INFERTILITY

THE INFERTILE COUPLE

 Objectives

• Definition of infertility
• Know the basic requirement for fertility
• Be able to take a good history from an infertile
couple
• Know the causes of infertility
• Understand the basic investigations required for
the infertile couple
• Know the basic management options
 Outline

• Definition and importance of infertility

• Prevalence of infertility
• Basic Biologic requirement for
conception
• Causes of infertility
• Evaluation of the infertile couple
• Treatment options
 Infertility

• Definition : It is the ‘inability of a couple to

achieve conception after 12 months of
regular, satisfactory, unprotected sexual
intercourse.’
• The duration is cut to 6 months when the
female partner is ≥ 35 years because,
fertility begins to decline.
• It does not depend on the age of the man
• The couple should be living together!!!
 Classification of
Infertility
i.Primary:→
• There is no history of previous
pregnancy
ii. Secondary: →
• Past history of pregnancy; no matter
the outcome (uneventful, miscarriage,
ectopic, etc)
 Importance of Infertility
Social importance
• Importance is attached to child birth in our setting
• A woman’s worth is determined by number of
children
• Children consolidate marriage
Economic Importance
• Numerous visits to the hospital means loss of
productive hours.
• Lots of resources required in evaluation and
treatment
 Importance of Infertility
–2
Physiological
-Infertility and its treatment is very stressful
-Most couples with infertility express
emotions like sadness, depression, anger,
desperation, confusion, embarrassment and
humiliation
-They may express behavioral reactions like
moodiness, distractibility, lack of sleep,
exhaustion, etc.
 Prevalence of infertility

• Globally about 10% of couples will have

some difficulty achieving conception.
• In W/A prevalence is estimated at 20-46%!
• Significant proportion of these is due to
tubal disease
• High rate of poorly treated PID
• High rate of unsafe abortions
• High rate of puerperal sepsis from home
deliveries, TBAs etc.
 Basic Requirements for
Conception
• Regular unprotected sexual intercourse
• Patent genital tract (both in men &
women)
• Regular ovulation
• Quality semen
 Causes of infertility

• Ovulatory disorders :10-15%

This is on the rise due to the emergence
of PCOS
• Pelvic/tubal factors :30-40%
• Male factor :30-40%
• Cervical factors :10-15%
• Unexplained :10%
 Causes of anovulatory
infertility
• Thyroid dysfunction, either hyper or hypo
• Hyperprolactinaemia
• Polycystic ovarian syndrome (PCOS)
• Premature ovarian Insufficiency (POI)
Women <40yrs experiencing menopause
• Extremes of weight (Underweight and
morbid obesity)
• Hypothalamic dysfunction
 Evaluation of infertility
• HISTORY: Assess for Ovulation/Anovulation
These tell that the woman is ovulating
• Regularity of Menstrual cycle
• Mid-Cycle pain (Mitttelschmerz)
• Premenstrual symptoms (breast engorgement, bloatedness,
headaches)
• Cervical mucus changes (clear and stretchy)
These may mean anovulation
• Galactorrhea; Heat/Cold intolerance →Thyroid dysfunction?
• Abnormal facial /Body hair distribution →PCOS?
• ? Hot flushes → Menopause, POI
 Evaluation

• HISTORY: Tubal Disease

• Previous History of PID
• Previous Pelvic or tubal surgery ; adhesions
• Previous of Ectopic pregnancy
• History of Endometriosis
• History of 2ndary Dysmenorrhea, dyspareunia
• Previous of puerperal sepsis ; offensive vaginal
discharge after previous delivery requiring
hospitalisation
• Previous History of Unsafe abortion or post abortal
complications
 Evaluation-Male Factor

• Ability to achieve and sustain erection for

intercourse and ejaculation
• Hx of post pubertal mumps; Mumps orchitis?
• Groin or pelvic surgery (especially bilateral);
important structures may have been nicked
• Tight fitting nylon underwear; poor sperm
production
• ?? Long distance truck drivers; heat from
engine
 Physical exams/TVS
• Height, weight, BMI
• Look out for hyperandrogenism (hirsutism, acne)
• Anterior neck swelling
• Breast-Galactorrhea
• Uterine/pelvic masses
• TVS:
• Uterine appearance
• Ovarian morphology and antral follicular count
• Presence of ovarian cysts
 Investigations

