Infertility.ppt

INFERTILITY
Dr Rupali Mahadik
Principal/Prof
PAMCHRC
LUCKNOW

Definition
 Infertility is defined as a failure to conceive
within one or more years of unprotected coitus
 The term "primary infertility" is applied to
the couple who has never achieved a
pregnancy
 “Secondary infertility" implies that at least
one previous conception has taken place but
failure to conceive subsequently within one or
more years of unprotected regular coitus

Factors responsible for fertility are-
 Healthy spermatozoa should be deposited high
in the vagina
 The spermatozoa remain healthy and penetrate
into the uterine cavity and hence into the
uterine tubes
 The ovum finds its way into the uterine tube
where it can be fertilized by a spermatozoon.
 The fertilized ovum migrates into the uterus
and the endometrium must be in a state
,suitable for the nidation and subsequent
development

Fecundability
 20-25% of couples will conceive/cycle
 50% should conceive after 3-4mos
 95% should conceive after 1 yr

Infertility Facts
 origin of problem:
 30% female
 30% male
 30% both partners
 10% unexplained

Female Infertility Etiologies
Cervical/mucus
Endometrial/uterine
Pelvic/peritoneal
Tubal
Ovarian
 20%
 10%
 5-10%
 30-50%
 25%

 Faults in the female
Ovarian factors
The ovarian dysfunctions (dysovulatory) encompass :
 Anovulation or oligo–ovulation –
disturbed hypothalamo-pituitary-ovarian axis either primary or
secondary from thyroid or adrenal dysfunction
 Corpus luteum insufficiency (CLI)
lifespan of CL is shortened to less than 10 days-insufficient
secretion of progesterone-less secretory changes-hinder
implantation
 Luteinised unruptured follicle (LUF)
ovum is trapped inside the follicle which gets luteinised-
associated with endometriosis or hyperprolactemia

 Tubal factors
The impaired tubal function (tubopathy)
includes
1. Defective ovum pick up (octopus function).
2. Impaired tubal motility,
3. Loss of cilia and
4. Partial to complete obstruction of the tubal
lumen

 Uterine factors
The endometrium must be sufficiently receptive enough for
effective nidation and growth of the fertilized ovum.
The possible factors that hinder nidation are
 Uterine hypoplasisa ,
 Uterus endometritis (tubercular in particular).
 Uterine synerchiae or
 Congenital malformation of uterus.

 Cervical factors
Anatomic
Anatomic defects preventing sperm ascent may be
due to
1. Congenital elongation of the cervix,
2. Second degree uterine prolapse and
3. Acute retroverted uterus .
These conditions prevent the external os to bathe in
the seminal pool.
Pin hole os may at times be implicated , or the
cervical canal may be occluded by a polyp.

Physiologic
1. The fault lies in the composition of the cervical
mucus, so much that the spermatozoa fall to
penetrate the mucus .
2. The mucus may be scanty following amputation,
conization or deep cauterization of the cervix.
3. The abnormal constituents include excessive,
viscous or purulent discharge as in chronic
cervicitis.
4. Presence of antisperm or sperm immobilizing
antibodies immobilizing antibodies may be
implicated as immunological factor of infertility

 Vaginal factors
1. Atresia vagina (partial or complete),
2. Transverse vaginal septum,
3. Septate vagina or narrow introitus
causing dyspareunia are included in the
congenital group.

Others
 Age - fertility decreases after the age of
30!
 Even if severely low sperm count present
…the female prior to the age of 30 may
compensate by her fertility!
 Maximum fecundity is around 25

Faults in the male
Defective spermatogenesis
Obstruction of the efferent duct
system
Failure to deposit sperm high in the
vagina
Errors in the seminal fluid
Male Infertility

Common causes of male infertility
Defective
spermatogenesis
Obstruction of
efferent duct
Failure to
deposit sperm
high in vagina
Error in
seminal fluid
•Undescended
testes
•Tubercular •Impotency •Low fructose
content
•Varicocele or big
hydrocele
•Gonococcal •Premature or
absence of
ejaculation
•High PG
content
•Mumps orchitis •During
herniorrhaphy
•Hypospadias •Undue
viscosity
•Thyroid
dysfunction
•Diabetes

Sperm Count
 Fresh sample (to lab within 30 mins.) –most
sperm in initial ejaculate
 Male should be abstinent for 48 to 72 hours
 ejaculate volume - 2-6 ml
 pH - Alkaline(7-9)
 Liquefication - within ½ hr
 count (sperm density) - 60 million
 Motility - 60% progressive forward
 normal shapes (morphology) > 60%

Sperm Terms
 Asthenozoospermia
 Teratozoospermia
 Azoospermia
 Aspermia
 Oligospermia
 Necrospermia
 Reduction in vitality of
spermatozoa
 <30% spermatozoa with
normal morphology
 No spermatozoa in the
ejaculate
 No ejaculate
 Spermatozoa
Count <20 million /ml
 Spermatozoa are dead or
motionless

Tx Goals
To identify the cause of the infertility
To provide a basis for potentially
successful treatment options
To provide a realistic prognosis
To offer emotional support

First visit
 Have both come to all visits!!
 Get a complete history
 Sexual history!!
 Educate!!

