE OF MAN:

Although age does not affect sperm capabilities but it does affect the sexual functions and coital frequency thus indirectly affecting the reproductive performances.

COITAL FREQUENCY:

Frequency of coitus is positively related with the frequency of pregnancy.

TIMING OF INTERCOURSE:

Sperm survives for 48 - 72 hours in genital tract, where as ovum survives only for 12 - 24 hours and the window time for fertilization is only few hours, so for fertilization to occur sperm should be available in genital tract shortly after ovulation.

DOUCHING:

Douching of vagina soon after intercourse can destroy sperms.

PREVIOUS OR CURRENT DRUG USE:

Many a drugs can like narcotics, anticancer, phenothiazines, monoamine oxidase inhibitors, methyldopa, cimetidine, salfasalzine and toxins like arsenic and lead can interfere with ovulation, change semen quality and reduce sperm count.

Contraceptives like depot medroxy progesterone acetate or norplant can temporarily delay the return of fertility in female clients for few months.

Some drugs, alcohol, tobacco and exposure to radiation can cause pregnancy wastage. Drugs like guanethidine, methyldopa may affect ejaculation.

CAUSES OF INFERTILITY

Only 5% of couples will suffer from infertility due to anatomical, genetic, endocrinological and immunological causes. All remainder are largely because of preventable conditions that include:

Genital tract infections due to STIs, non STIs & parasitic diseases.

Health care practices Unhygienic practices

Exposure to toxins in the diet and in the environment,

Cultural and social factors like age at marriage, female genital mutilation, consanguineous marriage;

Use of alcohol, tobacco & caffeine etc.

In 5 15% infertile couples even thorough evaluation will not find any cause for their infertility.

MANAGEMENT OF FEMALE INFERTILITY EVALUATION OF INFERTILE FEMALE I HISTORY

MANAGEMENT OF FEMALE INFERTILITY

EVALUATION OF INFERTILE FEMALE I HISTORY

Evaluation should begin with asking full medical history, doing physical examination and investigations as per the availability of health personnel expertise and laboratory back up at health care facilities.

It is very important to take proper obstetrical, fertility history and history of any previous investigations done, to avoid unnecessary repetition.

PERSONAL HISTORY

Age: If exact age of the partners is not known, approximate age should be determined. Address and Telephone No: To be able to contact and recall whenever required.

INFERTILITY HISTORY:

Whether infertility is primary or secondary duration of infertility (number of months

with unprotected intercourse, excluding separation abstinence & use of contraception).

MARITAL HISTORY:

Number of marriages.

PERSONAL HISTORY:

Excessive smoking, alcohol intake or addition of drugs likes heroin.

COITAL HISTORY:

Frequency of coitus (coital frequency 2-3 times a week is considered to be within normal range), coital difficulties. If husband is away and comes homes only on weekends missing the fertile periods.

ENVIRONMENTAL AND OCCUPATIONAL HISTORY:

Intense physical activity, exposure to petroleum, chlorinated hydrocarbons, organic,

dyes, inorganic mercury etc.

MENSTRUAL HISTORY:

Age of menarche, late menarche is associated with ovulatory disorders.

Even with regular periods a patient may have luteinising

hormone: follicular stimulating hormone ratio > 3:1 indicating polycystic ovarian disease.

Oligomenorrhoea (cycle > 42 days) with scanty menses may indicate high prolactin levels.

Polyn and menorrhagia may indicate anovulation.

Secondary dysmenorrhoea may indicate endometriosis, PID or fibroid uterus.

OBSTETRICAL HISTORY:

Outcomes of previous pregnancies - abortions, miscarriages, live born, ectopic pregnancy, and molar pregnancy, and history of post abortion sepsis or puerperal sepsis and severe post partum haemorrhage leading to amenorrhoea (Sheehans. syndrome).

MEDICAL HISTORY:

Present or past history of: Systemic diseases like tuberculosis, diabetes mellitus, thyroid disease, pelvic inflammatory diseases and STIs.

Galactorrhoea: history should be elicited and searched for, as it may indicate high prolactin levels with or without pituitary adenoma.

DRUG HISTORY:

Present or past use of drugs, their dosage and duration - cytotoxic agents, phenothiazines, haloperidol, tricyclic arni depressants - monoamine oxidase inhibitors, hypotensive drugs methyldopa, metaclopromide Cimetidine, steroids, ovulation induction drugs.

CONTRACEPTION HISTORY:

History of use of contraceptives in immediate past: oral, injectable depot medroxv progesterone and IUCD insertion

SURGICAL HISTORY:

Appendicectomy, laparotomy, laparoscopy and related procedures or any major gynae surgery.

