2. Basal body temperature-
BBT falls at the time of ovulation by ½*c
During progestational half of the cycle ,the
temperature is raised above the preovulatory
level by ½ - 1*F. if patient conceives , the
temperature does not fall as it normally would
with the onset of menstruation.
This is due to thermogenic effect of
progesteron. Which is secreted by functioning
corpus lucteum after ovulation.
Recordings of BBT will therefore indicate
weather cycle is ovulatory or not and also
denote the time of ovulation.
3. Method -
Patient is instructed to measure the oral
temperature just after waking up in the
morning before taking any hot or cold drinks
,& to record temperatures on a graph.
Use –
Reveal corpus luteal phase insufficiency.
Defective folliculogenesis .
Now become obsolete because of –
Tedious daily recording.
Not very accurate.
Retrospective diagnosis and not useful
therapeutically.
Better modalities available now (USG).
4.
5. Endometrial biopsy-
Curetting small pieces of endometrium from
the uterus with a small endometrial biopsy
curette, preferably 1/2 days before the onset of
menstruation.
Material is fixed in formalin saline and sent for
histological examination.
Secretory changes prove that cycle has been
ovulatory .
Endometrium is subjected to culture , PCR,
staining .to rule out genital TB.( in 5-10%indian
women complaining sterility)(now a days
Only reason to do the test )
It can also diagnose corpus LPD.
6.
7. Fern test-
A specimen of cervical mucus obtained using a
platinum loop or pipette is spread on a clean
glass slide and allowed to dry.
Low –power microscopy Fern formation
(Oestrogenic phase)
disappear after ovulation.
Due to presence of NaCl in the mucus
(secreted under estrogen effect)
8.
9. Physical charcter of cervical mucus-
1. At ovulation- thin , profuse , clear discharge ,
great elasticity & will withstand stretching upto
10 cm.
SPINNBARKEIT/THREAD TEST (for
oestrogen activity)
2. Secreatory phase- tenacious , viscosity increase
, loses the property of spinnbarkeit , fracture
under tension.
TACK
This change in cervical mucus is an evidence of
ovulation.
12. Ultrasound -
Standard.
Non invasive , accurate and safe.
It is used to monitor –
Maturation of graffian follicle
Normal follicle grows at the rate of 1-2mm daily
to reach 20mm or > when follicular rupture and
ovulation occur.
Detect imminent ovulation in IVF, IUI & in timing
intercourse.
This require daily ultrasonic visualization of
ovaries from10th -16th day of menstrual cycle.
Endometrial thickness (normal-8-10mm)
measurement for diagnosing pelvic pathology.
If thickness is less , it indicates CLPD (corpus
luteal phase deficiency).
13.
14. Other USG findings relevant to infertility
are-
Tubo-ovarian mass
Uterine fibroid
PCOD
Endometrial volume and its blood
supply into the basal layer
3 layered endometrial echogenicity
Endometrial junction upward peristalsis .
Other – Doppler USG, 3D USG.
15. Harmonal study-
1.Plasma progesterone-
Rise after ovulation and reaches
peak of 15ng/ml at mid –luteal
phase (22-23day) and declines as
corpus leuteum degenerates.
<5ng/ml - CLPD
16. Aetiology-
Hypopitutarism with low FSH ,LH
Poor follicular development
Hyperprolactinemia
Clomiphene citrate (CC) ovulation induction
Retrieval of egg in IVF. (CLPD is seen in
postmenarchal and premeopause period)
Poor response of endometrium to endogenous
progesterone.
19. 2. LH-
LH surge from anterior pitutary occur
~24hr. Prior to ovulation.
Radioimmunoassay of morning sample of
urine and blood give the LH result in 3 hr.
Use-
To predict ovulation
Approximate time of ovulation can be
gauged and coitus around this time increase
chances of conception.
( it has therapeutic application in IVF &
artificial insemination).
LH –kits are now available.
20. 3.FSH-
Normal level in preovulatory
phase is 1-8mlIU/ml.
Raised level – ovarian failure (
>25IU/ml on day 3)
Low level- pituitary dysfunction
and anovulation.
21. Aetiology-
During embryogenesis- Poor migration
of premature eggs from the yolk sac .
Early and increased apoptosis of eggs.
Radiotherapy.
Hysterectomy ( deprives blood supply to
ovaries)
Ovarian hyperstimulation.
22.
23. Diagnosis-
Day 3 serum FSH should be 10-15 IU/L or
more .
LH <10IU/L
Day3 serum E2 ( estradiol) should be 60-80
pg/ml or less.
Anti-Mullerian harmone is low (normal0.2-
0.7ng/ml).
