Infertility

DEFINITION
• Infertility:
- Failure of couple of reproductive age to conceive after (1 year <35 —6 months >35)
of regular coitus without contraception.
- 10%-15% of married couples
• Primary infertility:
- Infertility in a woman who has NEVER been pregnant.
• Secondary infertility:
- Infertility in a woman who has had one or more previous pregnancies.
• Fecundability:
- Probability of achieving pregnancy within one menstrual cycle. (Regardless outcome)
- For a normal couple, this is approximately 25%.
- 50% after 3-4 months — 95% after 1 year.
• Fecundity:
- Ability to achieve a live birth within one menstrual cycle.
• Unexplained
- It’s de nition by exclusion and that depend on the standard investigation used.

EVALUATION
Infertility evaluation comprises eight major elements:
1. History and physical examination.
2. Semen analysis.
3. Sperm—cervical mucus interaction (postcoital testing (PCT))—for select patients.
4. Assessment of ovarian reserve.
5. Tests for occurrence of ovulation.
6. Evaluation of tubal potency.
7. Detection of uterine abnormalities.
8. Determination of peritoneal abnormalities.

Image (indication and timing of the infertility evaluation). Image for male + female cau
CAUSES OF INFERTILITY
Female Male

M/C → ovulatory disorder (25%), Idiopathic (40-50%).

Endometriosis (15%). Testicular (30%).

Pelvic adhesion (12%) Post-testicular (20%)

Tubal blockage (11%). Pre-testicular (1-2%).

Hyperprolactinemia.

Uterus + luteal phase defect.

Cervical factors
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 History of infertility
Male Female

Personal data

1. Name
2. Age
4. Have you ever get pregnant? How many children? (GTPAL)
5. Duration of infertility?
6. Previous marriage ?
7. Fertility in other relationships?
8. Previous infertility testing and therapies?
Sexual history

1. intercourse (frequency and regularity?) N: 2-3/week,

2. Contraception? (Method + for how long?) (IUD, depoprovera).
3. Use of lubricant?
4. Deep dyspareunia? (Endometriosis).
5. Erectile dysfunction (impotence)? .
Past-medical hx

1. History of mumps 1. STD → vaginal discharge “bleeding”, itching.

2. STD 2. PID.
3. Diabetes → impotence. 3. Endometriosis.
4. Varicocele. 4. Fibroids.
5. Hx of undescended testis? 5. UTI.
6. Hypospedius? 6. Glactorrhea.
7. Lactation.
8. DM, thyroid.
9. PCOS (obesity “BMI”, hirsutism, acne).
10. Uterine anomaly.
11. PPH (sheehan syndrome).
12. Diet and exercise? (Anorexia nervosa or athlete).

Past-surgical

Pervious surgery near genital area Hx of pelvic, abdominal surgery, (ectopic pregnancy).

Family hx

1. Mental retardation.
2. Birth defect.
3. Reproductive failure,
Medical hx

1. Chemotherapy or radiation?
2. Cigarette smoking, alcoholics?
3. Other drug abuse?
Menstrual and gyncological hx

1. Age pf menarche?
2. LMP?
3. Regularity of menses? (Past-present)
4. Length of her cycle?
5. Hx of OCP?
6. Papa smear?
7. Hx of dysmenorrhea or menorrhagia?
EXAMINATION
1. General: BMI, Vitals, dysmorphism.
2. Face: hirsutism, acne.
3. Neck: thyroid.
4. Breast: galactorrhea.
5. Abdomen: masses, hair distribution, scars.
6. Pelvic examination: ovarian masses and broid.

INVESTIGATION
A. Male:
- semen analysis (images):
1. The specimen should be collected after 2-3 days of abstinence.
2. The specimen should be obtained by masturbation.
3. The specimen should be reach the laboratory within an hour of ejaculation.

B. Female:
• Ovulation problem:
1. Increase basal body temperature >0.5 °C (at beginning of luteal phase).
2. progesterone mid-luteal phase (day 21) → >6mg/ml.
3. USG follicular study .
4. LH kit → detect surge and peak → ovulation occurs 10-12hr after peak.
• Ovarian reserve test:
1. Day 3 FSH → N: <10 — if >15 reduce reserve.
2. Day 3 estradiol → >70-80 poor reserve.
3. Serum Anti-müllerian hormone (AMH) → from granulosa cell.
4. Antral follicle count → by TVU [>6 normal] —[<4 poor].
• Tubes + uterus
1. Hystrosalpengiography (HSG) → 1st test uterine and tubes contour & patency.
2. Saline infusion ultrasonography.
3. Diagnostic laparoscopy → Gold standard.
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MANAGEMENT OF INFERTILITY
A. Male:
• mild oligospermia (5-15 million) → IUI (intrauterine insemination) .
• Sever oligospermia (<5 million)
- Hypergonadotropic hypogonadism (↑FSH & ↑LH) – Testicular biopsy (to check
whether sperms are present in testis ) is not useful.
- If hormonal levels are normal – Testicular biopsy is done. If sperm is present in
biopsy → ICSI is the option following retrieval of sperms by TESE and PESA.
- Men with normal gonadotropin and testosterone level having low volume of
ejaculate might be having retrograde ejaculation → . Sperms are obtained from
post ejaculatory neutralised urine and then IUI/ICSI done.

B. DISEASES
1. Klinefelter’s Syndrome:
- Karyotype is 47, XXY.
- Most common genetic anomaly in azoospermic men.
- Found in 1:500 to 1:1000 live male births.
2. Y-chromosome Microdeletions:
- May be found in up to 7% of men with male factor infertility.
- While these men may be able to father children via IVF/ICSI, male o spring will
inherit the Y-chromosome microdeletion and be infertile.
3. Congenital Absence of the Vas Deferens (CAVD)
- Associated with cystic brosis gene mutations in the cystic brosis
transmembrane conductance regulator (CFTR) gene.
- Partners of men with CAVD must be tested for the CFTR gene mutation before
pursuing infertility treatment with retrieved sperm.

C. DIAGNOSIS OF MALE INFERTILITY

- In azoospermia + oligospermia → FSH,LH, PRL, Karyotype.
- In azoospermia the diagnostic test which can distinguish between testicular failure
and obstruction of vas deferens is Estimation of FSH levels:
1. A very high FSH would indicate a testicular cause.
2. A very low FSH would indicate pretesticular cause.
3. A normal FSH would indicate a post-testicular cause.
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