INFERTILITY
• INFERTILITY-FAILURE TO CONCEIVE WITHIN 1/MORE YRS OF REGULAR UNPROTECTED
INTERCOURSE
• CAN BE PRY/SEC
• FECUNDABILITY IS THE PROBABILITY OF ACHIEVING A PREGNANCY EACH MONTH (~0.22/MO).
• FECUNDITY IS THE ABILITY TO ACHIEVE A LIVE BIRTH WITHIN 1 MENSTRUAL CYCLE ( ~0.15-
0.18/MO).
EPIDEMIOLOGY
• AFFECTS 10-15% OF COUPLES OR 1 IN 6 COUPLES OF
CHILDBEARING AGE.
• 60% HEALTHY WOMEN UP TO 25 YOA ACHIEVE PREGNANCY
WITHIN 6 MONTHS OF TRYING.
80% OF COUPLES ACHIEVE PREGNANCY WITHIN 1 YEAR OF
TRYING.
MORE COMMON IN DEVELOPING COUNTRIES.
TAKES 2/3 OF CONSULTATION TO GYNAECOLOGIST IN AFRICA.
FACTORS ESSENTIAL FOR CONCEPTION
• HEALTHY SPERMS
• CAPACITATION/ACROSOMEREACTION
• MOTILE SPERMS
• OVULATION
• PATENT FALLOPIAN TUBES
• FERTILISATION
• EMBRYO TOREACH UTERINE CAVITY BY 3-4DYS OF FERTILIZATION
• RECEPTIVE ENDOMETRIUM
AETIOLOGY
MALE FACTORS – 18.8%
FEMALE FACTORS – 32%
MALE AND FEMALE FACTORS COMBINED – 18.5%
UNEXPLAINED AFTER INVESTIGATION – 11.1%
OTHER CAUSES – 5.6%
MALE INFERTILITY CAUSES
• DEFECTIVE SPERMATOGENESIS
• OBSTRUCTION OF EFFERENT DUCT SYSTEM
• FAILURE TO DEPOSIT SPERM HIGH UP IN THE VAGINA
• ERRORS IN SEMINAL FLUID
MALE FACTORS
1. INADEQUATE OR ABNORMAL PRODUCTION OF SPERM
• CONGENITAL E.G. CRYPTORCHIDISM
• TRAUMA, E.G. SPORTS INJURY, VASECTOMY, TORSION
• VARICOCELE
• INFECTION - USUALLY MUMPS ORCHITIS
• RARE: MALIGNANT DISEASE, ENDOCRINEDISEASE,
EXERCISE (OLIGOSPERMIA - LONG DISTANCE RUNNERS)
INADEQUATE PRODUCTION CONT’D
• ENVIRONMENTAL FACTORS – SMOKING REDUCES SPERMATOGENESIS AND TESTICULAR
SIZE; ALCOHOL REDUCES TESTOSTERONE AND SPERM CONCENTRATION;
CANNABINOIDS REDUCE SPERM COUNT AND QUALITY.
• EXCESSIVE RADIATION, HEAVY METALS- LEAD, PESTICIDES, EXPOSURE TO HIGH TEMPS.