FAMILY HISTORY:

Endocrine disease e.g. polycvstic ovarian disease is often familial

PHYSICAL EXAMINATION

GENERAL EXAMINATION:

Weight:

Over weight or under weight women may have ovulatory disorders. Sudden gain or decrease of 10% in weight within past one year may be associated with oligomenorrhoea or amenorrhoea and anovulation.

Height:

Short stature with primary amenorrhoea with webbed neck suggests Turners syndrome.

Build:

Very thin patients may often give a clue- anorexia nervosa - WHO Group I. Obese and short patients- Polycystic ovarian disease - WHO Group II.

Development of secondary sexual characteristics:

Examine breast to check developmental deficiencies such as hypogonadism and hyper- prolactinemia. Confirm galactorrhoea by gentle pressure on areola.

Visualize hair distribution:

Presence of abnormal distribution of hair may suggest hyperandrogenism, adrenal hyperplasia, hypothyroidism and ovarian dysfunction. SYSTEMIC EXAMINATION:

To rule out any cardio-vascular, respiratory, gastrointestinal and uro-genital diseases that could influence fertility. Do abdominal examination to look for organomegaly, which could indicate systemic diseases.

GENITAL TRACT EXAMINATION:

Speculum exam:

Inspect vagina and cervix for any lesions and discharge. Collect cervical smear and vagina swab for microbiological examination wherever indicated.

PELVIC EXAMINATION:

Examine external genitalia, clitoris greater than 2cm and gland more than 1cm indicates virilism. Palpate uterus to rule out uterine hypoplasia and congenital anomalies, adnexae to reveal any adenexal tumours. pelvic inflammatory diseases or endometriosis, and cervix to feel cervical lesions.

INVESTIGATIONS

ROUTINE INVSTIGATIONS (at PHC facility)

On first visit: Do/order semen analysis for the male partner. Investigations for female client can be initiated on first visit where male partner has children from previous

wife/s or from other wife/s with whom he is currently married

On follow up visit Review semen analysis report if normal/acceptable proceed with complete blood count, urine routine and microscopic, VDRL, and RBS/OGCT for the female client. Review the all the test reports and then refer the case to near by health care facility with gynaecologist If semen analysis is abnormal/if abnormality is

found in both partners refer the couple to secondary health care facility with

infertility clinic

EVALUATION

EVALUATION AT SECONDARY CARE LEVEL BY GYNECOLOGISTS

Reconfirm clienf s history and physical examination findings and review the investigations carried at PHC level. Do or order semen analysis if not already done. If semen analysis is normal proceed with investigations like abdominal and pelvic ultrasound and other investigations that are indicated and are feasible on the first visit like high vaginal swab, cervical swab for chlamydia trachamatis, PAP smear etc.

PLANNED INVESTIGATIONS AT THE SECOND AND SUBSEQUENT VISITS

The patient is to be called according to her menstrual cycle for subsequent visits for investigations as detailed below:

“ Type of test, timing in relation to menstrual cycle, indications and interpretation ” Follicular

Type of test, timing in relation to menstrual cycle, indications and interpretation

Follicular stimulating hormone and leutinizing hormone and serum prolactin should be done on day 2 to 4 of the menstrual cycle.

In ovulatory patients with regular cycles follicular stimulating hormone and leutinizing

hormone are not mandatory.

Anovulatory patients with regular cycles, leutinizing hormone: follicular stimulating

-

hormone ratio more than 3:1 indicates poly-cystic ovarian disease.

High levels of follicular stimulating hormone and leutinizing hormone indicates primary

ovarian failure for which there is no treatment.

Prolactin levels 1000 miu/litre on two occasions requires ruling out of pituitary tumours

by imaging of hypothalamic pituitary region by CT Scan or MRI.

Note: Prolactin test should not be done after pelvic or breast examination or early in the morning as that may give high false positive results. Repeated test for prolactin are advised.

Mid luteal serum progesterone test (Day 20-24 of 28 days/Day 28 of 35 days cycle): avalue of >25 nmo/litre suggests ovulation (Progesterone test has replaced endometrial biopsy, as far evidence of ovulation is concerned).

Thyroid function test: Is indicated if there is oligomenorrhoea, polymenorrhoea, or hyperprolactinaemia.

Androgen studies: should be done in patients with hirusutism, virilism and in patients who do not respond to the highest permitted doses of clomiphene citrate therapy (serum dehydro epiendestrone acetate levels are> 2.5 ng/ml).

Ultrasound: Abdominal, trans-vaginal and hydrosonography to detect any abdominal organomegaly, and uterine, ovarian and tubal pathology.

