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INFERTILITY

Negeso G. (BSc, MSc)

 Introduction
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 Failure of couples of reproductive age to conceive for one year of

unprotected regular intercourse

 It is a common condition with implication.

 Psychologic

 Demographic

 Medical implications.
 Affects 15% of couples
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 Chance of pregnancy

 25% of couples will conceive within 1 month

 50% of couples will conceive within 6 months

 75% of couples will conceive within 9 months

 80% of couples will conceive within 1 year

 Terminologies
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 Fecundabilty: is expressed as the likelihood of

conception per month of exposure(20-25%)

 Fecundity: is the probability of achieving a live birth in

single menstrual cycle

 Sterility :implies an intrinsic inability to achieve

 Types
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 primary infertility: implies to those who have never

conceived

 secondary infertility designates those who have

conceived at some time in the past.
 Causes of infertility
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 Female factor: 40-55%

 Male factor: 25-40 %

 Both: 10%

 Unexplained:10%

Relative sub fertility in one partner is counterbalanced

by high fertility of the other.
 Male factor infertility
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1. Defective spermatogenesis

2. Errors in seminal fluid

3. Obstruction of efferent duct system

4. Failure to deposit sperm high in the vagina

 Defective spermatogenesis
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1. Congenital:

 Cryptorchidism= tests fail to decent to the scrotum

 kartengner’s syndrome

 Klinefelter's syndrome = genetic disorder with three

chromosomes i.e XXY

2. Thermal factor

3. Infection

4. Iatrogenic: Radiation, cytotoxic drugs

 Defects in seminal fluid
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Normal values
1. Volume: 2ml -6ml
2. PH: 7.2-7.8
3. Concentration: >20 million/ml
4. Motility: > 50% progressive
5. Morphology: > 30% normal shape
6. Leucocytes: < 1million
 Terminologies for Abnormal values
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1. Aspermia: failure of formation or emission of semen

2. Azoospermia: no spermatozoa
3. Oligospermia: < 20 million/ml
4. Polyzoospermia:>350 million/ml
5. Asthenozoospermia: abnormal motility
6. Necrozoospermia: dead or motionless
7. Teratozoospermia: abnormal morphology
 Obstruction of the ducts
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Infection

Trauma
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 Failure to deposit high in the vagina
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Erectile dysfunction

Ejaculatory defect
 Premature ejaculation
 Hypospadias= urethral opening on the underside of penis
 Epispadiasis= urethral opening on dorsal (upper) surface
of penis
 Female causes
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1. Anovulatory : 30-40 %
2. Tubal factors : 30-40%
3. Uterine factors: 1-10%
4. Cervical factors:
5. Miscellaneous :
 Anovulatory problems
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Ovulation is a complex event in which hormonal

signals and physical events are linked in a delicate
balance.
 Causes of An ovulation
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A. Hormonal causes
1. Malfunction of the hypothalamus
2. Malfunction of the pituitary gland
B. Ovarian Failure to produce mature eggs
1. Scarred Ovaries :Physical damage to the ovaries.
2. Premature Menopause
3. Follicle Problems “ unruptured follicle syndrome"
 Tubal factor
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Affects 25% of infertile couples

The main causes of tubal damage include:
1. PID
2. Appendicitis
3. Previous Surgeries
4. Ectopic Pregnancy
5. Congenital Defects
 Uterine factors
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1. Asherman syndrome
2. Anatomic problems
3. Endometritis
4. Thin or abnormal uterine lining
 Cervical factor
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Involves inability of the sperm to pass through the cervix.

1. Abnormally thick cervical mucus.
2. Cervical stenosis.
3. Immune attack of sperm or "sperm allergy“
4. Cervical incompetency.
5. Infections of the cervix.
 Evaluation of infertility
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Objectives:

Discover etiologic factor

Correct the abnormality

Reassure the couples

 Guiding principles:
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Involve both partners at first

Take detailed general & reproductive history

separately

Clinical examination to be done separately

 Evaluation of Male factor infertility
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History:
 Age, proven fertility if any

 Duration of marriage

 History of previous marriage

 Medical history related to diabetes, STDs

 Surgery: herniorraphy

 Occupation: radiation, heat

 Sexual history

 Social habits: smoking, alcohol ingestion

 cont...
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Physical examination
 Full physical examination pertaining to general
health
 Examination of reproductive system: inspection &
palpation of genitalia
 Size & consistency of testis
 Urethral meatus
 Male investigations
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U/A
Seminal fluid analysis

Testicular biopsy

Trans rectal ultrasound(TRUS)

 Female evaluation
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History:
 Age, duration of marriage

 History of previous marriage, proven fertility

 General medical history: Tuberculosis, STD, PID or DM

 Contraceptive history

 Sexual problems
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Female evaluation…
Physical examination:
General examination:
Obesity or weight loss
Hair distribution
Secondary sexual characteristics
Physical features for endocrinopathy
 Cont...
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Gynaecologic examination:
Adequacy of hymenal opening
Evidences of cervical infection
Uterine size, mobility & position
Adnexal mass, nodules at cul de sac
Speculum examination:
Abnormal cervical discharge
Cervical smear
 Female investigation
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Ovulation
Direct: laparoscopic visualization of recent corpus
luteum or detection of ovum from aspirated
peritoneal fluid
Indirect:
 BBT,

 cervical mucus

 Endometrial biopsy

 Hormonal estimation: progestrone, LH

 Treatment of male infertility
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 Improve general health

 Avoid smoking, alcohol ingestion, tight underwear
 Testestrone
 GnRH therapy
 Surgery
 Treatment of female infertility
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1.Hormonal therapy
 Clomiphene citrate :This medicine causes ovulation

by acting on the pituitary gland.

 hMG( Human menopausal gonadotropin): directly

acts on the ovaries to stimulate ovulation
 Cont...
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FSH (Follicle-stimulating hormone )

GnRH (Gonadotropin-releasing hormone analog)

 2. Assisted reproductive technology (ART)
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1. In vitro fertilization (IVF)

2. Intra cytoplasmic sperm injection(ICSI)

3. Gamete intra fallopian transfer (GIFT)

 3.others
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Adoption

serogation