• DRUGS – ANTI-CANCER, CIMETIDINE, SPIRONOLACTONE, KETOCONAZOLE, ANABOLIC
STEROIDS, ANTIHYPERTENSIVES, ANTIDEPRESSANTS
MALE FACTORS II
• 2. DEPOSITION PROBLEMS
• BILATERAL OBSTRUCTION OF EPIDIDYMIS OR DUCTS
• EJACULATORY DYSFUNCTION, E.G. RETROGRADE EJACULATION
• ERECTILE DYSFUNCTION
• ABNORMAL POSITION OF URETHRAL ORIFICE
FEMALE INFERTILITY CAUSES
• OVARIAN FACTORS-ANOVULATION, CORPUS LUTEUM INSUFFICIENCY
• TUBAL FACTORS-INFECTIONS/PID, TUBAL LIGATION, ADHESIONS
• UTERINE FACTORS-UNRECEPTIVE ENDOMETRIUM,CHRONIC
ENDOMETRITIS,FIBROID,SYNECHIAE
CONGENITAL MALFORMATION
• CERVICAL FACTORS-CHRONIC CERVICITIS,IMMUNOLOGICAL
FACTORS(ANTISPERM ANTIBODIES)
• PELVIC FACTORS-ENDOMETRIOSIS, ADHESIONS
FEMALE FACTORS I
1. OVULATORY DYSFUNCTION (15-20%)
• HYPERPROLACTINEMIA (E.G. PITUITARY MICROADENOMA)
• POLYCYSTIC OVARIAN DISEASE
• DRUGS (E.G. CIMETIDINE, PSYCHOTROPIC)
• SYSTEMIC DISEASES E.G. THYROID, HEPATO-RENAL
DISEASE, CUSHING SYNDROME, DM
• CONGENITAL - TURNER SYNDROME, TESTICULAR FEMINIZATION,
GONADAL DYSGENESIS, AND GONADOTROPIN DEFICIENCY
• LUTEAL PHASE DEFECT (LPD)
• EXCESSIVE EXERCISE (EVEN IN ABSENCE OF AMENORRHEA) INDUCES
ENDORPHINS - SUPPRESS FSH & LH - LPD
• PREMATURE OVARIAN FAILURE - AUTOIMMUNE DISEASES
HISTORY
• FEMALE; MENSTRUAL HX, PAST GYN HX, H/O PELVIC INFXN,
RUBELLA STATUS, WEIGHT, GEN STATE OF HEALTH &
NUTRITION, IF MENSES IRREGULAR H/O PCOS, ENDOCRINE
DISORDERS, COC HX, DX & RX OF INFERTILITY, OB HX
• MALE; H/O SEXUAL FXN, ERECTION, EJACULATION, ANY H/O
ORCHITIS/VENEREAL DZ, NATURE OF JOB, ABSENCE FROM
HOME, CHRONIC ILL HEALTH.
• BOTH; FREQUENCY OF INTERCOURSE, PENETRATION?,
DISCOMFORT, MALE SATISFACTION?,
CLINICAL EXAMINATION
• FEMALE; GEN. EXAM (ENDOCRINE ABNORMALITIES) & ROUTINE PELVIC EXAM
• MALE; ASSESS SIZE & CONSISTENCY OF TESTES & EPIDYDYMIS, VARICOCELE/HERNIA,
SIZE OF PROSTATE
DIAGNOSIS / INVESTIGATION
OVULATION TESTS
• BASAL BODY TEMPERATURE (BIPHASIC)
• MUCOUS QUALITY (MID-CYCLE)
• ENDOMETRIAL BIOPSY (D&C) 4 LUTEAL PHASE DEFECT (DAY
24-26)
• SERUM PROGESTERONE LEVEL (DAY 20-22); >20NMOL/L
=OVULATION
• SERUM PROLACTIN, TSH, LH, FSH
• IF HIRSUTE (PCOS): SERUM FREE TESTOSTERONE, DHEAS
• OVULATION PREDICTOR KITS
• U/S SCAN DETECTS FOLLICULAR GROWTH & OVULATION
TESTS FOR TUBAL PATENCY
• HYSTEROSALPINGOGRAM, DAY 8-10 = DIAGNOSTIC AND THERAPEUTIC (I.E. MAY OPEN
TUBE JUST PRIOR TO OVULATION)
• LAPAROSCOPY INJECTION OF TUBES WITH DYE
CERVICAL TESTS
• POST-COITAL TEST (DAY 12-14, SPERM MOTILITY IN CERVICAL MUCOUS 2-6 HOURS
AFTER INTERCOURSE)
INVESTIGATIONS CONT’D
• UTERINE TESTS
• HYSTEROSALPINGOGRAM
• HYSTEROSONOGRAM
• HYSTEROSCOPY
REASSURE THE COUPLE THAT COMPLETE INFERTILITY
EVALUATION IS PERFORMED ACCORDING TO THE WOMAN’S
MENSTRUAL CYCLE & MAY TAKE UP TO 2 CYCLES UNTIL THE
CAUSE IS FOUND.