Laparoscopy: If the initial blood analyses including hormonal assay and semen analysis are

normal then diagnostic laparoscopy or hysterosalpingography for tubal patency testing

should be done.

Diagnostic laparoscopy is preferred to hysterosalpingography as it has advantage of direct visualization of the pelvis, but being an invasive procedure it can be deferred for couples with infertile period less than 2 years and whose clinical evaluation, hormonal and other investigations are normal.

Early Investigation for pelvic pathology by laparoscopy is indicated in female client with

history suggestive of PID, history of long standing infertility and if clients age is above 30

years and she is just beginning her fertility evaluation work up.

Hysteroscopy: if indicated can be combined with laparoscopy.

If laparoscopy facilities are not available. Hvsterosalpingography can be done as a preliminary procedure for tubal testing. But if. when laparoscopy is done and it reveals a tubal block, it is advisable then that the hysterosalpingography is done to localize the site of the block.

{Note: HSG is typically performed early in the menstrual cycle after bleeding on the day 7 - 10 of 28 days cycle}

Post coital test: should be carried out in pre-ovulate phase (on 12 day of a 28 days regular

menstrual cycle) This test is done to confirm that ejaculation has taken place in vagina and to

rule out any impaired semen cervical mucus interaction in patients who are ovulating

normally and whose other infertility investigations are normal.

Instruction to the female client/couple prior to Post coital test (PCT):

To abstain from intercourse at least 48 hours prior to test (as per appointment date)

To have intercourse early in the morning on the PCT date.

Not to take a vaginal douche after the intercourse.

Explain to the client procedure before taking the sample that you/doctor will gently insert a

speculum and take samples for examination and she will not experience any pain except for

some discomfort while doing pelvic examination.

Pre-menstrual endometrial biopsy: indicated if there is a past history suggestive of endometrial tuberculosis.

Immunobead test (MAR Test): for detection of antisperm antibodies.

Once the above work up is complete, couples cause of infertility

will be categorized as:

S

Infertility due to female factors:

Anovulatory cycles

S

Cervical factors (assessed by PCT)

Uterine factors (assessed by clinical assssment)

Tubal disease

Infertility due to Male factor.

ANOVULATION

INCIDENCE: 30 - 40 % infertile females have ovarian dysfunction. If appropriately diagnosed and managed the success rate is as high

98%

Regular ovulation occurs when the hypothalamic-pituitary ovarian axis is intact. Any disorder occurring at one or more levels of hypothalamic-pituitary ovarian axis may lead to anovulation.

Treatment of anovulation depends on the site of involvement, which is assessed by specific hormonal assays. WHO classification (based on the hormonal assay results) for ovulatory disturbances is as follows:

WHO CLASSIFICATION:

ovulatory disturbances is as follows: WHO CLASSIFICATION: CLINICAL PRESENTATION: • Regular menstrual cycle: •

CLINICAL PRESENTATION:

Regular menstrual cycle:

Menstrual irregularities:

Amenorrhoea: primary and secondary

Oligomenorrhoea

Galactorrhoea

Obesity

Abnormal development of secondary sexual characters

Hyperandrogenic state- hirsutism, virilism

Anosmia

Manifestation of other endocrine abnormalities e.g. thyroid dysfunction

MANAGEMENT OF ANOVULATION/OVULATION INDUCTION

The commonly used drugs for ovulation induction are:

1. Clomiphene citrate

2. Human menopausal gonadotropins (HMG)

3. Human chorionic gonadotropins (HCG)

CLOMIPHENE CITRATE: (WHO Group 1)

Start with clomiphene citrate 100 mg from Day 2-6 of menstrual cycle. Give three cycle If no ovarian response is seen increase the dose by 50 mg every cycle until maximum dose i.e. 250 mg. is reached and the ovarian response is seen (serum progesterone nmol/litre on Day 21 23 of menstrual cycle)

The dose at which ovulation occurs, should be continued for a period of 6-9 months. If there is failure of ovulation with maximum dose of clomiphene citrate (250 mg), administration of human chronic gonadotropins (HCG) whenever trans-vaginal ultrasound expertise is available, can be initiated (see below) or client should be referred to endoscopic center for laparoscopy plus ovarian drilling.

GONADOTROPINS (WHO GROUP - I & II)

Gonadotropins are to be administered if patient fails to ovulate with clomiphene citrate. From Day 2/3 of menstrual cycle start Human Menopausal Gonadotropin (HMG) 2 ampules intra muscular daily for 5 days (one ampoule of HMG = 75 IU of follicular stimulating hormone + 75 IU of leutinizing hormone)

Do follicular study by trans-vaginal ultrasound on Day 7/8 of menstrual cycle. Continue with same dose of HMG & follicular study every 2 3 days interval until follicles reach to 18 mm size.

