Infertility

Prof. Samah Alawady

s.basam@qu.edu.sa
Objectives:
By the end of the lectures the students
will able to:
• Define infertility
• Identify the type of infertility
• Describe the causes and risk factor of
infertility
a.Female infertility
b.Male infertility
• Discuss diagnosis and management of
infertility
INTRODUCTION

• Infertility is a significant social and medical

problem affecting couples worldwide.
• Infertility refers to an inability to conceive
after having regular unprotected sex.
• Average incidence of infertility is about
15% globally. (varies in different
populations ).
• Some causes can be detected and treated,
whereas others can not: Unexplained
infertility constitutes about 10 % of all
cases.
 DEFINITION OF INFERTILITY

Infertility is the failure to achieve a birth ever a 12 months
period of unprotected intercourse.

Infertility is the inability of a sexually active non contracepting
couple to achieve pregnancy in one year.
Types of infertility:
1- Primary infertility: When a women is unable to ever bear child
2- Secondary Infertility: When a women has been pregnant but
failure to achieve live birth after having a live birth previously.
Cont.…

Research reveals a growing prevalence of infertility among
individuals aged 15–49 years worldwide from 1990 to
2021, with an expected continued increase through 2040.

Research indicates that 20% cases of infertility are due to
a problem in man.

40% to 50% cases are due to women.

30% cases are due to problem in both men & women.
Causes/risk factor of Infertility
In MEN:
o
Low Sperm count:-
Normal count is 20 million sperm per ml of semen or more.



No sperm: - Absence of sperms in semen.
o
Low sperm motility: -
•Sperms are immotile, can not swim.
•Abnormal sperms: (Unusual shape , more difficult to move and fertilize
egg) it caused by:
Testicular infections.
Testicular cancer.
Testicular surgery.
 Continued….
• Overheating testicles.
• Ejaculation disorders (Retrograde ejaculation).
• Variocele (includes varicose vein in scrotum).
• Undescended testicles.
• Hypogonadism (testosterone deficiency).
• Genetic abnormality.
• Mumps (testicular inflammation).
• Hypospadiasis.
• Chlamydia infection
Cont….(Causes/risk factor of Infertility)

In Women
•Premature ovarian failure (before age of 40)
•Polycystic ovary syndrome.
•Hyper-prolactinemia (in non pregnant state)
• Poor egg quality.
•Problems in uterus & fallopian tubes
•Surgery.
•Sub-mucosal fibroids.
•Endometriosis.
•Previous sterilization treatment.
Requirement of normal pregnancy and delivery of a viable fetus
1. Normal health reproductive organs
2. Discharge of a healthy ovum from the ovary
3. The ovum find its way into fallopian within a few hours
4. Insemination occurs and the spermatozoa migrate to the tubes
5. Fertilization of ovum in ampulla
6. Fertilized ovum implanted and develops in a favorable site in the
endometrial
7. Maturation proceeds normally until delivery
Etiology of female infertility

• A- (ovulation) problems: anovulation

• B-Tubal factor infertility
• C- Uterine problems causing infertility
 Female infertility
Etiology of female infertility
:A- (Ovulation) problems: anovulation

1. Significant weight gain; will lead to increase

estrogen secretion and hormonal imbalance which
will leads to polycystic ovary syndrome,
endometrial hyperplasia, uterine leiomyomas and
endometrial cancer
 2- Polycystic ovary syndrome
• Polycystic ovary syndrome (PCOS) is a condition that
affects a woman's hormone levels. Women with
PCOS produce higher-than-normal amounts of male
hormones. This hormone imbalance causes them to
skip menstrual periods and makes it harder for them
to get pregnant (Stephanie Watson, 2017).
3- Premature menopause
4- Systematic diseases like (renal failure, diabetes, sever anemia).
5- Other factors:
 Age: infertility increase with age
because it affects on the quality,
numbers, shape and regularity of A "good"
egg from a

the eggs. 32 year

old
woman

 Smoking

low quality, oocyte from a

Egg is irregularly shaped and dark woman over 40
The most common PCOS symptoms are:

