Fertility Dr. Ashraf Sabry WWW.ASHRAFSABRY.COM

Dr.Ashraf Sabry WWW.ASHRAFSABRY.COM How does pregnancy happen? Female Genital Tract A female reproductive system consists of internal and external parts. The internal parts consist of the VAGINA which is a muscular tube, 10 cm in length and extends from external opening vulva to the uterus inside. After the vagina comes the uterus which is a hollow muscular organ in the pelvis. It hosts the sperms and the fertilized ovum. The cervix is the entrance gate to the uterus. Two thin tubes extend from the sides of uterus which ends with the ovaries. When an ovary releases an ovum, the fimbria at the end of the tube picks up the ovum and enters it inside the tube. By the end of the tubes and on the sides of the pelvis there lie two almond shaped organs, one on each side called the ovaries. The ovary contains 400,000 eggs by the age of puberty.

Dr.Ashraf Sabry WWW.ASHRAFSABRY.COM How does pregnancy happen? Female Genital Tract The external genitalia consist of mons pubis which is a fat cushion in front of the hip bone. It is covered by hair after puberty. After that comes the labia major which are skin folds on each side of the vulva. It is also covered by hair after puberty. Labia minora are thin skin folds on the inside of the labia major and on the sides of the vulva. The clitoris is a small organ in the upper part of the labia minora which contains sensitive nerves which result in sexual arousal of women. The hymen is a thin layer of skin which covers the entrance of the vagina in virgins; it is torn after the first sexual intercourse.

Dr.Ashraf Sabry WWW.ASHRAFSABRY.COM How does pregnancy happen? Male Genital Tract The man is born with his organs outside his body. On the outside it consists of a penis and scrotum which contains the testis, while inside it consists of the prostate and the seminal vesicles. The L.H hormone from the pituitary helps in production of TESTESTERONE hormone. F.S.H and TESTESTERONE together help in production of sperms from the testes. The prostate and seminal vesicles release the seminal fluid which offers nutrients for the sperms. The sperms move towards the spermatic cord where it mixes with the seminal fluid and is ejaculated outside from the penis during intercourse.

Dr.Ashraf Sabry WWW.ASHRAFSABRY.COM How does pregnancy happen? Menstrual Cycle and Ovulation At the beginning of each month the pituitary gland releases F.S.H hormone which to chooses some eggs in the each ovary to prepare them for fertilization by increasing their size. The growing eggs release ESTROGEN which prepares the endometrial cavity of the uterus and the cervical secretions. Usually one egg reaches the optimal size for fertilization, followed by release of L.H hormone from the pituitary which starts the maturation and ovulation process where the ovum breaks from its cover of cells and is released outside the ovary to be picked by the fimbrial ends of the fallopian tubes, this occurs at the middle of the month approximately. The egg leaves behind the layers of cells (Sac) which used to surround it (Yellow body now); this sac releases PROGESTERONE which supports pregnancy if it happens. If pregnancy does not happen the hormone levels decrease and the endometrial cells starts to break and come out as menstrual blood.

Dr.Ashraf Sabry WWW.ASHRAFSABRY.COM How does pregnancy happen? Fertilization Pregnancy happens after the ability of the male to produce healthy sperms and the female healthy eggs, Release of the ovum to be picked by the tubes, Ability of the sperms to move from the vagina through the secretions of the cervix and continues its way through the uterus to the tubes till it meets the egg and fertilizes it. Cell cleavage happens while moving towards the uterine cavity. Two cells after 30 hours, 4 cells in 48 hours, 8 cells in 72 hours then the morula and blastocyst at 5 days. The blastocyst starts to implant into the endometrial cavity on the sixth or seventh day.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Causes

Varicocele Erection problems WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Male Causes - Blockage in the spermatic cord - Problems in the testicular tissue not being able to produce sperms at all. - Disturbance in the hormones concerned with making of sperms. - Defects in the seminal fluid created. - Sexually transmitted diseases. - Genetic diseases - Bad habits like nervousness and smoking. - Other causes like injuries to the testes and other chronic illness of the body.