30

Give human chronic gonadotropins (HCG) 10, 000 units (when

follicle is

following HCG administration.

If on Day 8 no follicular response is seen, increase HMG by one ampoule followed by follicular study every 2 3 days for 5 6 days.

Abandon the cycle and refer client to tertiary health care centre:

If no response

If on day 8 of menstrual cycle multiple follicles of 8 mm and 8 or more in number are seen, it indicates hyper-stimulation syndrome secondary to gonadotropins therapy.

Ovarian Hyper Stimulation Syndrome (OHSS)

This is a known life threatening complication of gonadotropins therapy and needs early recognition and management.

Symptoms and Signs are

Nausea, vomiting, diarrhea, abdominal pain and distension, signs of ascites and pulmonary embolism.

hydrothorax,

Patients should be referred to tertiary health care center immediately whenever OHSS

is suspected.

18mm). Advise intercourse between 24 36 hours

18mm). Advise intercourse between 24 — 36 hours BROMOCRYPTINE (dopamine receptor a2onist) : (WHO GROUP V

BROMOCRYPTINE (dopamine receptor a2onist) : (WHO GROUP V & VI)

It is indicated in anovulatory cycle associated with hyperprolactinaemia.

It is given in progressively increase dose orally with meals

Start with dose 1.25mg twice aday for 7 days then increase gradually to 5 mg twice a day over next 2-3 weeks,

Followed by doubling of dose every 4 weeks until maximum

daily dose of 30mg is reached i.e. 10 mg three times a day and beyond which the dose should, not exceed.

Monitor Serum.Prolactin level on monthly basis and adjust

bromocryptine dose accordingly as per the response (i.e. decrease in serum prolactin level and reduction in Ga

Once prolactin levels are normal maintain same dose for 4 6 months.

Confirm ovulation by mid-luteal serum.progesterone (Day 21-24 of 28 days menstrual cycle)

If still not ovulatory inspite of normal prolactin levels add clomiphene citrate as per above guidelines

If prolactin levels are still high inspite of maximum dose of bromocryptine refer patient to endocrinologist.

NOTE: If the female is < 25 years, has history of infertility less than 3 years, has anovulatory cycles, and has no history suggestive of previous inflammatory disease or pelvic surgery, then the trial with clomiphene citrate for induction of ovulation without evaluating her tubal factors is justified.

TUBAL FACTORS

TUBAL FACTORS SHOULD BE ASSESSED AFTER INITIAL WORK UP OF OVULATION AND SEMEN ANALYSIS ARE COMPLETED.

EVALUATION FOR TUBAL FACTORS

HYSTEROSALPINGOGRAM (HSG):

HSG gets priority when the couple is very young with past history of P.I.D.

HSG should be performed during proliferative phase (day 7 to

day 10) of the cycle.

Inform the patient regarding the procedure.

Carry out a detailed physical examination and if indicated high vaginal swab (HVS) to rule out acute infection.

Give non steroidal anti inflammatory drug/antispasmodic 30-60

mm before procedure to lessen the pain and tubal spasm.

In clients with history of PID give antibiotic cover with Doxycycline 100 mg twice for a week to both partners.

Carry out the procedure under aseptic precautions.

Inject 20 ml of water soluble dye slowly through the cervical canal into the uterine cavity.

Avoid leakage by steady traction on the volsellum accompanied

by gentle push on the cannula. Partial or complete withdrawal of the bivalve speculum will allow an adequate view of the cervix.

A late film would help in visualizing peritubal adhesions and delayed spill.

LAPAROSCOPY:

Laparoscopy should be the primary investigation for tube testing.

It should be done during the proliferate phase on day 7 to day 10.

Visualization of the pelvic organs should be systematic and

thorough describing each organ in detail including its dimensions, thickness, appearance, relation to adjacent structures, mobility etc.

LAPAROSCOPY ENABLES CLASSIFICATION OF TUBAL DISEASES INTO TWO CATEGORIES:

1. Advanced disease -poor surgical outcome- patients benefit with

in vitro fertilization

(IVF).

2. Mild to moderate disease- microsurgery is indicated and may be

beneficial.

MANAGEMENT

Early and meticulous treatment of patients with pelvic inflammatory disease (PID).

Advise oral contraceptives in patients with chronic PID.

incidental surgery should be avoided e.g. shortening of round

ligaments, wedge resection of ovary, excision of small ovarian cyst

with out proper evaluation etc.