• Irregular periods: Some women with PCOS get fewer than eight
periods a year
• Heavy bleeding: The uterine lining builds up for a longer period
of time, so the periods you do get can be heavier than normal.
• Hair growth: More than 70 percent of women with this
condition grow hair on their face and body is called hirsutism.
• Acne: the skin oilier than usual.
• Weight gain: Up to 80 percent of women with PCOS are
overweight or obese .
• Darkening of the skin: Dark patches of skin can form in body
creases like those on the neck, in the groin, and under the
breasts.
Anovulation

Symptoms Evaluation*
• Irregular menstrual • Follicle stimulating
cycles hormone
• Amenorrhea • Lutenizing hormone
• Hirsutism • Thyroid stimulating
hormone
• Acne
• Prolactin hormone
• Galactorrhea
• Androstenedione hormone
• Increased vaginal
(oestrogen &testosterone )
secretions
B-Tubal factor infertility:
It caused by:
1-Completely blocked fallopian tubes.

2-No tubal blockage but tubal scarring

or other tubal damage.

3-Pelvic infection, such as pelvic

inflammatory disease (PID) that
caused by gonorrhea or Chlamydia
raised from the cervix up to the
uterus and tubes.
 Pelvic inflammatory disease

• An infection of the organs of a women's reproductive

system. They include the uterus, ovaries, fallopian tubes,
and cervix. It's usually caused by a sexually transmitted
infection (STI), like chlamydia or gonorrhea, and is treated
with antibiotics (Traci Johnson , 2019)

4- Endometriosis: resulting from the appearance of

endometrial tissue outside the uterus causing pelvic pain,
especially associated with menstruation.
Testing for tubal infertility:
Hysterosalpingogram: This is an x-ray examination in which
contrast material (dye) is injected through the cervix to the
uterine cavity.

-If the fallopian tubes are open the dye flows into the tubes
and then spills out to the abdominal cavity.

Treatment of tubal factor infertility

The treatment for tubal factor infertility is

usually either tubal surgery to repair some of
.the damage or in vitro fertilization (IVF)
C- Uterine problems causing infertility:
.Uterine Fibroids (leiomyoma) -1

Intrauterine adhesions - scar tissue within the uterine -2

cavity. This can interfere with conception or can increase the
.risk of a miscarriage

3. Congenital uterine malformations

4. Uterine Polyps: are formed by the overgrowth

of endometrial tissue also known as endometrial polyps.

Investigated by (Hysteroscopy)
Uterine Polyps
Investigation for infertility females:

• Personal &family history with a thorough physical

examination.
• Clomiphene citrate challenge test (CCCT): is a fertility test
to check your ovarian reserve, to see if your eggs are still
good enough for fertilization and implantation.
It is done as follows:
• Cycle Day 3: Check the FSH
• Cycle Day 5-9: Give Clomiphene citrate 100 mg
(2 tablets)
• Cycle Day 10: Check FSH
Cont.….

• Blood test that measure various hormone.

• Hysterosalpinogram(HSG) : test tube potency
• Hysteroscopy: is a procedure that allows your doctor
to look inside your uterus in order to diagnose and
treat causes of abnormal bleeding. a thin, lighted
tube that is inserted into the vagina to examine the
cervix and inside of the uterus.
• Endometrial biopsy.
• Laparoscopy
Hysteroscopy
 Investigation for infertility females:

• The Postcoital test (PCT) (also known as Sims test,

Huhner test or Sims-Huhner test) is a test in the
evaluation of infertility. The test examines interaction
between sperm and mucus of the cervix.
Tests done to predicate ovulation:

1-Basal body temperature (BBT):

body temperature is drops before ovulation, then
raised just after ovulation & remain elevated for
at least 3 days.
2. Cervical mucous : it is become thinner , clear,
copious and watery at the time of ovulation. it also
show Frening pattern when dried on a slide ,
called fren test
3. Ovulation prediction kit :
most accurate methods. The test detects an increased level of
luteinizing hormone (LH) present in an early morning urine
sample 1 to 2 days before ovulation.

