Female & Male Infertility, Sexual Dysfunction PDF

FEMALE AND MALE INFERTILITY, SEXUAL DYSFUNCTION K. Doğa Seçkin, Prof Dr. ISTINYE UNIVERSITY FACULTY OF MEDICINE LEARNING OBJECTIVES 1.DEFINITION OF INFERTILITY 2.INCIDENCE 3.CAUSES OF INFERTILITY 4.RESEARCH METHODS 5.MALE FACTORS 6.CONCEPS OF SEXUALITY 7.RISK FACTORS FOR...

FEMALE AND MALE INFERTILITY, SEXUAL DYSFUNCTION K. Doğa Seçkin, Prof Dr. ISTINYE UNIVERSITY FACULTY OF MEDICINE LEARNING OBJECTIVES 1.DEFINITION OF INFERTILITY 2.INCIDENCE 3.CAUSES OF INFERTILITY 4.RESEARCH METHODS 5.MALE FACTORS 6.CONCEPS OF SEXUALITY 7.RISK FACTORS FOR SD Infertility is generally defined as 1 year of unprotected intercourse without conception. Approximately 85-90% of couples conceive within 1 year and therefore infertility affects approximately 10-15 % of couples Fecundability is the probability that a single cycle will result in pregnancy( 20-25% in normal couples) Fecundity is the probability that a single cycle will result in a live birth.  The epidemiology of infertility in the US The crude birth rate was 55 per 1,000 population in 1790, it was 14.1 per 1,000 population in 2001 representing nearly a 75% decline over the past 200 years This decline can be attributed to several factors Greater interest in education and carreer Later marriage and more frequent divorse Improvement in contraception Delayed childbearing Decreased family size  Normal reproductive efficiency Time Required for Conception In Couples Who Will Attain Pregnancy ---------------------------------------------------------- Time of Exposure %Pregnant ---------------------------------------------------------- 3 months 57% 6 months 72% 1 year 85% 2 years 93%  Indication for Evaluation Evaluation should be offered to all couples who have failed to conceive after a year or more of unprotected intercourse. Women older than age 35 Women with irregular menses Women with family history of early menopause Previous ovarian surgery, chemotherapy or radiation Demonstrated poor response to exogenous gonadotropin stimulation  The Female Infertility Evaluation History Gravity, Parity Cycle length and characteristics Coital frequency and any sexual dysfunction Duration of infertility and result of any previous evaluation and treatment Past surgery ,its indications and outcomes Previous abnormal pap smear Current medications and allergies Occupation and use of tobacco, alcohol, drugs History (continue) Family history of birth defects , early menopause or reproductive failure Symptoms of thyroid disease, pelvic or abdominal pain, galactorrhea , hirsutizm, and dyspareunia Medical history for male factor infertility. Congenital abnormalities Undescended testes Prior paternity Frequency of Intercourse Exposure to toxins Previous surgery Previous Infections, treatment Drugs and medications General health (diet, exercise, review of systems) Decreased frequency of shaving  Physical Examination Weight and body mass index Any thyroid enlargement , nodule and tenderness Breast secretions and their character. Signs of androgen excess. Pelvic or abdominal tenderness Vaginal or cervical abnormality, secretions , discharge Any mass, tenderness, or nodularity in the adnexa or cul-de sac.  Screening Tests Pap smear A blood type, Rh factor, antibody screening (in Rh-negative women) Screening for cystic fibrosis Screening for TORCH , sexually-transmitted disease, hepatitis B, Chlamydia(RNA/DNA based test), hepatitis c antibody, Human immunodeficiency virus type I (HIV-1) syphilis  Causes of Infertility Ovulatory dysfunction % 15 Tubal or peritoneal pathology %30-40 Male factors %30-40 Unexplained %15-20 Male Factors: Abnormalities of Semen Quality  Ovarian Factor : Ovulatory dysfunction Menstrual History Basal body temperature (BBT) Serum progesterone concentration( > 3 ng/ml) Urinary LH excretion Transvaginal ultrasound Ovulatory Factor An ovulatory dysfunction is responsible for approximately 20-25% of infertility cases ( -40% of female factor infertility). Follicular pool- Early in gestation, the germ cells undergo mitosis to produce oogonia -- approximately 6 million, in her ovaries at 20 weeks -- 1-2 million oocytes at the time of birth. -- approximately 500,000 oocytes at the time of first ovulation