During laparotomy for ectopic pregnancy, tuboplasty of the contra lateral tube should not be attempted.

IUCD insertion should be avoided in patients with past history of ectopic pregnancy and chronic PID, or those at risk of sexually transmitted infections (STIs).

TUBOPLASTY

PRINCIPLES:

Ensure meticulous haemostatsis.

Do minimum handling during surgery and usage of Teflon/glass probes.

Irrigate continuously with an isotonic solution to prevent dryness of tissues.

Use fine suture material e.g. 8/0 prolene.

In procedures like tubocornual implantation, end-to-end

anastomosis, and salpingostomy, magnify to delineate the correct plane for tissue dissection enabling proper apposition and better results.

ONLY SKILLED PERSONNEL SHOULD CARRY OUT THESE PROCEDURES.

Postoperative evaluation

Repeat HSG/Laparoscopy- 12 weeks later to evaluate tubal patency.

After surgery, a period of 18-24 months should be allowed for client to conceive, failing

which; she can be told on the alternative methods like IVF that can be availed outside

MOH.

IVF is a preferred alternative method to tuboplasty

ENDOMETRIOSIS:

INCIDENCE OF ENDOMETRIOSIS:

1% of women in reproductive age.

15

25% infertile women.

70

80% unexplained infertile women

CLINICAL PRESENTATION:

Severe dysmenorrhoea (pre, during and post menstrual)

Dyspareunia.

Pelvic pain.

Infertility.

Menstrual irregularity.

Haematurialdysuria.

Abdominal cramps (cyclic).

Clinical signs depend on the site of involvement:

In mild cases no abnormality may be found clinically despite severe symptoms.

In pelvic endometriosis discomfort and tenderness on bimanual examination along with! without palpable adenexal masses and indurations of utero-sacral ligaments may be found.

DIAGNOSIS:

Ultra sonography: Probable diagnosis may be possible

Laparoscopy: Facilitates a definitive diagnosis and staging as per the American Fertility society (A.F.S) revised classification. Further confirmation of the diagnosis can be done by biopsy. (Ref to appendix 5 & 6)

The staging should be followed judiciously to ensure uniformity in

classification of severity of the disease and further management.

TYPES OF MANAGEMENT:

Medical:

1. Danazol

2. Leutinizing hormone release hormone Analogues

3. Progestogens

(Ref to page 33 for Medical Management of Endometriosis)

Surgical (Mainly by Laparoscopic surgery):

Laparoscopy procedure:

1. Cystectomy for endometriomas

2. Adhesiolyses/excision using sharp/blunt dissection for pelvic

adhesions.

3. Cauterization for endometriotic lesions: avoid cautery around

the bladder, ureter, bowels and other vital organs

Laser surgery- precise vaporization of endometnotic nodules of 1-2

mm without severe damage to the surrounding tissue.

Clients needing laparoscopic procedures should be referred to Endoscopic units

UNEXPLAINED INFERTILITY

INCIDENCE:

5 -15% of infertile couples will have unexplained fertility for which no cause will be found.

POSSIBLE REASONS ATTRIBUTED ARE:

Poorly developed follicle

Abnormal oocyte- genetically or functionally

Poor quality luteal phase that may not provide the optimal endocrine environment for tubal transport or endometrial maturation.

Aberrant or asynchronous endometrial gland secretion.

Abnormal acrosomal reaction of sperm

Improper transport of fertilized egg to the site of implantation due to defective function of cilia.

Influence of ovarian steroids directly or indirectly by

prostaglandin and the sympathetic nervous system of the process of oocyte pick up by the fallopian tube, fertilization, zygote maturation and transport due to effect on muscular co ordination, cilial activity and tubal secretion.

TREATMENT:

Three attempts with super ovulation with clomiphene citrate/gonadotropins followed by intra uterine insemination should be carried out. Failing which client can be counseled on alternative methods of Assisted Reproductive Technologies (ART) that are available out-side MOH institutions, IVF I GIFT is one of them.

ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

PROCEDURES ARE

I. INTRA-UTERINE INSEMINATION (IUI)

II.

IN VITRO FERTILIZATION AND EMBRYO TRANSFER

(IVF-ET)

III. GAMETE INTRA FALLOPIAN TRANSFER (GIFT)

IV. INTRA CYTOPLASMIC SPERM INJECTION (ICSI)

V. PARTIAL ZONA DISSECTION (PZD)

VI. SUB ZONAL INSEMINATION (SUZI)

INDICATIONS FOR ART:

Tubal disease with tubal block orabsent tubes

Severe Endometriosis- endometriosis after sufficient treatment without success.

