presentation on infertility, causes and its management. it gives an idea of the scope of the problem especially in sub Saharan Africa . the challenges in its management.

1. INFERTILITY
DR DUUM NWACHUKWU
MBBS, FWACS, FMCOG, FMAS, DMAS
CONSULTANT OBGYN, UROGYNAECOLOGY,
MINIMAL ACCESS SURGEON

3. Introduction.
Definition:
 Infertility is the inability to achieve and sustain a
pregnancy to delivery after at least 1 year of regular
unprotected ejaculatory vaginal sexual intercourse
with an adult of the opposite sex.
• Subfertility - a special case of infertility when there
are deliveries but not having any or desired number
of children alive.

4. Introduction cont.
• Infertility is a world wide problem affecting (5-20%) of
couple.
• In Africa, infertility is often overshadowed by a high
fertility rate and population density.
• African is the poorest of the continents with low capacity
and technologies to handle these two problems.

5. Prevalence of infertility.
• Infertility may be primary or secondary.
• Primary infertility occurs when the couple has not
achieved any pregnancy.
• Secondary infertility occurs in a couple who have had
at least a pregnancy irrespective of the outcome.

6. Prevalence cont.
Clinic based studies:
• In our environment, 20-30% is primary while 70-
80%of cases is secondary.
• In the developed countries primary is 80% as against
secondary of 20%.
• Population based studies suggest that secondary
infertility is more than primary infertility worldwide.

7. Prevalence cont.
• This reflect marked differences in the causative factors.
• Voluntary infertility often masks involuntary infertility in
developed countries.
• Desire for a large family size increases the burden of
infertility in developing countries.
• In Africa, the prevalence of infertility tend to follow the
pattern of pelvic infections.

8. FECUNDITY

9. Trend in the prevalence of infertility
• There is an overall increase in prevalence of infertility
in the last 3 decades compared to 3 decades before
that.
• Increase is prominent amongst the blacks, rising
from 3% to 13%
• This coincides with a rise in the prevalence of STD
and ectopic pregnancy.
• Amongst the whites the prevalence od infertility
caused by STI is about 0.7% -1%

10. Factors affecting fertility.
• Age:
9-16years – due to irregularity of menstrual
cycle. Desire to achieve a vocation.
Age > 35 years – reduction in ovulation
potential. Increased risk of chromosomal
abnormalities.

11. Factors affecting fertility cont.
• Social / Nutritional status / Income.
• Education – educated women tend to delay
conception.
• Marital status.
• Occupation – Foundry workers, agriculturists.
• Exposure to environmental toxicants eg benzene,
heavy metals.
• Fertility rate has dropped by 3% worldwide due to
uncertain factors.

12. Gender distribution of infertility
• The problems of infertility is often born by the
woman.
• Men are responsible for 33.3 % of infertility
cases.
• Women contribute to only about 25% of
cases.
• Both male and female factors for 20% and in
15% of cases not detectable. (WHO, 1992)

13. Causes of infertility
• 85 to 90% of couples or individuals who experience
infertility have a diagnosis for their infertility.
• In about 3% - 6% of couples the underlying causes of
infertility are not known.
• Causes vary with area and development.

14. Causes of infertility: Female factors.
1) Tuber disease like blockage and adhesion.
2) Anovulation - Regular
- Oligo-ammenorrhae
- Secondary “
- Primary “
- High prolactin level

15. Tubal blockage: Hydrosalpinges

16. FIBROID

17. VAGINAL SEPTUM

19. Female factors cont.
Uterine factors
• Fibroids at the corpus or cervix
• Endometriosis
• Uterine Synaechae
• Cervical incompetence.
• Cervical hostility.
• Aplasia / dysplasia.
Vaginal factors:- gynaetresia

20. Male factors
• Testicular varicose
• Genital infections
• Mumps orchitis.
• Previous groin/scrotal surgery
• Heavy smoking/chronic alcohol intake
• Chronic and serious systemic illness
• Men currently on fertility drugs or steroid
preparations.

21. Infertility – Lifestyle
• Weight.
Overweight BMI greater than 25
Obese BMI greater than 30
Underweight BMI less than 17
• Smoking
• Cocaine / Marijuana Use
• Alcohol Consumption

22. Evaluation of Infertility.
Normal Reproductive Efficiency.
Time required for conception in couples who will attain
Pregnancy.
Time of Exposure % Pregnant
3months 57%
6months 72%
1 year 85%
2years 93%
Guttmacher AF 1956.
Factors affecting normal expectancy of conception J.A.M.A. 161: 855,

23. Evaluation of Infertility.
History 1
• Gravidity, parity, pregnancy outcome and
associated complications
• Cycle length, and characteristics , onset and
severity of dysmenorrhoea
• Coital frequency and any sexual dysfunction
• Duration of infertility and results of any previous
evaluation and treatment.
• Past Surgery, its indications and outcome and
past or current medical illnesses, to exclude
episodes of PID or exposure to STI.

