DR/ ADEL FAROUK M.D.

ASSISTANT PROFFESOR of
Obstetrics & Gynecology
Cairo university
Infertility IV
 Uterine factor of infertility
 Etiology: see causes of infertility.
Diagnosis:
 History:

 Aplasia: Primary amenorrhea.

 Hypoplasia: Hypomenorrhea or habitual abortion

with increasing duration.
 Intra-uterine synechiae: History of curettage.

 Tuberculous endometritis: History of pulmonary

T.B, pelvic pain and menstrual disturbance.
 Fibroid polyp: Menometrorrhagia, discharge and

spasmodic dysmenorrhea.
 Uterine factor of infertility
 Examination:
 Aplasia: Bimanual examination and P.R
examination.
 Hypoplasia: Bimanual examination and
sounding.
 Intra-uterine synechiae: Failure to pass a
sound or limited mobility of the sound.
 Tuberculous endometritis: Bimanual
examination may reveal: retroverted fixed
uterus, tender adnexal cystic swellings or
nodules in the Douglas pouch.
Uterine factor of infertility
 1- Ultrasonography: Absent uterus (aplasia)
Hypoplasia or Fibroid polyp.
 2- Hysterosalpingography or HyCoSy:
 - Intra-uterine synechiae (filling defects).
 - Submucous fibroid.
 - Pelvic T.B (characteristic hysterographic picture)
(see pelvic T.B).
 3- Hysteroscopy: office hysteroscopy can be done
as outpatient procedure or under general
anesthesia
 - Submucous fibroid or fibroid polyp.
 - Intra-uterine adhesions.
 4- Laparoscopy: can detect Aplasia, Hypoplasia or
Pelvic T.B.
 Treatment of uterine factor
Treatment of the cause:
 Aplasia: No treatment.

 Hypoplasia: cyclic estrogen and

progesterone.
 Fibroids: Myomectomy for those causing
bilateral cornual obstruction.
 Adhesions: Cutting adhesions by
hysteroscopic resectoscope, prevention of
recurrence by insertion of lippes lope I.U.D.
or pediatric Foley’ s catheter with antibiotics
and corticosteroids for 1 week ; later
stimulation of endometrial growth by
 Cervical factor of infertility
 Diagnosis:
 History: May be suggestive of one of the causes:
 Cervicitis: Backache, vaginal discharge and
congestive dysmenorrhea.
 Prolapse: Mass filling the vagina or protruding
from the vulva.
 History of cauterization or conization.
 Examination:
 Chronic cervicitis: Erosion, hypertrophy or nabothian
follicles.
 - Prolapse or retroversion.
 Cervical fibroid or polyp.
 - Cervical stenosis or elongation using a sound.
 Cervical factor of infertility
 1- Quality of cervical mucus:
 Assessed in the pre-ovulatory period (the
cervical mucus most suitable for sperm
penetration) it should be:
 - Profuse. - Thin. - Clear.
- Acellular. - Alkaline.
 - Ferning: Maximum +4 (due to presence of NacL
and KcL).
 - Thread test: Maximum (length of thread about
10cm).
 Cervical factor of infertility
 2- Bacteriological studies: Of the cervical
mucus as infection can affect the quality of the
cervical mucus (mucopurulent, thicker, cellular
mucus containing Leucocytes).
 A scoring system (Moghissi score) is used to
evaluate the cervical mucus, whereas every
item (volume, viscosity, cellularity, thread and
ferning) takes a score of 0,1,2or 3 with a
maximum of 15. If the score is 11 or more, it is
considered adequate if less than 5 it is
considered inadequate i.e. hostile.
 Post coital test
It is done at the time of ovulation.
should be preceded by semen analysis to exclude male
factor.
No sexual intercourse or vaginal douching for the past 2
days.
Sexual intercourse is done without lubricants not followed by
douching.
Method:
 - The patient is examined 6-10 hours following intercourse
by a non-lubricated speculum.
 - A drop of the discharge is taken from the posterior fornix
and another drop is taken from cervical mucus.
 - Both drops are examined microscopically for the number
of living and dead sperms, the type of motility whether
progressive (active) or sluggish and the number of
Leucocytes (denoting infection).
 N.B: The presence of more than 5 progressively motile
sperms/ high power field in the cervical mucus indicates
 Post coital test
Vaginal drop Cervical drop Result

No sperms No sperms Failure of

deposition (or
azoospermia)
Dead sperms No sperms. Excessive vaginal
acidity.

Living sperms Dead sperms. Hostile cervical mucus.

Living sperms Living sperms. Normal.