Unexplained infertility

Poly cystic ovarian disease with failed ovulation induction

Oligoasthenozoospermia

Hostile cervical mucus.

PRELIMINARY REQUIREMENT:

Age <40 years preferable

Psychological evaluation- mentally sound and stable marriage

Semen analysis- count >5-20 million (for IVF), motility - 30%

Laparoscopy and if possible Hysteroscopy

HSG if indicated

Cervical patency - depth and direction of cervical and uterine cavity, to ensure atraumatic transfer of embryo.

Patient to be fully informed about the procedure, the cost involved and the poor success rate (15-40%).

I. INTRA-UTERINE INSEMINATION (IUI)

Intra-uterine insemination is the only ART procedure provided by MOH, at Wattaya Polyclinic.

INDICATIONS FOR IUI

i. Poor quality semen

ii. Hostile cervical mucus

iii. Unexplained infertility

PROCEDURE:

Sperm preparation is carried out to separate the highly motile sperms from the seminal plasma by centrifugation or Percoll gradients, or using the sperms natural swimming ability.

The washed Spermatozoa are injected directly into the uterine cavity using a fine Teflon Catheter.

II. IVF-ET (In Vitro fertilization and embryo transfer)

Oocyte is recruited by induction of ovulation with various drugs.

Oocyte is retrieved transvaginally or under ultra sonography guidance

Fertilization of ova and growth of embryo is done in vitro (2- 3) embryos

replaced back into the uterus at 4-cell stage trans- vaginally.

III GIFT (Gamete intra fallopian transfer)

Oocyte recruitment and oocyte retrieval is the same as in IVF

Sperms are prepared

Oocyte and sperm are placed separately in a catheter and injected

directly into the patients fallopian tubes. It is a one step procedure.

In patients with patent tubes, IVT-ET and GIFT procedures can be done

simultaneously thereby improving conception rate further.

IV. INTRA CYTOPLASMIC SPERM INJECTION (ICSI)

A single human sperm cell is injected through the zona right into the cytoplasm of the egg.

V. PARTIAL ZONA DISSECTION (PZD)

A hole is made in the outer layer of a single egg making it easier for the Sperm cells to penetrate and fertilize.

VI. SUB ZONAL INSEMINATION (SUZI)

This is one Further stage of PZD. A few individual sperm cells

are placed just beneath the outer zona of the egg, so that they only

have to cross the cytoplasm of the egg to achieve fertilization.

MANAGEMENT OF MALE INFERTILITY

EVALUATION OF INFERTILE MALE

HISTORY:

A good history can contribute to diagnosis of infertility in 25% of

cases. It will also facilitate in decision making about management

of

the case. It is best to stan by asking the client about his duration

of

infertility. The number of months the couple has been having

the intercourse without the use of contraception. Duration of involuntary infertility has implications on the prognosis of the case.

MARITAL HISTORY:

Number of years of marriage.

Number of wives.

Number of pregnancies that his wife/s have had.

Number of live born his wife/s have had.

Number of living and dead children.

Consanguineous marriage.

SEXUAL HISTORY:

Desire

Frequency of coitus (twice or less/month unless done during ovulation is considered inadequate).

Potency Masturbation.

Extra marital relationships.

Use of lubricants during intercourse.

PERSONAL & FAMILY HISTORY:

History of excess alcohol consumption, tobacco/marijuana smoking,

Drug abuse, addicted to opiates.

Away from wife for long periods.

Hereditary/familial disorders that can affect fertility.

ENVIRONMENTAL AND OCCUPATIONAL HISTORY:

Exposure to x-rays, radiation, high temperature or sauna

Heavy metals like Lead, Cadmium, Mercury. substances like pesticides, herbicides etc.

MEDICAL HISTORY

General health

Age of onset of pubert weight loss or gain history of scrotal trauma or swelling

Systemic Disease

Diabetes mellitus hypertension tuberculosis chronic respiratory diseases cystic fibrosis leprosy and neurological disorders

Infections

STIs (syphilis gonorrhea chlamydia. granuloma venereum mvcoplasma or

nonspecific urethritis, HIV), urethral discharges. urinary tract infections.

Viral infections like Mumps (age of onset, unilateral/bilateral).

Medication

History of use of hormonal drugs Androgens, anticancerous drugs - alkylating agents, other drugs that can cause temporary infertility, like cimetidine, suiphasalazine spironolactone nitrofurantoin niradozole and colchicines Contraception duration and method used etc

SURGICAL HISTORY

Surgery on urethral valve bladder neck operations repair of urethral stricture reconstructive surgery for hypospadias epispadias operation for testicular maldescent varicocele testicular torsion and hernia Prostatectomy hydrocelectomy vasectomy orchiopexy or orchiectomy appendicectomy lumber sympathectomy etc

PHYSICAL EXAMINATION

Weight

Gross over obesity is associated with decreased testicular volume.

