Infertility

Mohammed A.
Outline
Definition of infertility
❑ Primary

❑ Secondary

Male factor infertility

❑ Causes

❑ Diagnosis

❑ treatment

Female factor infertility

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 INFERTILITY
Infertility is failure of a couple to conceive after 12 months
of regular intercourse without use of contraception in
women <35 years of age; and after 6 months of regular
intercourse without use of contraception in women >35
years
Some clinicians use the term subfertility to describe this
failure to conceive unless the couple has been proven to be
sterile
Sterility implies an intrinsic inability to achieve pregnancy,
whereas infertility implies decrease in the ability to
conceive

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Cont’d.
Fecundablity, the probability of achieving a pregnancy in one
menstrual cycle
Fecundity is the probability of achieving a live birth within a
single cycle
Fecundablity of couples in a single menstrual cycle is 20-25%
Based on this estimate 85% of apparently normal couples will
conceive within the first year of attempted conception
Patients who have not achieved pregnancy after 12 months have
even lower fecundability.

4
Cont’d.
Infertility is a common condition with important
psychological, economic, demographic, and medical
implications
A unique medical condition because it involves a couple,
rather than a single individual
Infertility could be
Primary infertility – applies to those who have never
conceived
Secondary infertility – designate those have conceived at
some time in the past

5
Cont’d.
Epidemiology
Global incidence 8 – 12%
The incidence rise to 20 – 30% in sub-Saharan Africa
Factors contributing to high prevalence in sub-Saharan
Africa
STI
Unsafe abortions
Unhygienic obstetric practice
Female genital cutting
High prevalence of Tuberculosis
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Cont’d.
Etiology(Causes of infertility)
Female factor =40%
Male factor =30%
Both =20%
Unexplained=10%

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Cont’d.
The basic investigations that should be performed before
starting any infertility treatment are
Semen analysis
Confirmation of ovulation
Assessing ovarian reserve for woman >35years
Documentation of tubal patency

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Cont’d.
Seminal analysis
Most important male fertility evaluation
Cheap and non-invasive
Normal result exclude male factor infertility
Test should be done after 2-3 days abstinence
Condom shouldn’t be used for sample collection
It should be examined within 1 hour of collection

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Cont’d.
Normal parameters of sperm
analysis(WHO)
Volume – 2-5 ml
Total sperm count – >20 million/ml
Sperm motility of >50-60%
Morphology >50% normal(Strict
criteria >15%)
PH -7.2 -7.8
Of which sperm count & motility are
the most important factor

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Physiology of spermatogenesis

The male reproductive tract consists of the testis,

epididymis, vas deferens, prostate, seminal vesicles,
ejaculatory duct and urethra.
In the man, the hypothalamus and pituitary gland should be
normal for the spermatogenesis and testosterone synthesis
The testes is the site of spermatogenesis and testosterone
synthesis

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Cont’d.
The epididymis is an important site for sperm maturation
and an essential part of the sperm transport system.
The vas deferens then transport sperm from the epididymis
to the urethra, where they are diluted by secretions from
the seminal vesicles and prostate.
Finally, semen must be ejaculated
Abnormalities at any of these sites, particularly the
epididymis and vas deferens, can cause infertility

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Cont’d.
The semen released is a gelatinous mixture of spermatozoa
and seminal plasma; however, it thins out 20 to 30 minutes
after ejaculation by a process called liquefaction.
Liquefaction occurs secondary to the presence of
proteolytic enzymes within the prostatic fluid.
The released spermatozoa are not usually capable of
fertilization.
Instead, a series of complex biochemical and electrical
events, termed capacitation, must take place within the
sperm's outer surface membrane before fertilization in the
cervical mucus
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Cont’d.
Finally, as part of fertilization, the sperm must undergo the
acrosome reaction, in which the release of enzymes of the
inner acrosomal membrane results in the breakdown of the
outer plasma membrane
The acrosome reaction and binding of sperm and ovum
surface proteins are important for the penetration of the
ovum's zona pellucida and subsequent fusion between the
ovum and sperm.
As the sperm penetrates the egg, it initiates a hardening of
the zona pellucida (cortical reaction), which prevents
penetration by additional sperm
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Causes of male infertility
The causes of male infertility can be divided into 4 main
areas
1. Hypothalamic pituitary disease(hypogonadotropic
hypogonadism = Pretesticular disorders)
Low level LH, FSH, testosterone
1 to 2%
Constitutional
Emotional stress
Malnutrition
Obesity
Tumors 15
Cont’d.
2.Testicular disease(gonadal
failure)
Hypergonadotropic hypogonadism
Elevated levels of LH and FSH with
low serum levels of testosterone
30 to 40%
Congenital or developmental disorders
Undescended testicle
Genetic defects
Klinefelter syndrome(47,xxy)
Acquired(e.g., radiation therapy,
chemotherapy, testicular torsion, or
mumps orchitis)