 Post coital test
 If post coital test is abnormal, it is
repeated in the next cycle after treating
any obvious infection, and if still
abnormal a sperm penetration test is
done to detect the cause of abnormal
PC.T is in the sperm or in the mucus.
PCT,not
necessary,
because
same ttt of
normal, abn.
 Sperm penetration test (Miller Karzok test)
 It is done in cases with poor results in
post coital test to confirm its results.
 - Done at the expected time of ovulation
to detect the vitality of the sperms and
the density of the cervical secretion.
 - A drop of cervical secretion is placed on
a dry slide beside a drop of the seminal
fluid
 (Both drops should be just in contact with
each other) and covered by a dry cover.
 The slide is examined under the high
power after 15 minutes.
 Sperm penetration test (Miller Karzok test)

 Interpretation:
 Normally; semen and cervical mucus do
not mix.
 The test is considered normal if the
sperms can penetrate the cervical mucus
in a spear head manner and the sperms
remain motile for several hours.
 If the mucus is hostile, the sperms may
fail to penetrate it or lose their motility in
few minutes.
 Treatment of cervical factor
 1- Treatment of the cause.
 2-assisted reproduction technology:

- Artificial (intrauterine) insemination (I.U.I).

- Gamete intra-fallopian Transfer (G.I.F.T).
- Zygote intra-fallopian Transfer: (Z.I.F.T)
- In vitro fertilization & Embryo Transfer
(I.V.F,E.T):
 Treatment of cervical factor
1- Treatment of the cause:
 Chronic cervicitis: Cautery and antibiotics.
 Prolapse and retroversion: Surgical repair.
 Cervical stenosis: Dilatation.
 Cervical fibroid: Surgical removal.
 Congenital elongation: Amputation of a part of the
elongated cervix.
 Incompetent isthmus: (causing habitual abortion) is
treated by cerclage operation.
 Excessive viscosity of cervical mucus: Is treated by
small doses of estrogen e.g. 0.01-0.02 mg ethinyl
estradiol daily for 10 days starting or day 5 from the
onset of menstruation. Larger doses may inhibit
ovulation.
 Anti-sperm antibodies: Male uses condom for 6
 vaginal factor of infertility
Etiology
Diagnosis (post-coital test).
Treatment: treatment of the cause
 - Excessive vaginal acidity can be corrected by pre-
coital douches of 1% sodium bicarbonate
 - Vaginitis (if present) should have the proper
treatment.
 Treatment of infertility
 Treatment of General causes: treatment of endocrine
disorder as myxoedema and diabetes.
 Treatment of disturbance of sexual relations:
 - Timing the sexual relation in the fertile period.
 - Proper treatment of dyspareunia and vaginismus
(see later).
 - Sometimes artificial insemination by husband’s
semen under anesthesia may be needed in
vaginismus resistant to treatment.
 - Raising the buttocks on a pillow during sexual
relation may be helpful for effluvim seminis
 Assisted reproduction (conception)
technology (ART)
 Assisted reproduction technology (ART) are
recent methods designed for helping married
couples with infertility problems in whom other
natural methods failed to overcome their
problems.
 They are mainly indicated in( male factor of
infertility, cervical factor, endometriosis and
unexplained infertility) some of them are
indicated in other conditions as tubal factor
(IVF& ET) and (ICSI)
Assisted reproduction technology (ART)
 Intrauterine insemination (AIH) (IUI)
 Invetro Fertilization and Embryo transfer (I.V.F.,
E.T).
 Gamete-intra-fallopian Transfer (G.I.F.T.). The
oocytes are collected under laparoscopic control,
mixed with the prepared semen and transferred to
the fallopian tube by a special catheter
 Zygote intra-fallopian Transfer (Z.I.F.T). Fertilized
oocytes (zygotes) are transferred into the falloipian
tube
 Subzonal insemination (SUZI)
 Intra-cytoplasm sperm injection (I.C.S.I.).
 Testicular sperm aspiration (TESA)
 Percutaneous sperm aspiration (PESA)
 Micro-epididymal sperm aspiration (MESA)
 Of all techniques mentioned above, I.VF and ICSI are
Intrauterine Insemination
 The rationale
is that
increasing
the density
of both eggs
and sperm
near the site
of
fertilization
will increase
the likelihood
 Indications for IUI
• The impossibility of • Abnormal male
vaginal ejaculation factor
- psychogenic or - oligospermia
organic impotence - asthenospermia
- severe - teratospermia
hypospadias, • Unexplained
retrograde infertility
ejaculation • Cervical factor
- cry preservation of infertility
sperm in cases of • Husband is away
cancer treatment. from wife for long
time (work abroad)
• HIV negative women
 IUI : Step by Step
 Patient’s selection
 Natural cycle or
 Controlled Ovarian stimulation.
 Monitoring of treatment, to
measure the growth of follicles,
individualize drug doses, and
prevent hyper stimulation.
 Sperm preparation
 Insemination
 Luteal support.
 Selection of patients
 A Valid indication for IUI
 Normal or mildly abnormal semen parameters
(Semen analysis within 3 months of the
planned IUI)
 No evidence of intrauterine disease and
patent tubes (at least one) as
shown in a Recent HSG or (laparoscopy /
hysteroscopy)
 Female age < 43 years ?
(Day 3 FSH < 10-15
mIU/Ml, if age > 37 yrs)
 Protocol of natural
cycle IUI
 Monitoring begins 16 days before
expected menses by TVS for follicular
maturation.
 Once a mature sized follicle of 18-24
mm & > 9mm trilaminar endometrium
are obtained the woman will monitor
urinary LH every 4-5 hours.
 Intrauterine insemination is timed 36-
40 hours from the LH surge and will
be repeated within 12 hours if the
oocyte had not released as yet.
 Sperm processing
Rationale
 Concentration of progressively motile and
morphologically normal spermatozoa into a
small volume of culture fluid.
 Elemination of seminal PG, lymphokines,
cytokines and infectious agents
 Reduce the number of free oxygen radicals.
 Sperm processing