Vagina Uterus : Adhesions in cavity Fallopian Tube Ovary : low reserve – genetics WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Female Causes

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Endometriosis It is the presence of endometrial tissue outside the uterus (ovaries, tubes, pelvis, abdomen, rectum, liver, bladder, etc). This tissue menstruates like a normal uterus but the blood is trapped in the pelvis leading to adhesions and pelvic scarring therefore possible delayed conception. The causes of endometriosis are still unknown but theoretical regurge of endometrial cells through the fallopian tubes and into the pelvis is one of the reasons.

Others : Sperm antibodies Severe anemia or choric illness Lack of awareness Bad Habits Anxiety Weight Problems Unexplained WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Hormones

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Diagnosis

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry When the couple agrees on starting their quest to know their problem they visit the reproduction specialist. The specialist: 1- Takes information from the couple on the history of the case and their personal history. 2- History of sexual intercourse. 3- General clinical examination then performs specialized tests. Diagnosis

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Semen analysis Ultrasound on testis and scrotum Hormonal Analysis Biopsy from the testes Male Diagnosis

Hormonal analysis Female diagnosis WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry They are done on specific days of the period Testosterone – prolactin - thyroid – progesterone – pituitary FSH and LH – estrogen levels

Ovarian Reserve Testing WWW.ASHRAFSABRY.COM Day 3 FSH and Estradiol (E2) test Antimullerian hormone in any day of the cycle Antral follicles in the follicular phase of the cycle Dr.Ashraf Sabry

Vaginal discharges Body Temperature Ultrasound Ovulation kits Blood progesterone level WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Ovulation detection

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Ultrasound It is a machine that uses ultrasound waves to draw the internal organs of the wife on a display screen. There is two dimensional black and white ultrasound, 3D ultrasound which gives a more detailed 3 dimensional picture. It is used to look at the size and shape of the uterus and the thickness of the uterine lining (endometirum), Look at the size and shape of the ovaries, Check the condition and size of the ovaries during treatment for infertility and Pelvic ultrasound may also be done to check the growth of uterine fibroids.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Hysterosalpingography The doctor injects a solution through the cervix which is reflected by X-Ray. Normally The solution passes through the cervix then fills the endometrial cavity, and comes out from the fallopian tube into the pelvis. This is important to check patency of the tubes and endometrial cavity and abnormalities in the shape of the uterus. It also gives an idea about the pelvic cavity.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Hysterosalpingography Hysterosalpingography

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Laparoscopy The doctor inserts a scope through a small incision in the abdomen which is connected to a monitor allowing the surgeon to see what is inside. It is used to check the ovaries, pelvis, and uterus. It is the most important test for endometriosis and pelvic adhesions. It can also be used to perform small surgeries like removing an ovarian cyst or cutting adhesions or cutting endometriosis patches using other instruments entered from different incisions.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Laparoscopy

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Hysteroscopy It is a scope that allows the doctor to look into the uterus directly by inserting it into the uterus after inflating it with certain fluid or gas. It is attached to a TV system. It used to check for abnormalities in the uterus and can be used to perform small surgeries like cutting a uterine septum, clearing intra uterine adhesions or removing a fibroid.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Hysteroscopy

Endometrial Biopsy WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Post Coital Test The couple has intercourse on ovulation day then the wife comes to the doctor without vaginal washing to take a sample from the fluids inside it which is then tested for presences of sperm problems which occurs after ejaculation in the vagina and any problems or diseases in the cervix.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Treatment

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Treating the general health like anemia or chronic illness Weight control and exercise No bad habits like smoking General Treatment

Surgical extraction of sperms WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Male Factor Treatment Treating male factor by varicocelectomy operation or tonics

Fixing hormonal disturbances like HIGH PROLACTIN WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Medical Treatment For Women Without induction Induction WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Ovulation induction and monitoring: Ovulation induction is the use of certain medication to stimulate development of multiple mature follicles and eggs or to help in cases of anovulation. Before using the drug the woman has to test her hormones and undergo ultrasound test to check her readiness for induction. During induction she should be followed by hormonal testing and Ultrasonographic for egg growth and endometrial growth and pattern to monitor the effectiveness of the drugs in inducing ovulation.