Ovarian reserve An inverse relationship exists between fecundity and the age of the woman There is a decrease in follicular quality as a result of an increase in oocytes with chromosomal anomalies and progressive deletions in mitochondrial DNA. Ovarian reserve should be evaluated in women older than 35 years of age FSH ESTRADIOL ANTI-MULLERIAN HORMON (AMH) INHIBIN-B ANTRAL FOLLICUL COUNT (AFC)(BY USG) Confirmation of ovulation Mittelschmerz Regular menses with molimina(headaches, bloating, cramping) Mild dysmenorrhea Serum progesterone assay performed in the mid- luteal phase or 1 week before expected menses (Progesterone levels of< 3 ng/mL are consistent with ovulation) Pelvic ultrasonography Basal body temperature (BBT) Cervical mucus changes (with loss of the crystalline fernlike pattern on drying).  Cervical Factor Postcoital test (Sims – Hühner test) :Cervical mucus is collected before the expected time of ovulation, a few hours (2-12 hours) after intercourse. It is examined in both a gross and microscopic examination to grade mucus characteristics and to asses the number and motility of surviving sperm  Physical characteristic of mucus include: Its volume, pH , clarity, cellularity , viscosity (spinnbarkeit) and salinity (ferning) The presence of motile sperm in the mucus confirm effective coital technique and sperm survival Uterine factor:Anatomic and functional Abnormalities Congenital malformations Leiomyoma Intrauterine adhesions , endometrial polyps Chronic endometritis  Basic Methods for Evaluation of Uterine Cavity Hysterosalpingography (HSG) Standard transvaginal ultrasound Transvaginal ultrasound with saline contrast Hysteroscopy Hysterosalpingography (HSG) HSG is a fluoroscopic study performed by instilling radiopaque dye into the uterine cavity through a catheter to determine the contour of the endometrial cavity and patency of the fallopian tubes. Sensitivity and specificity of an HSG are approximately 65% and 85%, respectively. Transvaginal ultrasound with saline contrast Hysteroscopy  Sexual dysfunction Sexual health is strictly related with general health in both genders Sexual health is characterized by a complex and multidimensional process coordinated by neurological, endocrine, and vascular systems The impairment of sexual function may have a detrimental effect on: Self-esteem Body image interpersonal relationships Physical health Fertility ED The modifiable risk factors for male and female sexual dysfunctions are: Smoking Physical inactivity Obesity Excessive alcohol Drug consumption Obesity Together with the high prevalence, obesity negatively impacts on physical, psychic, and sexual health prevalence rates of sexual dysfunctions in the obese population: 7–22% for women (coital pain, arousal problems, and sexual dissatisfaction) 5–21% for men (ED and decrease of desire) Patients with ED generally have a body weight and a waist circumference on average higher than healthy patients. Overweight and obese women also have a lower sexual function than healthy women Physical activity Physical activity is associated with a lower risk of developing ED because it increases endothelial NO production and decreases oxidative stress. The presence of a sexual dysfunction, measured by Female Sexual Function Index (FSFI), was found in 67% of the women and associated with a sedentary lifestyle. Loss of weight and dietary factors Weight loss is associated with an improvement of many biological, psychological and sexual factors. Smoking One of the main effects of cigarette smoking is the decrease in vasodilatation of vascular endothelial tissues Chronic smoking causes ED in men, while Alcohol The alcohol consumption, particularly in alcohol-dependent subjects, lead to the development of a sexual dysfunction, especially to ED in men and reduced vaginal lubrication in women Female patients seeking treatment for alcohol dependence syndrome reported mostly low sexual desire (55%), inability to reach orgasm (52,5%) and, when reached, unsatisfactory Substance use Marijuana Cocaine Amphetamine Heroin Ecstasy Chronic stress Physiological perspective, an increase in chronic stress induces high levels of cortisol, which can cause harmful effects if it remains altered in the long term.