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Infertility
Definition
• Infertility is defined as lack of conception
  following 1 year of frequent unprotected
  intercourse.
• Define primary and secondary infertility

• Describe the causes of infertility

• Diagnosis and management of infertility
Requirements for Conception
• Production of healthy egg and sperm
• Unblocked tubes that allow sperm to reach
  the egg
• The sperms ability to penetrate and fertilize
  the egg
• Implantation of the embryo into the uterus
• Finally a healthy pregnancy
Infertility
• The inability to conceive following
  unprotected sexual intercourse
  – 1 year (age < 35) or 6 months (age >35)
  – Affects 15% of reproductive couples
     • 6.1 million couples
  – Men and women equally affected
Infertility
• Reproductive age for women
   – Generally 15-44 years of age
   – Fertility is approximately halved between 37th and 45th
     year due to alterations in ovulation
   – 20% of women have their first child after age 30
   – 1/3 of couples over 35 have fertility problems
      • Ovulation decreases        •Health problems develop
      • Health of the egg declines •SAB
• With the proper treatment 85% of infertile couples
  can expect to have a child
Infertility
• Primary infertility
  – a couple that has never conceived


• Secondary infertility
  – infertility that occurs after previous pregnancy
    regardless of outcome
Causes for infertility
• Male                         • Female
  –   ETOH                       –   Age
  –   Drugs                      –   Stress
  –   Tobacco                    –   Poor diet
  –   Health problems
                                 –   Athletic training
  –   Radiation/Chemotherapy
                                 –   Over/underweight
  –   Age
  –
                                 –   Tobacco
      Enviromental factors
       • Pesticides              –   ETOH
       • Lead                    –   STD’s
                                 –   Health problems
Causes of Infertility
• Anovulation (10-20%)
• Anatomic defects of the female genital tract
  (30%)
• Abnormal spermatogenesis (40%)
• Unexplained (10%-20%)
Causes of Infertility
               According to WHO
•   Hypothalamic disease (1 -2%)      Testicular disease (30-40 %)
•   Posttesticular disease (10-20%)   Sexual Dysfunction (1-2 %)
•   Systemic Illnesses (Uncommon)     Male Factors (23 %)
•   Ovulatory Dysfunction (18 %)      Tubal Damage (14%)
•   Endometriosis (9%)                Coital Problems (5%)
•   Cervical Factors (3%)             Unexplained (28%)
Evaluation of the Infertile couple
•   History and Physical exam
•   Semen analysis
•   Thyroid and prolactin evaluation
•   Determination of ovulation
    – Basal body temperature record
    – Serum progesterone
    – Ovarian reserve testing
• Hysterosalpingogram
Abnormalities of
Spermatogenesis
Male Factor
• 40% of the cause for infertility
• Sperm is constantly produced by the germinal
  epithelium of the testicle
   – Sperm generation time 73 days
   – Sperm production is thermoregulated
      • 1° F less than body temperature
• Both men and women can produce anti-sperm
  antibodies which interfere with the penetration of
  the cervical mucus
Semen Analysis (SA)
• Obtained by masturbation
• Provides immediate information
    – Quantity             Morphology
    – Quality              Motility
    – Density of the sperm
•   Abstain from coitus 2 to 3 days
•   Collect all the ejaculate
•   Analyze within 1 hour
•   A normal semen analysis excludes male factor
    90% of the time
Normal Values for SA
Volume                – 2.0 ml or more
Sperm Concentration   – 20 million/ml or more
Motility              – 50% forward progression
                        25% rapid progression
Viscosity             – Liquification in 30-60 min
Morphology            – 30% or more normal forms
pH                    – 7.2-7.8
WBC                   – Fewer than 1 million/ml
Causes for male infertility
• 42% varicocele
  – repair if there is a low count or decreased
    motility
• 22% idiopathic
• 14% obstruction
• 20% other (genetic abnormalities)
Abnormal Semen Analysis
• Azospermia                   • Oligospermia
  – Klinefelter’s (1 in 500)     –   Anatomic defects
  – Hypogonadotropic-            –   Endocrinopathies
    hypogonadism                 –   Genetic factors
  – Ductal obstruction           –   Exogenous (e.g. heat)
    (absence of the Vas
    deferens)
                               • Abnormal volume
                                 – Retrograde ejaculation
                                 – Infection
                                 – Ejaculatory failure
Evaluation of Abnormal SA
• Repeat semen analysis in 30 days
• Physical examination
  – Testicular size
  – Varicocele
• Laboratory tests
  – Testosterone level
  – FSH (spermatogenesis- Sertoli cells)
  – LH (testosterone- Leydig cells)
• Referral to urology
Unexplained infertility
• 10% of infertile couples will have a
  completely normal workup