4. Ultrasound scanning (USS): to detect follicle and thickening of

the endometrial

5.Hormonal assays: Blood tests that measure the levels of various

hormones, such as luteinizing hormone (LH), follicle-stimulating
hormone (FSH), prolactin (PRL), estradiol, and progesterone, aid
greatly in determining the cause of infertility
 Treatment of female infertility:

1. Medical treatment
2. Correction of coital Difficulties
3. Improve vaginal and\or cervical secretion through:
a. treatment of infected cervical erosion
b. improve deficient or viscous cervical secretion by
administration of estrogen in the first 10 days of cycle
4. Correction of any lesion in the uterine body
5. Correction of the lesion of the tube
6. Stimulation of ovulation:
Before start the treatment, you must do hormonal assay to
assess the prolactine, estrogen, FSH,LH, and progesterone
A. If prolactine level is high this will lead to decrease level of
estrogen , and progesterone and prevent ovulation. After
exclusion of pituitary tumor, high level prolactin is treated
by parlodel
B. If an ovulation occurring due to FSH, and LH she is treated
by clomid as the following
1. 50 mg\day start from the 3rd day of menstrual cycle
2. treatment is given for 3 month . Ovulation should occur
around day 12-16 and intercourse advice each other day
from 10-18 day
 Causes of male infertility
Disruption of testicular or ejaculatory function
•Varicocele: a condition in which the veins within a man’s
testicle are enlarged. Although there are often no
symptoms, varicoceles may affect the number or shape of
the sperm and decreased sperm quality, which can cause
infertility.
•Trauma to the testes may affect sperm production and
result in lower number of sperm.
•Hormonal disorders: Improper function of the
hypothalamus or pituitary glands. The hypothalamus and
pituitary glands in the brain produce hormones that
maintain normal testicular function
 Causes of male infertility …
(Cont.)
• Heavy alcohol use, smoking, anabolic steroid
use, and illicit drug use.
• Cancer treatment involving certain types of
chemotherapy, radiation, or surgery to remove
one or both testicles.
• Medical conditions such as diabetes, cystic
fibrosis, certain types of autoimmune
disorders, and certain types of infections may
cause testicular failure.
• Obesity
• Psychological problem and stress.
Treatment of the husband:
 Medical:
 Good diet , vitamins and attention to
causative habits as smoking, alcohol and
drug addiction
 Treatment of diabetes.
 Treatment of specific & nonspecific
infection.
 Hormonal agents as testosterone to improve
spermatogenesis.
 Cortisone in cases with circulating antisperm
antibodies.
Surgical treatment
Prevention of infertility:
some but not all of infertility causes are
preventable as:
 - general advices female marriage and
childbearing should be planned earlier rather
than in the latter fertile years. An advice to
complete family before 35 years female age.
 - Prevention and control of genital infection:
1- Sexually transmitted diseases especially
gonorrhea, chlamydia and mycoplasma.
2- Control of non venereal disease as T.B.
3- Immunization of children against Mumps.
4- Prevention & treatment of puerperal & post
abortive infections
5- Treatment of appendicitis which lead to
pelvic adhesions.
Avoidance of unnecessary pelvic operations:

Follow the precautions that minimize

adhesions during pelvic and abdominal
operations .
- Early treatment of diseases that may affect
fertility: as
1- Thyroid disorders.
2- Treatment of severe nutritional disorders &
obesity.
- Prevention of Male infertility: avoid
- The use of alcohol.
- Radiation to the genital organs which can
cause genetic mutations.
- Heat which  spermatogenesis.
References
o
Brunner & Suddarth’s , A textbook of Medical Surgical
Nursing, 2nd Volume, 13th Edition, Published by
Wolters kluwer Publication, Page no.- 1636-1639.
o
Joyce MB, Jane HH, A Textbook of Medical Surgical
Nursing , 1st Volume, 8th Edition , Sounders Elsevier
Publication , Page no.- 866- 868.
o
Alexander H, Freeman, Jeffrey DK, Arthur L, Reingold ,
and Purnima M. Prevalence & correlates of primary
infertility among young women in Mysore, India : Indian
J. Med Res, 2011 [ Cited 2001,oct.]; [P. 440-446]:
Available at:
http://www.ncbi.nlm.nih.gov/PMC/articles/PMC 327240/.
Any Questions?

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