24. Evaluation of Infertility
History 2.
• Previous abnormal Pap smears and any
subsequent treatment.
• Current medications and allergies.
• Occupation and use of Tobacco, Alcohol, and
other drugs.
• Family history of birth defects, mental
retardation, early menopause or reproductive
failure.
• Symptoms of thyroid disease, pelvic or abdominal
pain, galactorrhoea, hirsutism, and dyspareunia

25. Evaluation of Infertility
Physical Examination.
• Weight and body mass index
• Any thyroid enlargement, nodule or tenderness.
• Breast secretions and their character.
• Signs of androgen excess
• Pelvic or abdominal tenderness, organ
enlargement or mass.
• Vaginal or cervical abnormality, nodularity in the
adnexa or cul-de-sac.

26. INVESTIGATIONS
• The male partner should normally have two
semen analyses performed during the initial
investigation.
• Laboratories that perform semen analysis
should undertake this according to recognised
WHO methodology.
• Laboratories should also practice internal
quality control and belong to an external
quality control scheme .

27. INVESTIGATIONS
• While regular menstruation is strongly suggestive of
ovulation, this should be confirmed by the
measurement of serum progesterone in the mid-
luteal phase
• There is no value in measuring thyroid function or
prolactin in women with a regular menstrual cycle, in
the absence of galactorrhoea or symptoms of thyroid
disease

28. INVESTIGATIONS
• Early follicular phase estimation of FSH and LH
is only performed if clinically indicated
• The female partner should normally have a
test of tubal patency during the initial
investigation of infertility

29. INVESTIGATIONS
• A hysterosalpingogram may be used as a
screening test for tubal patency in low risk
couples
• When an evaluation of the pelvis is required,
however, a diagnostic laparoscopy with dye
transit is the procedure of choice

30. Hysterosalpingography.

31. MANAGEMENT
The management of infertility should take
place in a dedicated infertility clinic staffed
by an appropriately trained professional
team with facilities for investigating and
managing problems in both partners.

32. MANAGEMENT
• Both partners should be seen together
• Privacy and sufficient clinical time
• Classical history taking with emphasis on
exploring a couple’s anxieties
• Counseling is very important and essential
• Routine examination is not necessary unless
indicated by the history

33. GENERAL ADVICE TO THE COUPLE
• Sexual intercourse every 2-3 days
• Timed intercourse to coincide with ovulation
causes stress and not to be recommended
• Smoking reduces both, women’s fertility as
well as semen quality
• Excessive alcohol is detrimental to semen
quality and may cause erectile dysfunction

34. GENERAL ADVICE TO THE COUPLE
• A body mass index of more than 29 is
associated with reduced fertility in both men
and women
• Folic acid supplement prior to conception and
up to 12 weeks of conception
• Rubella immunity should be checked
• If vaccinated then advise to avoid pregnancy
for at least one month after vaccination

35. UNEXPLAINED INFERTILITY
• Unexplained infertility is a diagnosis of
exclusion
• Spontaneous pregnancy rate are high in first
three years of trying
• Clomiphene encourages multifollicular
ovulation and increases the chances of
pregnancy in couple’s with unexplained
infertility

36. ASSISTED REPRODUCTION
• These techniques have revolutionized the
management of infertile couples
• Entry guidelines should be followed
• The women should be less than 40 years old
and in good health
• The couple should be aware of the emotional
and financial strain

37. ASSISTED REPRODUCTION
• The most common techniques used are:
Intrauterine Insemination
In-vitro fertilisation
Intracytoplasmic sperm injection
• The success rate of the clinic should be told to the
patient
• The take home baby rate is roughly around 20%
• There is no increase in the incidence of the
congenital abnormalities

38. Bad habits to break to increase fertility
• Staying up late
• Too many cups of coffee
• Over or under exercise
• Over eating and junk food binges
• Procastination
• Drinking too much alcohol
• Smoking
• Unsafe sex

39. WAYS TO IMPROVE FERTILITY
• Lose weight
• Manage stress
• Exercise
• Eat healthy

40. OTHER OPTIONS
• MUST KNOW WHEN TO STOP
• ADOPTION

41. PREVENTION OF INFERTILITY
• Effective Health care delivery system
• Wide spread accessible and affordable family
planning.
• Drugs and methods to treat pregnancy
complications and miscarriages.

42. PREVENTION CONT
• Public enlightenment on sex education and
sexual responsibility.
• Adequate prevention and treatment of pelvic
infections
Appropriate counseling on the dangers of late
marriages and post postpoment of child bearing
till the thirds decade of life.

43. Myths about Infertility.
• My periods are dark
• My uterus is tilted backwards
• All sperm run out after intercourse
• Need to lie on my stomach after sex
• Not having periods is bad for the body
• Having sex too often weakens the sperm
• Infertile men are weaklings

44. THANK YOU