Infertility Lecture (2) - 1

INFERTILITY
Defined as 1 year of unprotected

intercourse without pregnancy
Classified as primary or secondary
infertility
Fecundability- probability of achieving
pregnancy within a single menstrual cycle
Fecundity- probability of achieving a live
birth within a single menstrual cycle
INFERTILITY (contd.)
Fecundability of normal couple is

estimated at 20 to 25%
Time of exposure and pregnancy rate

3months=57% , 6months= 72%,
1year = 85% , 2years = 93%.
Evaluation for infertility is after 1 year
Exceptions are
1) women above 35 years.
2) couples with obvious pathology that

is associated with infertility.
At age 35years and above, fertility

decreases due to
1) decrease in number of ovarian follicle,
which becomes rapid after 36 years.
2) ovarian follicles becomes less
sensitive to GNT stimulation.
3) rate of estradiol rise and peak
concentration is low.
Infertility affects 10 15% of couples

in the U.S and about 20 to 30% in
Nigeria.
Couples who have conceived before

have a better prognosis
CAUSES (contd.)
Infrequent coitus due to separation,

erectile dysfunction, dyspareunia
Age. Female- as stated above. Male-

semen volume, sperm motility and
percentage of normal sperm gradually
decrease with age especially from 45 to
50 years.
CAUSES (contd.)
MALE
1. Abnormality of sperm production
1A. Primary testicular failure
(hypergonadotrophic hypogonadism) due
to
a) genetic causes like klinefelter
syndrome and Y-chromosome

microdeletion.
b) damage to the testis anatomy like
in cases of cryptochidism, varicocele.

CAUSES (contd.)
c) infections like viral and bacterial

orchitis
d) gonadotoxins-lead, agricultural
spray, x-ray, radioactive substance,
heat ,febrile illness, tight nylon
underwear, smoking, alcohol and
drugs like cimetidine, nitrofurantoin
and tetracycline.
CAUSES (contd.)
1B. Inadequate GNT stimulation from

a) genetic causes like isolated GNT
deficiency.
b) direct and indirect effect of

hypothalamic/ pituitary tumour.
CAUSES (contd.)
1C. Exogenous androgen use thus

suppressing GNT secretion.
2. Abnormality of sperm function

antisperm antibody , prostatitis, seminal
vesiculitis , varicocele , failure of
acrosome reaction, problems with sperm
binding and penetration of zona
pellucida.
CAUSES (contd.)
3. Obstruction in the ductal system-

vasectomy, congenital absence of vas
deferens in patients with cystic
fibrosis, congenital or acquired
obstruction of the epididymis or
ejaculatory ducts.
4. Idiopathic due to poor understanding

of mechanism of testicular function.
CAUSES (contd.)
FEMALE
1) Ovarian PCOS, hyperprolactinaemia
hypothyroidism, hyperthyroidism ,
underweight , overweight/obesity,
Kallaman syndrome.
2) Tubo- peritoneal- PID( GNC and
Chlamydia), post abortal sepsis,
puerperal sepsis, endometriosis.
3) Uterine fibroid, endometritis,
ashermans syndrome, adenomyosis ,
congenital uterine abnormality.
CAUSES (contd.)
4) Cervical/ immunological antisperm

antibody, hostile cervical mucus,
abnormality of the cervix.
5) Systemic conditions chronic

infections, chronic disease including
auto-immune conditions.
CAUSES (contd.)
Unexplained infertility applies to

couples that have failed to establish a
pregnancy despite
(a) evaluation uncovering no obvious
cause of infertility OR
(b) after correction of identified
cause(s) responsible for infertility.
PREVALENCE
Male factor 25 -40 percent
Male and female 10%
Female factor 40-50%
Unexplained 10%
PREVALENCE OF CAUSES OF FEMALE
INFERTILITY
Ovulatory dysfunction 30 40%

Tuboperitoneal 30 40%
Unexplained infertility 10 15%
Others 10 15%
CLINICAL EVALUATION (female)
Gravidity, parity, pregnancy outcome
and associated complication
Menstrual Hx cycle length ,flow,
dysmenorrhoea, intermenstrual
bleeding.
Coital frequency and sexual dysfunction
Duration of infertility, results of
previous evaluation and treatment
Past surgery indication and outcome
Past and current illness
contd.
Previous pap smear and treatment

Drug Hx, smoking, alcohol ingestion,
smoking
Occupation
Family Hx of early menopause and
reproductive failure
contd.
Symptoms of thyroid disease

Pelvic pain, abdominal pain,
galactorrhoea, hirsutism and
dyspareunia
Weight and BMI
contd.
Thyroid enlargement
Breast secretion
Signs of androgen excess
Pelvic/abdominal tenderness,
mass/organ enlargement
contd.
Vaginal/cervical abnormality, secretion

or discharge
Mass , tenderness, nodularity in

adnexia or cul de sac
CLINICAL EVALUATION (male)
Duration of infertility /previous fertility
Coital frequency, sexual dysfunction
Result and treatment from previous

evaluation
CLINICAL EVALUATION (male)
Childhood illness
Previous surgery herniorrhaphy,

prostatectomy,
Systemic illness D/M, cystic fibrosis,
Hx of STD
CLINICAL EVALUATION (male) contd.
Exposure to toxin including heat