• Pregnancy rates in unexplained infertility
  – no treatment 1.3-4.1%
  – clomid and intrauterine insemination 8.3%
  – gonadotropins and intrauterine insemination
    17.1%
Treatment of the Infertile Couple
Inadequate Spermatogenesis
• Eliminate alterations of thermoregulation
• Clomiphene citrate is occasionally used for
  induction of spermatogenesis
  – 20% success
• In vitro fertilization may facilitate
  fertilization
• Artificial insemination with donor sperm is
  often successful
Emotional Impact
• Infertility places a great emotional burden on the
  infertile couple.
• The quest for having a child becomes the driving
  force of the couples relationship.
• The mental anguish that arises from infertility is
  nearly as incapacitating as the pain of other
  diseases.
• It is important to address the emotional needs of
  these patients.
Test Question Case 1
• A couple in their late 20’s with primary infertility
  for 18 months. The women has regular monthly
  cycles. The husband has never fathered a child.
  Neither partner has a history of STD’s or major
  illness. No difficulties with erection or
  ejaculation. Which is the most likely cause of
  their infertility?
A. Anovulation
B. Abnormality of Spermatogenesis
C. Female Anatomic disorder
D. Immunologic disorder
Case 1
• Spermatogenesis- causes 40% infertility, anovulation-10-
  20% and anatomic defects- 30-40%-the majority of which
  being from salpingititis. Given the history of regular
  menstrual cycles and no infections, anovulation and
  anatomic defects is unlikely.
• Which study would not be indicated as part of the
  initial evaluation?
A. Basal Body temperature record
B. Semen Analysis
C. Hysterosalpingogram
D. Diagnostic Laparoscopy
Case 1
•   Diagnostic Laparoscopy- This should be reserved until
    the initial tests are completed. All the other tests are
    used in the initial workup.

•   Anovulation is found in the female partner,
    despite her regular cycles. The next step is?
A. Induce ovulation with clomid
B. Perform artificial insemination
C. Induce ovulation with gonadotropins (pergonal)
D. Perform diagnostic laparoscopy to rule out other causes
Case 1
• Induce ovulation with clomid- Gonadotropins
  would be used if the patient failed clomid.
  Artificial insemination and laparoscopy are not
  indicated yet.
Causes for Abnormal SA
               Abnormal Count


• No sperm                      • Few sperm
  –   Klinefelter’s syndrome      –   Genetic disorder
  –   Sertoli only syndrome       –   Endocrinopathies
  –   Ductal obstruction          –   Varicocele
  –   Hypogonadotropic-           –   Exogenous (e.g., Heat)
      hypogonadism
Cont. causes for abnormal SA
• Abnormal Morphology              • Abnormal Volume
   – Varicocele                      – No ejaculate
                                         •   Ductal obstruction
   – Stress
                                         •   Retrograde ejaculation
   – Infection (mumps)                   •   Ejaculatory failure
• Abnormal Motility                      •   Hypogonadism
   –   Immunologic factors           – Low Volume
                                         • Obstruction of ducts
   –   Infection
                                         • Absence of vas deferens
   –   Defect in sperm structure         • Absence of seminal
   –   Poor liquefaction                   vesicle
   –   Varicocele                        • Partial retrograde
                                           ejaculation
                                         • Infection
Conclusion
• Infertility should be evaluated after one
  year of unprotected intercourse.
• History and Physical examination usually
  will help to identify the etiology.
• If patients fail the initial therapies then the
  proper referral should be made to a
  reproductive specialist/Endocrinologist.
Thank you