MALE INVESTIGATIONS
• SEMEN ANALYSIS – SAMPLE COLLECTED AFTER 3-5DAYS OF
ABSTINENCE (SPERMATOGENESIS TAKES 72HOURS)
VOL – 2-5ML
PH – 7.2-7.8
SPERM CONCENTRATION – 20MILLION OR GREATER
MOTILITY – 50%, FORWARD PROGRESSION
MORPHOLOGY – NORMAL SPERM 50% OR GREATER
LEUCOCYTES - <1MILLION CELLS/MICROLITRE
TREATMENT
• WATCHFUL WAITING AND TIMED INTERCOURSE – AFTER 3YR 60% WILL CONCEIVE
SPONTANEOUSLY; AFTER 5YR 80%
• EXPECTANT THERAPY FOR 6-12MO IF WOMAN <35YR WITH 2YR OF INFERTILITY
• AGGRESSIVE THERAPY IF >35YR OR >3YR OF INFERTILITY
TREATMENT
MEDICAL
• BROMOCRIPTINE IF INCREASED PROLACTIN
• CLOMIPHENE CITRATE (CLOMID)- CORRECTS FOLLICULAR DVLPT & LPD,
INCREASES NO. OF FOLLICLES + OOCYTES
• HUMAN MENOPAUSAL GONADOTROPIN (PERGONAL) FOR OVULATION
INDUCTION
• UROFOLLITROPIN (FSH) (METRODIN)
• FOLLOWED BY ẞHCG FOR STIMULATION OF OVUM RELEASE
LETROZOLE- ORAL, REVERSIBLE NON-STEROIDAL AROMATASE INHIBITOR
WHICH RELEASES THE ESTROGEN NEG. FEEDBACK, INCR. GNTR,
STIMULATING FOLLICLE DVLPT & INCR. FOLLICLE SENSITIVITY TO FSH SO IS
EFFECTIVE IN INCR. FOLLICLE RECRUITMENT IN UNEXPLAINED INFERTILITY.
PREVENTION & RX OF STI’S & PID + OTHER UNDERLYING MEDICAL
CONDITIONS E.G. DM, HYPERTHYROIDISM, OBESITY/ UNDERWEIGHT.
TREATMENT
SURGICAL
• TUBOPLASTY – SALPINGOLYSIS, SALPINGOSTOMY,
SALPINGOTOMY, VASOSTOMY, MICROSURGERY
• ARTIFICIAL INSEMINATION (HETEROLOGOUS/THERAPEUTIC
INSEMINATION) - DONOR OR HUSBAND
• SPERM WASHING
• IN VITRO FERTILIZATION (IVF)- OVARIAN STIMULATION,
FOLLICULAR ASPIRATION, OOCYTE CLASSFN, SPERM
PREPARATION, OOCYTE INSEMINATION, EMBRYO CULTURE,
EMBRYO TRANSFER.
• GIFT (GAMETE INTRAFALLOPIAN TRANSFER)
• ICSI (INTRACELLULAR SPERM INJECTION)
ZIFT (ZYGOTE INTRAFALLOPIAN TUBE TRANSFER = GIFT+IVF)
COUNSELLING
• OFTEN DIFFICULT CZ OF THE INTIMATE NATURE
OF THE PROBLEM
• NOT ONLY A MEDICAL PROBLEM, BUT ALSO
AFFECTS HER ATTITUDE TO LIFE AND MARRIAGE
• DISPEL IN ANY IDEA THAT THE POSITION IS
HELPLESS
• EXPLAIN THE INVESTIGATIONS AND RESULTS
• DISCUSS THE OPTIONS
• INFERTILITY REGARDED TRADITIONALLY AS
“FAULT” IN THE FEMALE SO HARDER WHEN THE
PROBLEM IS FROM THE MALE.
SOCIAL EFFECTS OF INFERTILITY
STRESS
SOCIAL STIGMA-FEMALES BEAR MOST OF IT(INADEQUATE IN
SOCIETY)
PAIN-NEUROLOGICAL FORMS
ANXIETY/DEPRESSION
DIVORCE OR EXTRAMARITAL STATUS WITH COMPLICATIONS
EXPENSIVE,ETC.
