1. MRS. DEEPTI KUKRETI
PG NURSING TUTOR
OBSTETRICS AND GYNAECO
SGRRCON

2.  Infertility primarily refers to the biological
inability of a person to contribute to
conception. Infertility may also refer to the
state of a woman who is unable to carry a
pregnancy to full term.
OR
 The couple has not conceived after 12
months of contraceptive-free intercourse if
the female is under the age of 34.

3. Primary infertility
•means the couple have never
conceived
Secondary infertility
•means the couple may have
conceived before but are
unable to conceive again

4. Factors in
Male
Factors in
Female

5. Abnormalities
of the sperm
Abnormal
erection
Abnormal
ejaculation
Abnormalities
of seminal
fluid
Other
conditions

6.  Many factors can impair the number, structure or
function of sperm. Some conditions are
temporary, such as acute illness, others are
permanent such as genetic disorders.
 Evaluation of the semen may reveal that the
man has azoospermia or oligospermia. The
average number of sperm at ejaculation is 40
million. Twenty million sperm per milliliter of
semen is probably the minimum number
adequate for unassisted fertilization.
 Abnormal sperm structure or movement may
reduce fertility regardless of actual number of
sperm.

7.  Abnormal erections reduce the man’s ability
to deposit sperm bearing seminal fluid in the
woman’s upper vagina.
 Spinal cord disorders and disorders or surgery
that affects the autonomic nervous system
may also disrupt the normal erections.

8.  This prevents deposition of sperm in the
ideal place to achieve pregnancy.
 Retrograde ejaculation is the release of
semen backward in to bladder rather than
forward through the tip of penis.
 Conditions that may cause retrograde
ejaculation are diabetes, neurologic
disorders, drugs such as antihypertensive and
psychotropic.

9.  The seminal fluid nourishes, protects and carries sperm
into vagina until they enter the cervix.
 Only sperms enter the cervix, the seminal fluid remains
in the vagina.
 Semen coagulates immediately after ejaculation but
liquefies within 30 min, permitting forward movement
of sperm.
 Seminal fluid that remains thick traps the sperm,
impending their movement through the cervix.
 The pH of seminal fluid is slightly alkaline to protect the
sperm from the acidic secretions of the vagina.
 Seminal fluid that is abnormal in amount, consistency or
chemical composition suggests obstruction,
inflammation, or infection.

10.  Anatomic abnormalities such as varicocele,
or obstruction of the ducts that carry sperm
to the penis.
 Exposure to toxins such as lead, pesticides or
other chemicals.
 Excessive intake of alcohol

11.  A woman’s fertility depends on the following:
 Regular production of normal ova.
 An open path from her cervix to the fallopian
tube to permit fertilization and movement of the
embryo into the uterus for implantation.
 A uterine endometrium that supports the
pregnancy after implantation.

12. DISORDERS OF
OVULATION
ABNORMALITIES
OF THE
FALLOPIAN
TUBES
ABNORMALITIES
OF THE CERVIX
REPEATED
PREGENCY LOSS

13.  A dysfunction in the hypothalamus or
pituitary gland that alters the secretion of
GnRH, FSH and LH.
 Failure of the ovaries to respond to FSH and
LH stimulation, preventing maturation and
release of the ovum.

14.  At least one open tube is needed for the
conception and implantation to occur.
 Tubal obstruction may occur because of
scarring and adhesions following
reproductive tract infections or if adhesions
develop after pelvic surgery.
 Endometriosis may cause tubal adhesions,
painful menstrual periods, and painful
intercourse.
 The condition that causes obstruction also
may interfere with normal motility within
the fallopian tubes

15.  Polyps and scarring from the past surgical
procedures, such as cauterization or
conization, may obstruct the woman’s cervix.
 Abnormal cervical mucus caused by estrogen
deficiency, surgical destruction of the mucus-
secreting glands, and cervical damage
secondary to infection or other factors
prevent normal capacitation and movements
of the sperm into fallopian tubes for
fertilization