1. Anouvulation
• Mid-Luteal progesterone
• Mid-luteal endometrial biopsy
• Sub-nuclear vacuolation
• Secretory changes in the endometrium
• Follicular tracking with trans-vaginal USG scan
• Serum Prolactin, TSH
• Serum Androgens (Total or free Testosterone,
DHEA, Androstenedione, etc.)
• FSH, LH
 2.Evaluation of the
female genital tract
• Hysterosalpingogram (HSG)
• Laparoscopy and chromotubation
• Hysteroscopy
• Saline Infusion Sonohysteroscopy
• Falloscopy
 Hysterosalpingogram

• Radiological evaluation of the uterus and

fallopian tubes.
• Involves administration of a radio-opaque dye
• Done between days 5 -10 of the cycle
• Complications:
• Pain
• Allergy to the dye
• Post procedure PID
Hysterosalpingogram
(HSG)
Hysterosalpingogram
(HSG)
 Laparoscopy and Dye
• Superior to HSG in the investigation of tubal factor infertility.
• Used when results of HSG are inconclusive
• It is however
 more invasive
 requires general anaesthesia
 more expensive
 Limited in assessment of endometrial pathology (Unless
combined with Hysteroscopy)

• Helps in the diagnosis of pelvic pathologies like

endometriosis, peritubal adhesions, hydrosalpinx.
 Saline Infusion
Sonohysterogram
• Makes use of 2 procedures
a. Ultrasound Scan (Trans-vaginal)
b. Hydrotubation to open up blocked tubes (done under sedation)

• It evaluates the uterine cavity (polyps, uniformity, distensions,

etc.)
• It assess patency of fallopian tubes
• It is non-invasive and uses no radiation
• Complications:
-Pain
-Post procedure pelvic infection
 3. Semen Analysis

• Must be done very early in the evaluation

• Must abstain from sex for 2-3 days
• Specimen collected by masturbation and
should reach lab within 30min.
• Specimen should be kept at room
temperature during transport and must
be analyzed within 30minutes of
collection.
 Semen Analysis: WHO
2010

Parameter Minimum Ref. Value

• Volume • ≥ 1.5ml
• pH • ≥ 7.2 (Alkaline)
• Complete Liquefaction • Within 30minutes
• Concentration • ≥15 million sperms/ml
• Total sperm per ejaculate • ≥ 39 million sperms/Ejac.
• Total sperm motility • ≥ 40%
• Sperm Progressive Motility • ≥ 32%
• Morphology (normal forms) • ≥ 4%
• Round cells • < One million
• Neutrophiles • < one million
 Abnormal Semen
Analysis
• Take through medical history
• Detailed physical examination (including
examination of the testicles)
• Scrotal imaging (Scrotal USG preferred)
• Hormonal assays
(FSH/LH/Prolactin/Testosterone)
• Manage together with urologist
 MANAGEMENT
Ovulation Induction
• Look for cause of the anovulation
• Treat the underlying cause (e.g.
Hyperprolactinaemia, thyroid dysfunction etc.)
• Induction Agents
• Clomiphene Citrate (Clomid)
• Tamoxifen ; same class as Clomid
• Aromatase inhibitors (Letrozole)
• Gonadotrophins
• Exclude all other causes of infertility before
starting ovulation induction!
 Clomiphene Citrate
• Most widely used ovulation induction agent.
• About 80% of clients ovulate but pregnancy rate only
about 50%.
• Clomid is a non-steroidal anti-Estrogen.
• Induces pituitary to produce gonadotropins
• Usually started on days 2-5 of the menstrual cycle
• Given for 5 days in each cycle
• Starting dose is 50mg daily.
• Can increase to maximum of 150mg daily if smaller
doses are not effective.
 Clomiphene citrate - 2
• Always monitor for ovulation by assaying mid-
luteal progesterone.
• Has a 5-8% risk of multiple pregnancy (Twins)
• Common Side effects
• flushing (warmth, redness, or tingly feeling);
• breast pain or tenderness;
• headache; or
• breakthrough bleeding or spotting.
Rarely may cause Ovarian Hyperstimulation
Syndrome (OHSS)
 Fertility Options

• Ovulation induction with intrauterine

insemination (IUI)
• Assisted Reproductive Technology (ART)
• IVF (in-vitro fertilisation)
• Intracytoplasmic sperm injection (ICSI) + IVF
• Ovum/sperm donation
• Surrogacy
• Adoption
 Summary

• Infertility is common in W/A.

• Most cases are secondary infertility
• The COUPLE must be taken through systematic
workout to determine the cause
• Male factor is becoming increasing common
and must be evaluated early in the work-up.
• Treatment is cause specific.
• Assisted reproductive technology, surrogacy,
adoption are available in Ghana
•QUESTIONS
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