Drug Hx
Smoking , alcohol ingestion
Examination of penis and urethral
meatus
Testicular size
CLINICAL EVALUATION (male) contd.
Presence and consistency of vas

deferens
Varicocele
Secondary sexual xtics
Digital rectal examination
INVESTIGTIONS (male)
Semen analysis
3 to 5 days abstinence, semen better
collected by masturbation ,
Volume 2 to 6mls
ph greater than 7.2 ,
sperm concentration> 20million per ml ,
Total sperm number >40million per ejaculate
Actively motile greater than 50%
Normal morphology >50%
WBC count less than 1 million per ml
Round cell less than 5 million per ml.
INVESTIGTIONS (male)
Endtz test is an immuno-peroxidase
staining technique to identify WBC.
What is oligospermia , teratospermia ,
azoospermia , aspermia ,
asthenospermia,leucocytospermia ,
necrospermia.
INVESTIGATIONS (male) contd.
Hormone profile FSH,LH, Prolactin,

thyroid function test
Testicular biopsy
Semen m/c/s
Vasography
Detection of antisperm antibody
Sugar profile
INVESTIGATIONS (female) contd.
Test for ovarian reserve day 3

menstral cycle FSH, clomiphene citrate
challenge test , serum inhibin-B level,
serum anti-mullerian hormone,
sonographic antral follicular count,
mean ovarian volume measurement.
INDICATIONS- women greater than

35years, unexplained infertility, family
Hx of early menopause, previous
ovarian surgery e.g ovarian
cystectomy,ovarian drilling,
ophorectomy, chemotherapy or
radiation treatment, smoking and poor
response to exogenous GNT
stimulation.
Test for ovulation-
1) Basal body temperature- rise of 0.5

to 1degree Farenheit in 2nd half of
MC
2) Pre-menstrual endometrial biopsy
3) Serum progesterone on 21st day of

MC- greater than 10nmol/l
INVESTIGATIONS (female) contd
4) Serial TVS for folliculometry
5) Serial LH monitoring for surge.

Ovulation occurs 34 to 36 hours after
the onset of LH surge and 10 to 12
hours after LH peak.
6) Cervical mucus for spinnbarkeit (8-

10cm) and ferning on dried
specimen.
Assessment of tubal factor
1) Hysterosalpingography
2) Laparoscopy and dye hydrotubation
3) Selective salpingography (Proximal)
4) Falloposcopy (distal)
Assessment of uterine factor

1 Hysterography
2 Hysteroscopy
3 Ultrasound
4 Endometrial biopsy
5 MRI, CT scan
Assessment of cervical factor

1) Kremers test or Postcoital test
abstinence for 2 to 3days, intercourse
around ovulatory period, aspirate
endocervical mucus for microscopic
examination. Positive test 6
spermatozoa phf with forward
progression and spinnbarkeit of
greater than 6cm
2) Serum and cervical level of

antisperm antibody.
TREATMENT (male)
Surgery varicocelectomy , vaso-
vasostomy
Medical antibiotic, clomiphene citrate,
Tamoxifen , FSH, HMG ,testosterone ,
bromocryptine and other.
Assisted reproduction artificial
insemination by spouse or donor
sperm, intracytoplasmic sperm
injection (ICSI) with spouse or donor
sperm
TREATMENT (female)
Ovulatory disorder
1) Clomiphene citrate, Tamoxifen
2) HMG and HCG
3) Insulin sensitizer like metformin for

PCOS
TREATMENT (female)
4) Ovarian drilling for PCOS
5) Bromocryptine, cabergoline for

hyperprolactinaemia
6) Assisted reproduction-IVF plus ET,

GIFT , ZIFT with patient or donor
egg
TREATMENT (female) contd.
Tubo-peritoneal problems
1)Tubal surgery
2)Assisted reproduction-IVF plus ET
Uterine factor Myomectomy for fibroid,

Adhesiolysis/insertion of inert IUD or
inflated foley catheter balloon/oestrogen
therapy for Ashermans syndrome
TREATMENT (female) contd.
Cervical factor IUI
Other forms of management

surrogacy, adoption

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INFERTILITY

Defined as 1 year of unprotected

Fecundability of normal couple is

Time of exposure and pregnancy rate

Evaluation for infertility is after 1 year

2) couples with obvious pathology that

At age 35years and above, fertility

Infertility affects 10 15% of couples

Couples who have conceived before

Infrequent coitus due to separation,

Age. Female- as stated above. Male-

syndrome and Y-chromosome

in cases of cryptochidism, varicocele.

c) infections like viral and bacterial

1B. Inadequate GNT stimulation from

b) direct and indirect effect of

1C. Exogenous androgen use thus

2. Abnormality of sperm function

3. Obstruction in the ductal system-

4. Idiopathic due to poor understanding

4) Cervical/ immunological antisperm

5) Systemic conditions chronic

Unexplained infertility applies to

Ovulatory dysfunction 30 40%

Previous pap smear and treatment

Symptoms of thyroid disease

Signs of androgen excess

Vaginal/cervical abnormality, secretion

Mass , tenderness, nodularity in

Coital frequency, sexual dysfunction

Result and treatment from previous

Previous surgery herniorrhaphy,

Systemic illness D/M, cystic fibrosis,

Exposure to toxin including heat

Presence and consistency of vas

Hormone profile FSH,LH, Prolactin,

Test for ovarian reserve day 3

INDICATIONS- women greater than

Test for ovulation-

1) Basal body temperature- rise of 0.5

2) Pre-menstrual endometrial biopsy

3) Serum progesterone on 21st day of

4) Serial TVS for folliculometry

5) Serial LH monitoring for surge.

6) Cervical mucus for spinnbarkeit (8-

Assessment of tubal factor

2) Laparoscopy and dye hydrotubation

3) Selective salpingography (Proximal)

Assessment of uterine factor

Assessment of cervical factor

2) Serum and cervical level of

1) Clomiphene citrate, Tamoxifen

2) HMG and HCG

3) Insulin sensitizer like metformin for

5) Bromocryptine, cabergoline for

6) Assisted reproduction-IVF plus ET,

Uterine factor Myomectomy for fibroid,

Cervical factor IUI