Inhibin B is low <40 pg/ml.
Antral follicuular count <4-5mm.on day 2-5
(normal 2-9 mm. in both ovaries )
Ultrasound ovaries volume low
Progesterone on 21st/22nd day >15ng/ml.
24. A.Clomiphene citrate –
It induce ovulation with a dose of 50mg/day
starting from 2 to day 6 of cycle for 5 days .
If response is not satisfactory dose is increased
to 100mg/day from 2-6 day.
Ovulation is monitored by serial USG
monitoring of the follicular size and occurrence
of ovulation.
If required dosage can be increased at infertility
set-up, where monitoring facilities are easily
available. (USG, hormone estimation etc.)
25. If CC therapy fails following 6-8cycles
FSH and hCG therapy recommended .
Risk- Multiple Ovulation and multiple
pregnancies (~10%)
In hypothalamic disorder –GnRH is
given.
Side Effect-
Suppress the peripheral oestrogen action
on cervical mucus and endometrium.
26. B.Letrozole-
More efficient to improve fertility rate.
Dosage- 2.5mg daily for 5 day (2-6 day) or 20
mg single dose on 3rd day.
Contraindicated – severe hepatic dysfunction.
Side effect- drowsiness (no driving).
It is banned by the Gov. Of India. For use in
infertility.(2011)
Because it is found to be teratogenic .( can
cause – bone malformation, cardiac stenosis ,
cancers)
In CC failure-
Clomephine 50 mg with 20mg.tamoxifen .
27.
28. Management –
Medical –
first line of treatment –
1.Combination of CC+ hMG-
CC 50-100mg/day from 2-6 day of cycle for 5
days.
+
Inj. hMG 75 units IM added on day 3,5,7 and
more if required.
If fail-
2. Combination of hMG +hCG is given.
29. 1. Perform baslime oestradiol assay and USG.
2. Give hMG, 2ampule (75IU each) /day for 3
days.
3. Repeat oestradiol.If it is doubled, monitor
hMG dosage, if not, Increase hMG dosage by
50%for3 days.
4. Repeat step 3 until oestradiol doubles.
5. USG every 2-3 days until the dominat follicle
is > or =to 14mm.Thereafter, daily
monitoring till size 20mm is reached.
6. IM inj. hCG5000IU.
7. Inj. hCG3000IU 7 days later.
8. Await onset of menses or perform UPT.
30.
31. 3.GnRH is used in alternative to hMG
Administered in a pulsatile fashion
preferably subcutaneously.
Advantage-
Risk of hyperstimulation is greatly
reduced.
Less monitoring required. When medical
line of treatment fail
Laparoscopic ovarian drilling with
monopolar cautery / laser.
32. 3.Prednisolone-
Used in women with Anovulation and
increased androstenedione .
5mg. Prednisolone at night +2.5mg every
morning.
Poor response to induction of ovulation is
indicated by –
<5follicles on day 5
Estradiol level <300pg/ml.
In such cases, testosterone patches or DHEA
given. 25mg t.i.d for 6 months.
33. It-
improve the number of follicles
Improves ovulation
Increase IGF 1
Decrease pregnancy loss
Reduce age related aneuploidy.
34. Peritubal adhesion
Endometriosis
Diagnosed by laparoscopy
Treated by laparoscopic surgeries.
Endometriosis
Treated medically surgically and by
combination of two
Luteinized unruputured follicular syndrome
Diagnosed by USG
Treated by micronized progesterone or hCG.
35.
36. ART comprises a group of procedures that
have in common the handling of oocytes and
sperms outside of the body. The gamets or
embryos are replaced into the uterine cavity to
establish pregnancy.
Definition –
Any fertility treatment in which the gametes
are manipulated.
It involves surgical removal of eggs known as
egg retrieval.
First successful IVF baby was Louis Brown in
1978.
38. Investigations prior to ART-
Thyroid function test
Random blood sugar test
Serum FSH on day 3 of cycle
Serum oestradiol on day 3
Test for ovarian reserve
Serological evidence of chlamydial
infection
Zona – free hamster oocyte penetrating
test
Enhanced sperm penetration test
Tesing antisperm antibodies
40. Poor prognosis -
Pt. is diabetic
Serum FSH on day 3 is >25mIU/mL.
Serum oestradiol on day 3 is >75pg/mL
Maternal age is >40 yr.
Women over 35 year age who is smoker
or presence of only one ovary and
unexplained fertility.
Presence of Hydrosalpinx ,endometriosis
etc.
41. Oocyte collection-
Antibiotics and
progesterone given
2 days prior to
oocyte collection to
prevent infection
and better
implantation.