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Male Infertility

  • 2. Definition • Infertility is defined as lack of conception following 1 year of frequent unprotected intercourse.
  • 3. • Define primary and secondary infertility • Describe the causes of infertility • Diagnosis and management of infertility
  • 4. Requirements for Conception • Production of healthy egg and sperm • Unblocked tubes that allow sperm to reach the egg • The sperms ability to penetrate and fertilize the egg • Implantation of the embryo into the uterus • Finally a healthy pregnancy
  • 5. Infertility • The inability to conceive following unprotected sexual intercourse – 1 year (age < 35) or 6 months (age >35) – Affects 15% of reproductive couples • 6.1 million couples – Men and women equally affected
  • 6. Infertility • Reproductive age for women – Generally 15-44 years of age – Fertility is approximately halved between 37th and 45th year due to alterations in ovulation – 20% of women have their first child after age 30 – 1/3 of couples over 35 have fertility problems • Ovulation decreases •Health problems develop • Health of the egg declines •SAB • With the proper treatment 85% of infertile couples can expect to have a child
  • 7. Infertility • Primary infertility – a couple that has never conceived • Secondary infertility – infertility that occurs after previous pregnancy regardless of outcome
  • 8. Causes for infertility • Male • Female – ETOH – Age – Drugs – Stress – Tobacco – Poor diet – Health problems – Athletic training – Radiation/Chemotherapy – Over/underweight – Age – – Tobacco Enviromental factors • Pesticides – ETOH • Lead – STD’s – Health problems
  • 9. Causes of Infertility • Anovulation (10-20%) • Anatomic defects of the female genital tract (30%) • Abnormal spermatogenesis (40%) • Unexplained (10%-20%)
  • 10. Causes of Infertility According to WHO • Hypothalamic disease (1 -2%) Testicular disease (30-40 %) • Posttesticular disease (10-20%) Sexual Dysfunction (1-2 %) • Systemic Illnesses (Uncommon) Male Factors (23 %) • Ovulatory Dysfunction (18 %) Tubal Damage (14%) • Endometriosis (9%) Coital Problems (5%) • Cervical Factors (3%) Unexplained (28%)
  • 11. Evaluation of the Infertile couple • History and Physical exam • Semen analysis • Thyroid and prolactin evaluation • Determination of ovulation – Basal body temperature record – Serum progesterone – Ovarian reserve testing • Hysterosalpingogram
  • 13. Male Factor • 40% of the cause for infertility • Sperm is constantly produced by the germinal epithelium of the testicle – Sperm generation time 73 days – Sperm production is thermoregulated • 1° F less than body temperature • Both men and women can produce anti-sperm antibodies which interfere with the penetration of the cervical mucus
  • 14. Semen Analysis (SA) • Obtained by masturbation • Provides immediate information – Quantity Morphology – Quality Motility – Density of the sperm • Abstain from coitus 2 to 3 days • Collect all the ejaculate • Analyze within 1 hour • A normal semen analysis excludes male factor 90% of the time
  • 15. Normal Values for SA Volume – 2.0 ml or more Sperm Concentration – 20 million/ml or more Motility – 50% forward progression 25% rapid progression Viscosity – Liquification in 30-60 min Morphology – 30% or more normal forms pH – 7.2-7.8 WBC – Fewer than 1 million/ml
  • 16. Causes for male infertility • 42% varicocele – repair if there is a low count or decreased motility • 22% idiopathic • 14% obstruction • 20% other (genetic abnormalities)
  • 17. Abnormal Semen Analysis • Azospermia • Oligospermia – Klinefelter’s (1 in 500) – Anatomic defects – Hypogonadotropic- – Endocrinopathies hypogonadism – Genetic factors – Ductal obstruction – Exogenous (e.g. heat) (absence of the Vas deferens) • Abnormal volume – Retrograde ejaculation – Infection – Ejaculatory failure