Height

Span (long limb length has been associated with Klinfelters syndrome).

Fat and hair distribution

Feminine fat distribution and sparse or absent pubic, axillary and chest hair, poor beard growth suggests hypogonadism.

Breast examination

For gynaecomastia (examine client with hands placed behind his head).

Abdominal examination

Liver enlargement and any pelvic mass.

GENITAL EXAMINATION:

Penis:

Size, deformities, phimosis, ulceration or urethral discharge

Surgical or traumatic scar (may indicate urethral stricture). indurations.

Testes:

Size

Normal Volume (normal 15 - 25 ml).

Consistency:

Normal - rubbery to firm (Klinfelters syndrome - hard & small, hypogonadotropic hypogonadism soft & small).

Site:

Normally in the scrotum ( abnormal locations - in scrotal neck, inguinal, ectopic. impalpable, incomplete descent).

Vasdifference:

Normally on palpation it feels like a cord when felt between the thumb and index finger) Check if it they are normal or if thickened/not palpable.

Scrotum:

Presence of any swelling, hydrococle, varicocele, Calcified nodules of VAS or absence of VAS.

Inguinal examination:

Presence of any hernia, scar of healed tuberculosis or lymphogranuloma venereum, or lymphadenopathy.

Prostate:

Normal prostate is soft regular and non-tender (Palpate by per rectum examination).

It is tender in infections and hard in malignancy.

SEMEN ANALYSIS Semen analysis is the principal test for the evaluation of the male. AS

SEMEN ANALYSIS

Semen analysis is the principal test for the evaluation of the male.

AS THE QUALITY OF THE SEMEN MAY VARY SUBSTANTIALLY

BETWEEN SAMPLES, TWO SPECIMENS MUST BE REQUESTED

BEFORE A FIRM OPINION IS MADE, PARTICULARLY IF ONE IS

ABNORMAL. THE INTERVAL BETWEEN THE SAMPLES SHOULD BE

AT LEAST 4 TO 8 DAYS. IF THE SECOND SAMPLE CONFIRMS AN

ABNORMALITY, A POST TREATMEN I SAMPLE SHOULD BE

EVALUATED AFTER 90 DAYS OF TREATMENT.

I SAMPLE SHOULD BE EVALUATED AFTER 90 DAYS OF TREATMENT. INSTRUCTION TO CLIENT ABOUT COLLECTION OF

INSTRUCTION TO CLIENT ABOUT COLLECTION OF SEMEN SAMPLE FOR

EVALUATION:

1 Abstain from intercourse (no ejaculation) for at least 3days.

2 Do not drink alcohol or take a hot shower or hot bath immediately prior to producing specimen.

3. Produce a semen specimen by masturbation into a small, sterile,

dry, wide mouth glass jar. Be sure, the entire specimen is captured in the container.

4. Label the jar with the clients name, hospital number, date and

time of collection.

5.

Lubricant jellies or soaps are not to be used for masturbation and

if required glycerin is permitted. Ordinary condoms contain spermicidal and hence should not be used.

6. Take the specimen to the laborator as soon as possible. The

specimen should arrive in the laboratory within 1 hour of collection maintaining the temperature between 15-

38 C.

If religious norms prohibit masturbation, then a milex sheath, which does not damage sperms, may be used.

OTHER INVESTIGATIONS:

1. Complete blood picture

2. Urine test: for sugar, albumin, pus cells, significant bacteruria,

and if indicated Chlamydia trachamatis antigen.

3. Fasting blood Sugar

4. VDRL

5. Serum iron concentration

6. Hepatic & renal function tests

7. Thyroid function test

8. Serum testosterone estimation: indicated where there are clinical

signs of hypoandrogenesim with normal Serum follicular stimulating hormone, suggesting hypogonadotrophic hypogonadism either of pituitary or thalamic origin.

9. Serum follicular stimulating hormone, high levels suggest defect

in spermatogenesis or primary testicular failure.

10. Serum leutinizing hormone

11. Serum prolactin: 2 3 samples are taken at interval of 15

minutes with in dwelling needle and record the lowest value. Indicated in cases of sexual dysfunction or if there are signs of hvpoandrogenesim with low serum testosterone and normal Serum follicular stimulating hormone values. High prolactin values may

be due to drugs like tranquilizers, sulphides, or presence of hypothyroidism or cranipharangioma.