Reproductive Surgeries drilling of the ovary in P.C.O excision of cysts by laparoscopy Treatment of uterine fibroids or polyps by open surgery or hysteroscopy or laparoscopy. WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry

التثقيب بالمنظار في حالة تكيس المبايض PCO استئصال الأكياس علي المبيض علاج الجراحي لبطانة الرحم الهاجر استئصال أورام ليفية أو التصاق داخل الرحم بالمنظار الرحمي علاج الأورام الليفية . Surgical removal of endometriosis by laparoscopy Reproductive Surgeries Lysis of adhesions can be performed or blocked tubes can be re-opened with surgery. Operations can be done either by laparoscopy or open laparotomy method. Laparoscopy is preferred as hospital stay is less but some operations laparoscopies cannot be used. WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Assisted reproductive techniques Assisted reproductive techniques involve the laboratory preparation of sperms, ovum or both and artificially bringing them together to raise the fertility rates. It is used in cases of tubal occlusion or severe endometriosis or adhesions in the pelvis or low sperm motility or prolonged unexplained infertility. It is also used in cases of high semen viscosity or male sub fertility like low count or motility. It is also used in cases of severe endometriosis or polycystic ovaries.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Intrauterine insemination It is a technique used for male problems with (erection problems, low count or motility of sperms) or sperm antibodies or unexplained infertility. Intra uterine injection of sperms after preparing them with special material that increases their motility. They are injected by a special catheter at ovulation time in the uterus which can be natural or drug induced.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry In Vitro Fertilization

Without induction Induction WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Ovulation Induction In case of IVF or ICSI we need more than one egg. Ovulation induction is performed by giving a preparatory drug (GnRh agonist or antagonist) then giving (HMG/FSH) which helps eggs to reach the correct size and maturity for fertilization. During induction the woman should be monitored well by ultrasound measurement till the eggs reach the best size and then other drugs are given which induces ovulation within 36 hours from taking them after which eggs are collected.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Egg collection by vaginal ultrasound with needle Eggs are collected through the vagina with the aid of vaginal ultrasound with a special aspiration needle attached. A needle is passed through the top of the vagina under ultrasound guidance to get to the ovary and follicles. The fluid in the follicles is aspirated through the needle and the eggs detach from the follicle wall and are sucked out of the ovary.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry A - In Vitro Fertilization Some sperms are placed into a special plate with media containing aspirated eggs.

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry B- intra cytoplasmic injection The mature egg is held with a specialized holding pipette. Then a very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm which is then carefully inserted through the zona (shell of the egg) and in to the center (cytoplasm) of the egg.

They are placed into plates with nutrient and enrichment media which are kept into incubators at certain temperature with enough oxygen WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry After fertilization

WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry Embryo transfer to the uterine cavity after 3-5 days After about 3 days 2-5 embryos of the best quality are transferred into the endometrial cavity using a special embryo transfer catheter which does not harm the embryos or endometirum. Before the transfer the doctor measures the cervical and endometrial length by ultrasonographic then injects the syringe with embryos inside them through the catheter and into the uterus.

The woman is given hormonal support drugs that help the embryos to implant inside the endometirum. After 14 days the woman is tested for pregnancy by checking her HCG levels and if found pregnant she would return for checking her pregnancy by ultrasound and during that time she would be under good medical care. Follow up After 14 days the woman is tested for pregnancy by checking her HCG WWW.ASHRAFSABRY.COM Dr.Ashraf Sabry if found pregnant she would return for checking her pregnancy by ultrasound

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