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Cont’d.
3. Post-testicular defects(disorders of sperm transport)
Normal level of FSH, LH, testosterone
10 to 20%
Congenital absence of vas deference
Obstruction of vas deference
Abnormalities of epididymis
Sexual disorders
Impotence
Retrograde ejaculation
4. Idiopathic male infertility
40 to 50%

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Cont’d.
Semen analysis is the fundamental investigation for the
infertile man and directs the subsequent evaluation.
If routine semen analysis is abnormal, it should be repeated.
If repeated semen analyses demonstrate severe
oligozoospermia (<5 million spermatozoa/mL) or
Azoospermia, basal serum FSH, LH, and testosterone
should be measured
If serum concentrations of FSH, LH, and testosterone are
normal the problem is post testicular
A post-ejaculatory urine sample to examine for
spermatozoa will provide evidence about retrograde
ejaculation if sperm are seen in the urine.
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Cont’d.
If spermatozoa are not present in the post ejaculatory urine,
the man has obstructive Azoospermia
In the absence of the vas deferens there will be low seminal
fluid volume and acidic pH
If FSH, LH is elevated with low level of testosterone the
problem is testicular
If FSH, LH, testosterone are low the problem is
Pretesticular

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Cont’d.
◼ Treatment of male factor infertility
Treatment depends on the specific cause
General
Emotional support & assurance
Avoid smoking, alcohol, chat
Correction of psychological problems
Maintain BMI at 20-24

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Cont’d.
❑ For hypothalmopituitary dysfunction(hypogonadotropic
hypogonadism)
◼ Hormonal treatment is effective

❑ pulsatile gonadotropin–releasing hormone(GnRH)

therapy is effective
❑ For post testicular Azoospermia
❑ Micro surgery to correct the obstruction

❑ Surgical Sperm Recovery for Intracytoplasmic Sperm

Injection(ART)
❑ For gonadal failure
❑ Donor Insemination may be used(ART)

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Cont’d.
◼ For severe sexual dysfunction and retrograde
ejaculation
Drugs
ART

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Cont’d.
If the semen analysis is normal, the female partner should be
thoroughly investigated
After detail history and thorough physical examination
Investigation of female infertility should be started with
Confirmation of ovulation
Assessing ovarian reserve for those women>35years
Documentation of tubal patency

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 Ovulation Physiology
At puberty there are 300,000 primordial follicles
Each month there is selection and growth of many primordial
follicles
Dominant follicle produces estradiol which leads to LH surge
Ovulation occurs 36 hours after LH surge
Progesterone is increasingly produced after the LH surge
Secretory changes to the endometrium occur secondary to the
increased progesterone levels

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Cont’d.
Assessment of Ovulatory function
Assessment of Ovulatory function is a key component of
the evaluation of the female partner since
Ovulatory dysfunction is a common cause of infertility
(40%)
The treatment of women with Ovulatory dysfunction is
aimed at improving or inducing Ovulatory function

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 Cont’d.
1. Clinical ways of assessing ovulation
By following pattern of basal Body Temperature
The least expensive method of confirming ovulation by
recording body temperature every morning
Thermogenic effect of progesterone increases body
temperature by at least 0.5 degree F. for at least 10 days
Following the cervical mucus pattern (billings method)
Loss of fern pattern
Loss of spinbarkiet (strechability of cervical mucus up to
10cm)

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 Cont’d.
2.Mid-luteal phase serum progesterone level
Laboratory assessment of ovulation
Monitored one week before the expected menses.
For a typical 28-day cycle, the test would be obtained on
day 21
A progesterone level >3 ng/mL is evidence of ovulation
If the progesterone concentration is <3 ng/mL, the patient is
evaluated for causes of an ovulation.