12. Serum estradiol: to be estimated only if gynaecomastia is there.

13. Testicular biopsy: done in case of severe oligozoospermia or

Azoospermia with normal testicular volume and normal Serum follicular stimulating hormone values.

14. Anti sperm anti bodies (Immunobead test or mixed antiglobulin

reaction)

15. Immunoglobulins G & M (for Chlamydia Trachamatis)

16. Post coital tests: man should abstain for 48 hours prior to

intercourse.

17. Scrotal thermography: to rule out sub clinical varicocele,

indicated where spermatozoa are abnormal and man has no obvious physical or urogenital abnormalities. Normal temperature of scrotum does not exceed 33 degree C. Ensure that the temperature of çxamination room does not exceed more than 22 degree C and man has stood for 5 minutes naked before applying the flexible strip on scrotum.

18. Ultra-sonography: to detect sub clinical varicocele or search for

the varicocele on the other side when present on one of the inguinal regions

19. Doppler ultrasound examination: Patients with varicocele have

reflux down the spermatic cord vein which can be heard by the Doppler stethoscope.

TREATMENT OF MALE INFERTILITY SURGICAL TTREATMENT FOR:

Varicocele high ligature operation ( H.L.O)

Obstructive Azoospermia

Cryptorchidism

Congenital Deformities i.e. Hypospadias.

HORMONAL/MEDICAL:(Treatment for idiopathic oligozoospermia or Oligoasthenozoospermia.)

1 And rogens:

a) Testosterone undecanoate capsules for oral use in divided doses

i.e. Andriol 40mg three times in a day for 3 months.

b) Synthetic androgens Mesterolone (Proviron) 25 mg T.I.D for 3

months.

c) Testosterone esters 250mg oily preparation I.M injection twice a

month for life long to improve the potency.

Clinical application of androgens:

I) Hypergonadotropic Hypogonadism i.e. testicular failure or complete atrophy

2)

Idiopathic delayed puberty.

3)

Asthenozoospermia

4)

Andropause and male aging syndrome.

1 Gonadotroph ins:

i) Leutinizing Hormone L.H. i.e. Human Chorionic gonadotrophins (H.C.G) (Pregnyl) 1500 lU. Twice /week for three months

ii) Human Menopausal gonadotrophins (H.M.G) i.e. (Pergonal)

Intramuscular Inj. One ampoule twice/week for three months

iii) Clinical application of HMG & HCG

1)

Hypogonadotrophic hypogonadism.

2)

Idiopathic oligozoospermia

3)

Maturation arrest (doubtful)

1. Cortisone:

For long period with small dose in autoimmune infertility treatment 10mg prednesoline OD for 3 months.

2.

Bromocryptine (Parlodel):

In hyperprolactinaemia start with low dose 2.5mg daily and

increase gradually weekly until desired dose is reached. The dose has to be adjusted according to the rise in the value of prolactin.

3.

Clomiphene citrate (Clomid)

It

is closely related to estrogens that compete with oestrogen for

steroid receptor in the hypothalamus inhibiting negative feedback mechanism exerted by oestrogens leading to increase of luteinising releasing hormone and follicular stimulating hormone. Increase in FHS & LH improves spermatogenesis. Clomiphene citrate has

cumulative effect, so lower dose is preferable i.e.25mg Once Daily for 3 months.

4. Tamoxifin (Nolvadex)

Similar to clomiphene citrate but with no cumulative effect.

Dose is 20mg/day for 3 months.

5.

Kalli Kerein Therapy

It

is given where there is motility problem as in case of

asthenozoospermia. Give padutin depot 40 I.U three times per

week for 3 months.

6. Vit A & E (Retinol)

A combination of Vitamin A 200,000 I.U with Vitamin E 40 I.U is

given once daily for 3 months.

PREVENTION OF INFERTILITY Frequent genital tract infections can lead to infertility in either of the partners or both hence should be treated judiciously.

Adequate hygiene should be practiced during delivery and post- partum to reduce the incidence of postpartum infections.

All cases that develop post abortion or post partum infection should be treated appropriately, adequately and if need may be,

should be followed up to prevent chronic pelvic inflammatory diseases.

All type of genital tract infections in both partners should be treated adequately and effectively as per the sensitivity of organisms (refer to antibiotic policy guidelines of MOH and SOP manual on STIs & Birth Spacing)

Couples with STIs should be explained on the long-term risk associated with STIs. Efforts should be done to change the high- risk behaviour of both or either of the partners as the situation may be.

Benefits of use of barrier methods should be explained.

APPENDIX