  • 18. Evaluation of Abnormal SA • Repeat semen analysis in 30 days • Physical examination – Testicular size – Varicocele • Laboratory tests – Testosterone level – FSH (spermatogenesis- Sertoli cells) – LH (testosterone- Leydig cells) • Referral to urology
  • 19. Unexplained infertility • 10% of infertile couples will have a completely normal workup • Pregnancy rates in unexplained infertility – no treatment 1.3-4.1% – clomid and intrauterine insemination 8.3% – gonadotropins and intrauterine insemination 17.1%
  • 20. Treatment of the Infertile Couple
  • 21. Inadequate Spermatogenesis • Eliminate alterations of thermoregulation • Clomiphene citrate is occasionally used for induction of spermatogenesis – 20% success • In vitro fertilization may facilitate fertilization • Artificial insemination with donor sperm is often successful
  • 22. Emotional Impact • Infertility places a great emotional burden on the infertile couple. • The quest for having a child becomes the driving force of the couples relationship. • The mental anguish that arises from infertility is nearly as incapacitating as the pain of other diseases. • It is important to address the emotional needs of these patients.
  • 23. Test Question Case 1 • A couple in their late 20’s with primary infertility for 18 months. The women has regular monthly cycles. The husband has never fathered a child. Neither partner has a history of STD’s or major illness. No difficulties with erection or ejaculation. Which is the most likely cause of their infertility? A. Anovulation B. Abnormality of Spermatogenesis C. Female Anatomic disorder D. Immunologic disorder
  • 24. Case 1 • Spermatogenesis- causes 40% infertility, anovulation-10- 20% and anatomic defects- 30-40%-the majority of which being from salpingititis. Given the history of regular menstrual cycles and no infections, anovulation and anatomic defects is unlikely. • Which study would not be indicated as part of the initial evaluation? A. Basal Body temperature record B. Semen Analysis C. Hysterosalpingogram D. Diagnostic Laparoscopy
  • 25. Case 1 • Diagnostic Laparoscopy- This should be reserved until the initial tests are completed. All the other tests are used in the initial workup. • Anovulation is found in the female partner, despite her regular cycles. The next step is? A. Induce ovulation with clomid B. Perform artificial insemination C. Induce ovulation with gonadotropins (pergonal) D. Perform diagnostic laparoscopy to rule out other causes
  • 26. Case 1 • Induce ovulation with clomid- Gonadotropins would be used if the patient failed clomid. Artificial insemination and laparoscopy are not indicated yet.
  • 27. Causes for Abnormal SA Abnormal Count • No sperm • Few sperm – Klinefelter’s syndrome – Genetic disorder – Sertoli only syndrome – Endocrinopathies – Ductal obstruction – Varicocele – Hypogonadotropic- – Exogenous (e.g., Heat) hypogonadism
  • 28. Cont. causes for abnormal SA • Abnormal Morphology • Abnormal Volume – Varicocele – No ejaculate • Ductal obstruction – Stress • Retrograde ejaculation – Infection (mumps) • Ejaculatory failure • Abnormal Motility • Hypogonadism – Immunologic factors – Low Volume • Obstruction of ducts – Infection • Absence of vas deferens – Defect in sperm structure • Absence of seminal – Poor liquefaction vesicle – Varicocele • Partial retrograde ejaculation • Infection
  • 29. Conclusion • Infertility should be evaluated after one year of unprotected intercourse. • History and Physical examination usually will help to identify the etiology. • If patients fail the initial therapies then the proper referral should be made to a reproductive specialist/Endocrinologist.