Manly Questions
 Infertility duration
 Prior fertility in relationship(s)
 Medical & surgical history
 Meds (anabolic steroids, cancer
chemotherapy, sulfasalazine, nitrofurantoin)
 Alcohol, drugs, pot
 Occupational exposures
 Sexual dysfunction
 Tight fitting underwear/pants
 Previous testing

Womanly Questions
 Infertility duration
 Detailed menstrual history
 Prior pregnancies
 Fertility in other relationships
 IUD’s, OCP’s, Depo
 Frequency of intercourse/sexual
dysfunction

Womanly Questions
 Gynecologic history (PID, endometriosis,
fibroids, cervical dysplasia)
 Medical and surgical history
 Medications
 Previous tests and therapy

DRUGS
Cause hyperprolactinemia:
 Neuroleptic, antidepressant, and hypotensive
drugs and drugs for gastrointestinal symptoms
 Recreational drugs such as marijuana and
cocaine
 Spontaneous galactorrhoea must be
ascertained and further investigated for
suspected hyperprolactinemia

Female infertility
Detailed history & Physical examination
Patient laboratory investigations
Ovulation Tubal factor
Hysterosapingogeaphy
Hysteroscopy
Endometrial biopsy
Peritoneal factor
[ eglendometriosis]
Laparoscopy
Cervitcal factor
Postcoital test
[at naximum cervical mucus score]
Invito cervical
Ulterine factor
Hysterodosalpingography
Hysteroscopy
Endometrial biopsy
Chromosomal worked
[if primary amenorrhoea with somatic annomlies.
Repeated adortions.
Hypergonadotropic
next slide

Serial cervical mucus
examinations
Serial
ultrasonography
Urinary LH
by ovulation kit
S.progesteron level
(on 7th postovulatory day)
Prolactin, TSH
Endometrial biopsy
(for premenstrual
dating of
endometrium)
If ovulatory dysfunction,
additional endocrine
workup:
if hyperprolactinaemia
visual ields
CT/MRI of pitutary
if hirsutism: S. tetesterone
DHEA-S 17 OHPetc
Ultrasonography of ovaries
& adrenals
Basal body
temperature chart

Male infertility
Detailed history [Medicosurgical, Psychosexual,Occupational, etc]Antrological examination
Analysis of 2 semen samples
Patient laboratory
investigations
Postcoital test [well- timed]
If a oospermia;
Testicular biopsy
S.FSH level
Fructose in semen
If significant oilgospermia.
Specific endocrine workup
If hyperprolactinemia:
Visual fields
CT/MRI of pitutary
Normal,but no
pregnancy
Abnormal
Semen culture &
antibiotic sensitivity
[if plenty of pus cells
in semen]
Immunobead
test[if sperm
agglutiation]
Electronmicroscopy
of sperms in
special conditions
Other sperm function tests

Other sperm function tests
dacvitro
central mucus
penetration test
Migration test
Hypo-osmotic
swelling test
Acrosome reactin
& Acrosin assay.
SPA [sperm
penetration assay
using hamester eggs]
Computer assisted
semen
analysis CASA
[for sperm velocity
&
morphplogy
Characteristics of Spermatozoa
Good ferulty Moderate fertility Low fertility Very Low fertility
Volume of fluid [ml.]
1.5- 4.0
1.0 – 1.5
40 -60
0.5 – 1.0
76 .0
<03
>30
Count [millions per ml] 30-80
>80 10 -30
<30
Progressive motility at 2-3 hours after being pro
duced [per cent] >80 60 - 80 30 - 60
<30
>120 60 - 80 30 -60
<30
50 -120 20 -50 <30
Normal morphology of the head , body and tail
[percent]
Total number of progressively motile a
nd morphologically normal sperm in an ejissions.