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 Cont’d.
2. urinary ovulation prediction kit
These kits detect luteinizing hormone(LH) and are highly
effective for predicting the timing of the LH surge that
reliably indicates ovulation
3. Serial ultrasound
To follow the development and ultimately the
disappearance of a follicle
4. Endometrial biopsy
To document secretory changes in the endometrium
Too expensive or invasive for routine use
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Cont’d.
Assessment of ovarian reserve
The identification of diminished ovarian reserve is an
increasingly important part of the initial infertility
evaluation
For women over 35 years of age and younger women with
risk factors for premature ovarian failure
Day 3 FSH level
Clomiphene citrate challenge test(CCCT)
Antral follicle count by ultrasound
Anti-mullerian hormone (AMH) level

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 Cont’d.
Confirmation of tubal patency
❑ Obstruction of the fallopian tubes

◼ PID is the commonest cause

❑ 12% of women will be infertile after a single episode

of PID
◼ Congenital

◼ The initial diagnostic test used to assess tubal patency,

hysterosalpingography(HSG)
◼ Has a sensitivity of 85% to 100% in identifying tubal
occlusion.

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HSG: Tubal Infertility

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Female infertility
Common causes
An ovulation
Tubal obstruction
Uterine & cervical factors

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Cont’d.
Ovulatory factor
Is due to an ovulation
Cause Could be
Hypothalamus
Pituitary
Ovary
Gonadal dysgenesis
Premature ovarian failure
Ovarian failure due to chemotherapy, radiotherapy, infections
Polycystic ovarian syndrome

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Cont’d.
Tubal/Peritoneal Factor
Damage or obstruction of fallopian tube
Peritubal/periovarian adhesions
PID
Pelvic Surgery
Endometriosis

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Cont’d.
Uterine Factor
Congenital malformation
Luteal phase defect
Endometrial polyps
Leiomyomas
Uterine synechiae - Asherman’s syndrome

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Cont’d.
Cervical Factor
Congenital elongation of Cervix
Uterine prolapse – 2o & above
Cervical polyp/ stenosis
Decreased amount of mucus
Conization
Antisperm antibodies

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Cont’d.
Vaginal Factors
Vaginal atresia(partial or complete)
Transverse vaginal septum
Systemic Diseases
Renal failure
Liver failure
Metastatic cancer
Unexplained

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Cont’d.
Anovulation/oligo–ovulation confirmed
Serum FSH
Prolactin
TSH
Serum Testosterone

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Treatment of female infertility
Treatment depends on the specific cause
General
Emotional support & assurance
Avoid smoking, alcohol, chat
correction of psychological problems
Maintain BMI at 20-24

39
Cont’d.
Medical Diseases that will affect ovulation like
hypothyroidism & Hyperprolactinemia should be
treated accordingly
Abnormality in hypothalamus & pituitary
❑ pulsatile gonadotropin–releasing hormone (GnRH)

therapy can be used for disorders like kallman

syndrome

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 Cont’d.
◼ Ovulation induction
❑ Ovulation induction refers to the therapeutic restoration
of the release of one egg per cycle in a woman who either
has not been ovulating regularly or has not been ovulating
at all
❑ By Clomiphene citrate

◼ A functional hypothalamic–pituitary–ovarian axis is

required
◼ Increases GnRH pulse amplitude
◼ Increases gonadotropin release from pituitary

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 Cont’d.
◼ Super ovulation is indicated for the treatment of
unexplained infertility in women who have been unable to
conceive despite regular, monthly ovulation
◼ The explicit goal of super ovulation is to cause more than
one egg to be ovulated, thereby increasing the probability of
conception.

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Cont’d.
◼ For ovarian failure(eg. Turner syndrome)
❑ Use of donor oocytes(ART)

◼ For those with no uterus and significant genital tract

abnormality(Mullerian agenesis)
❑ ART followed by Surrogacy of uterus

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 Cont’d.
◼ Tubal factor
❑ Obstruction of the fallopian tubes

❑ Diagnosis will be confirmed by hysterosalpingogram

❑ Treatment

❑ Tuboplasty –surgical technique used to correct tubal

patency
❑ If the surgery fails, assisted reproductive technique
is recommended

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 Cont’d.
◼ Treatment of Unexplained Infertility
❑ Unexplained infertility is a diagnosis of exclusion

❑ 12-15% of infertile couples

❑ chance of achieving pregnancy is very low

❑ Treatment:

◼ Clomiphene Citrate for super ovulation followed by

Intrauterine Insemination

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 Cont’d.

◼ Adoption should also be

considered as an option of
management of infertile
couples

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 THANK YOU!

8/1/2022 47