Clinical case

A 36-year-old G.O comes to see you regarding her concerns about

infertility.
She reports that she and her husband of 4 years have been trying to
achieve pregnancy for the past 14 months without success.
She is particularly frustrated because he has fathered children from his
previous marriage.
They have been timing intercourse using commercial ovulation
predictor kits, but she is unsure whether she is using them correctly.
She reports regular menses and no history of tubal surgery or tubal
disease. What is your provisional diagnosis?
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 INFERTILITY
By
Emmanuel Ayebazibwe

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Objectives
By the end of the session, learners should be able to;
1. Define infertility
2. Describe the types of infertility
3. List the causes of infertility
4. Mention the signs and symptoms of infertility.
5. Explain the management of infertility
6. Briefly explain the prevention of infertility.
7. List the complications of infertility

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Definition/introduction
• Infertility is defined as the inability to conceive and carry a pregnancy to
viability after at least 1 year of regular sexual intercourse with out use of
contraception.
• Or Infertility is the failure of a couple to conceive after 12 months of
frequent, unprotected intercourse.
• Infertility affects approximately 15% of reproductive-age couples in the
United States. Reproductive age generally encompasses 15 to 44 years,
although pregnancy can occur outside of this age range.
• The probability of achieving a pregnancy in one menstrual cycle is
termed fecundability and is estimated to be 20% to 25% in healthy
young couples.
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Types of infertility
• Primary infertility- is an inability to conceive and carry a pregnancy to
viability with no previous history of pregnancy carried to alive birth.
• Secondary infertility- is an inability to conceive and carry a pregnancy
to alive birth following one or more successful pregnancies.
• Although often used interchangeably the term infertility and sterility
are not synonymous. Sterility denotes a total and irreversible inability
to conceive.
• Broadly defined infertility includes the inability to carry a pregnancy
to viability.

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Etiology of infertility
Successful conception requires a specific series of complex events:
• Ovulation of a competent oocyte
• Production of competent sperm
• Juxtaposition of sperm and oocyte in a functional reproductive tract
and subsequent fertilization
• Generation of a viable embryo
• Transport of the embryo into the uterine cavity
• Successful implantation of the embryo into the endometrium

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Steps in successful conception: ovulation, production of viable
sperm and fertilization, development of the zygote, early
embryonic development, and implantation of the embryo into the

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Etiology of infertility
Conditions that affect fertility are divided into three main categories: 1.
1. Female factors (65%)
2. Male factors (20%)
3. Unexplained or other conditions (15%)

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Causes of infertility
Female
Vaginal - abnormalities
o Infectious
o Highly acidic vaginal PH
Cervical - Hostile environment (insufficient oestrogen or infection)
o Incompetent cervix
Uterine - Abnormalities
o Hostile environmental for implantation and survival of blastocyst

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Female (causes of infertility)

Tubal
o Adhesions
o Scar tissue due to PID
o Endometriosis
Ovarian - an ovulation
o Irregular or infrequent ovulation
o Secretary dysfunction
o Inadequate luteal phase

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Male (causes of infertility)
• Anatomical abnormalities / congenital factor
o Undescended testicles, klinefelter’s syndrome(XXY)
• Inadequate sperm production / Maturation
• Varicose( swelling of the veins that drain the testicle)
• Testicular inflammation
• Heat exposure
• Sexually transmitted disease
• Radiation exposure

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• Stress
• Certain drugs eg cimetidine, nifedipine, chemotherapy, alcohol
lower testosterone levels, smoking
• Inadequate motility of sperm
• Blockage of sperm in male reproductive tract
• Ejaculation issues eg retrograde ejaculation(semen enters bladder
during orgasim).
• Cancers and non malignant tumors affecting male reproductive
system
Unexplained infertility
• For some couples, comprehensive evaluation of both partners does
not identify an etiology for their infertility
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Symptoms
• Inability to get pregnant
• Oligomenorrhea
• Too short(less than 21days)
• Irregular or absent cycle
• Reduced sex drive
• Weight gain
• Testicle pain or swelling in men
• Problems in maintaining erection in men
• Small, firm testicle
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Investigations/diagnosis
• Ovulation • Male partner
o Serum progesterone in the mid luteal o Semen analysis
phase
o Testicular biopsy
o Serum FSH and LH day 3 from the cycle
o Basal body temperature o Sperm function test
• Tubal patency • Endocrine System
o Hysterosalpingography o Hormones test: Thyroid,
o Dye test and Laparoscopy prolactine tests
• Uterus • Endometrial biopsy
o Ultrasonography
o Hysterosalpingography • Vaginal swab, Urinalysis
o Hysteroscopy • Post coital test (Hühner test)
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Management
Management - Treatment depends on the cause and may include:
• Counselling on sexual technique and fertility awareness
• Antibiotics
• Ovulation induction: Clomiphene Citrate 50 mg OD for 5days starting
from 2-5 of menstrual cycle
• Tubal surgery - Male partner treatment including Vas surgery
• Assisted reproduction :In Vitro Fertilization (IVF), Intracytoplasmic
sperm injection (ICSI)
• Adoption
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Complications
• Depression
• Social stigma
• Stress
• Relationship troubles

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Prevention of infertility
• Avoid alcohol
• Quit smoking
• Maintain a healthy diet. Overweight and underweight women are at a
high risk
• Practice safe sex and avoid STIs
• etc

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