Condition Definition Possible symptoms Possible solutions Success rates
FEMALE -- accounts for 35-40 per cent of all fertility problems
Endometriosis This condition, in
which endometrial
tissue (the uterine
lining that sheds with
each monthly period)
grows outside the
uterus, is a major
cause of infertility in
women.
Painful menstrual
periods, irregular or
heavy bleeding and
possibly, repeated
miscarriages.
Laparoscopic surgery
to remove abnormal
tissue or unblock
tubes and assisted
conception
treatments.
Surgery: 40-60 per
cent conceive within
18 months after
surgery. IVF: usual
expected success
rates
Ovulation problems Any condition (usually
hormonal) that
prevents the release
of a mature egg from
an ovary.
Absent or infrequent
periods and
excessively heavy or
light bleeding.
Ovulation-stimulating
drugs such as
clomiphene, follicle-
stimulating hormones,
human chorionic
gonadotrophin (HCG)
and in vitro
fertilisation (IVF)
using these drugs.
70 per cent ovulate
and of those, 20-60
per cent get pregnant.
Poor egg quality Eggs that become
damaged or develop
chromosomal
abnormalities cannot
sustain a pregnancy.
This problem is
usually age-related --
egg quality declines
significantly in the
late 30s and early 40s.
None. Egg donation or
surrogacy.
43 per cent of women
who have a fertilised
donor egg implanted
become pregnant.
Polycystic ovary
syndrome
Patients whose
ovaries contain many
small cysts have
hormone imbalances
Irregular menstrual
periods, excessive
hair growth, acne and
weight gain.
Ovulation-stimulating
drugs such as
clomiphene, follicle-
stimulating hormones,
70 per cent who take
fertility drugs ovulate
and of those, half go
on to conceive within

MALE -- accounts for 35-40 per cent of all fertility problems
Male tube blockages Any obstructions in
the vas deferens or
epididymis (the tubes
that transport fertile
sperm). Varicoceles
(varicose veins) in the
testicles are the most
common cause of
male tube blockages.
Sexually transmitted
diseases, such as
chlamydia or
gonorrhoea, are also
linked to tube
blockage problems.
None. Surgery to repair the
varicoceles or other
obstruction.
About 40 per cent are
able to impregnate
their partner within a
year of surgery, most
within six to nine
months.
Sperm problems Low or no sperm
counts, poor sperm
motility (the ability to
move), and
abnormally-shaped
sperm can all cause
infertility.
None. Fertility drugs may
boost sperm
production. Other
options include
artificial insemination
with donor sperm and
injecting sperm
directly into the egg
(intracytoplasmic
sperm injection).
Fertility drugs: About
25 per cent are able to
impregnate a partner.
Artificial insemination:
5-20 per cent of
women become
pregnant per cycle.
Sperm injection:
About 15 per cent of
women get pregnant
per attempt.
Sperm allergy Fewer than 10 per
cent of infertile
women and men have
immune reactions to
sperm, which cause
them to produce
antibodies that kill
None. Sperm washing and
intrauterine
insemination, assisted
conception
treatments.
Immunosuppressive
drugs, such as
Success rates of 20-40
per cent per cycle
have been reported
for all these
treatments, but these
figures are considered
controversial.

Unexplained and combination -- accounts for 20-35 per cent of all fertility problems
Unexplained infertility This catch-all term is
used when doctors
can't find a cause for
infertility after a full
series of tests and
assessments. Some
experts think being
significantly over- or
underweight,
exercising excessively
and even
environmental toxins
may be contributing
factors but no direct
links have been
confirmed.
None. Beyond timed
intercourse, there is
no specific treatment.
Some couples try
fertility drugs and
assisted conception
procedures such as in
vitro fertilisation,
which have usual
success rates. Others
decide not to have
children.
How long the couple
has been infertile is
important. Couples
with unexplained
infertility who have
been trying for less
than five years have
about a 15-30 per cent
chance of becoming
pregnant in a given
year. After five years,
fewer than 10 per cent
become pregnant
without treatment.
Combination infertility The term used to
describe couples who
have both male and
female infertility
problems, or when
one partner has more
than one fertility
problem.
Symptoms vary,
depending on causes.
Once all infertility
causes are
determined,
appropriate
treatments follow.
Rates vary, depending
on infertility causes.

Intrauterine insemination
(artificial insemination)
 definition: sperm introduced into female
reproductive tract by means other than
coitus
 sperm can come from donor / sperm
bank or from husband

IVF protocol
 sperm and ova added to dish; fertilization
occurs 12-14hrs.
 eggs transferred to new dish and cell
division occurs
 embryos squirted into uterus at 4- to 32-
cell stage (optimal: blastocyst stage)
 3 to 5 embryos are injected to increase
chances of pregnancy
 woman given progestogen to prevent
miscarriage

GIFT
 GIFT = gamete intrafallopian transfer
useful for tubal blockage
1. ova are collected and inserted into
oviducts below point of blockage
2. husband’s sperm are placed in oviduct
3. woman is treated with hormones to
prevent miscarriage

ZIFT
 ZIFT = zygote intrafallopian transfer
 ZIFT is like IVF, only zygotes (1 cell stage)
are inserted below blockage in oviduct (24%
success rate)

Others
 Ovarian stimulation protocol
 Surrogate pregnancy
 Adoption

Environmental changes
 Vitamins
 Baggy shorts
 Sex not every
night…every other
 Diet changes
 Stop smoking

Infertility.ppt

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