 Simple Sperm wash

 Swim-up following
sperm wash once or
twice.
 Density gradient
column separation
(filtration in Percoll
gradients, PureSperm
or Isolate).
 Adding chemicals to
the washed sperms
(caffeine ,
 Sperm processing
 Samples with an acceptable number of
motile sperm ( > 20 millions / ml ) can be
processed efficiently by sperm wash twice
and swim-up.
 Poor quality semen samples should be
processed using density gradient
centrifugation DGC.

Morshedi M et al, 2003

 Timing and Frequency of IUI

Fixed protocol:
• Single insemination:
36 – 40 hrs post – hCG
• double insemination:
within 12 & 48 hrs post - hCG

Variable protocol:
• TVS 36 h post hCG:- Ovulated → single IUI
- Not Ovulated→ IUI at once
→ IUI 24 hrs later
 IUI technical aspects

- Partially filled urinary bladder; lithotomy position

& abdominal US
- Gently and atrumatically clean the cervix with
saline soaked swab
introduce IUI catheter through cervix; no touch to
fundus
- Slowly inject 0.3-.05 ml of processed semen
 Management following IUI
• Bed rest
A 10 minutes bed rest
after IUI has a positive effect on PR.
• Intercourse within 12-18 hours of IUI.
• Luteal phase support, OPTIONS:
- hCG: 1.500 IU hCG 3 & 6 days after 1st hCG
- Duphastone 10 mg PO / 8 hourly after IUI
x 14 days
- Cyclogest 400 mg supp. PV or PR; once
daily after IUI x 14 days
- Utrogestan: 100 mg PV / 8 hourly after IUI
x 14 days
G.I.F.T
 Indications of I.V.F, E.T
 1- Irreparable tubal damage.
 2- Endometriosis.
 3-Unexplained infertility.
 4- Male factor (oligospermia) as an
alternative to G.I.F.T. technique.
 5- Cervical factor as cases of sperm
antibodies if G.I.F.T or I.U.I fails.
 Complications: success rate around 30%
per cycle in well-selected cases, expensive,
increased risk of abortion and ectopic
pregnancy.
A typical IVF-ET cycle consists of
 Initial consultation and tests: to choose the most suitable
technique and to explain the procedure, its side effects
and success rates (patient counseling).
 Pituitary downregulation: using Gn-RH analogues to
avoid spontaneous LH surge.
 Ovarian stimulation: using FSH (recombinant or urinary)
[see later] or HMG until the leading follicle reach a mean
diameter of 18-20 mm.
 Ovulation trigger with HCG: oocyte collection is carried
out 34-36 hours after HCG administration.
 Oocyte collection: under transvaginal guide.
 Oocyte culture: the cumulus oocyte complex is identified
under the microscope in the folliculat fluid and incubated
at 37 degrees in culture media.
A typical IVF-ET cycle consists of
 Sperm preparation: sperms are collected by
masturbation or sperm aspiration (in cases with
azoospermia), collected sperms are added to a
special culture media.
 Sperm insemination: in IVF, prepared sperms
(between 100,000 and 200,000) are added to each
oocyte 4to 6 hours after they are collected, while in
ICSIa sperm is injected directly into the cytoplasm of
the metaphase II oocyte through the zona pellucida
under the microscope (micromanipulation) .
 Fertilization and embryo cleavage: cumulus cells
are removed from each oocyte 16-18 hours after
insemination, oocytes are then traferred to fresh
culture medium and examined for fertilization
(presence of two pronuclei)
 Embryo transfer: Embryos are normally transferred
to the uterus 2-3 days after oocyte collection.
 Luteal phase support: by administration of
Steps of I.V.F
 Oocyte
retrieval after
induction of
ovulation.
I.V.F
 I.V.F

Collection of the Detection of the

Ovum pick up by needle
follicular fluid oocytes in the
attached by the vaginal probe
follicular fluid
I.V.F
Steps of I.V.F (continued)
 Two cell
stage of the
fertilized
ovum.

 4 cell stage
of the
fertilized
Steps of I.V.F (continued)

 Embryo
transfer by a
special
cannula to
inside the
uterine cavity.
I.V.F
ICISI

 Injection of the
sperm in the
cytoplasm of
the mature
ovum.
I.C.S.I