16. ABNORMALITIES OF THE FETAL CHROMOSOMES
•Errors in the fetal chromosomes may result in the spontaneous
abortion, usually in the first trimester
•Chromosome abnormalities often disrupt development severely.
HYPOTHYROIDISM AND HYPERTHYROIDISM may be
associated with the inability to conceive and with
recurrent pregnancy loss.
ABNORMALITIES OF THE CERVIX OR UTERUS
•Stenosis or congenital malformation of the cervix or uterine cavity
•Women who were exposed prenatally to diethylstilbestrol
ENDOCRINE ABNORMALITIES
•Inadequate progesterone secretion by the corpus luteum.
•Woman’s endometrium may not respond to progesterone secretion.

17. IMMUNOLOGICAL FACTORS
•The women’s bodies respond inappropriately to the embryo,
rejecting it as foreign tissue.
•Women with autoimmune disease, such as lupus erythematosous,
are more likely to experience spontaneous abortion.
ENVIRONMENTAL AGENTS
•Some environmental agents have a well established relationship to
impairment of fertility and pregnancy loss.
•Examples of established toxins are ionizing radiations, alcohol and
isotretinoin (accutane).
INFECTIONS
•Infections of the reproductive tract are associated with poor
pregnancy outcomes in general, and they may be related to early
pregnancy losses as well.

18. PATIENT EDUCATION
HISTORY
PHYSICAL EXAMINATION
DIAGNOSTIC TESTS

19.  Education of the infertile couple is the cornerstone to the
treatment of their problem.
 The couple should be advised to have intercourse within
the fertile zone (cycle days 12 - 16), and should be
informed that conception can occur with intercourse
occurring as distant as five days prior to ovulation.
 Couples should be discouraged from using any form of
artificial lubricants.
 They should be informed that conception usually occurs
within 4-6 months.
 Couples should be encouraged to alter any unfavorable
lifestyle practices that would decrease their chance of
pregnancy.
 The woman should be started on prenatal vitamins with
adequate folic acid content to reduce the risk of neural
tube defects.

20. The woman’s menstrual pattern
Any pregnancies and their outcome
Patterns of intercourse in relation to the
woman’s menstrual cycle
Length of time the couple has had
unprotected intercourse

21.  Couples who seek help for infertility are
usually healthy.
 However, a thorough examination of each
partner may identify endocrine disturbances,
cranial tumors, or undiagnosed chronic
disease.
 Examination of reproductive organs may
reveal structural defects, infection, cysts, or
other abnormalities.
 Chromosomal analysis may be performed for
couples experiencing repeated pregnancy
loss.

22. Progesterone Level
• 6 to 8 days prior to the onset of the expected menses.
• Level 10³ ng/ml is considered indicative of adequate
ovulation
Endometrial Biopsy
• 3 days prior to the onset of expected menses.
Ultrasound Evaluation
• To assess the development of a dominant follicle
• Reaches maturity and is prepared to ovulate when it
becomes approximately 1.8 to 2.0 cm in size.

23. Post coital Test
• Once a patient detects a surge, she
presents to the physician's office 24
hours later and approximately 2 to 6
hours after intercourse
• At that time, a speculum exam is
performed and cervical dilation,
Spinnbarkeit and amount of the cervical
mucus, and numbers of motile sperm
per high power field (HPF) are assessed.
• Ideally, one would like to see a dilated
cervix with abundant clear, watery
mucus (with Spinnbarkeit measuring at
least 8 to 10 cm), and at least 515
progressively motile sperm per HPF.

24. Hysterosalpingogram
• Soon after menses has ceased
• The study is performed under fluoroscopy
Laparoscopy
• when intrapelvic pathology is suspected or at the end
of an infertility workup
Basal body temperature
• It is designed to detect the slight elevation in
temperature that accompanies increased
progesterone secretion in response to the luteinizing
hormone surge and ovulation.

25. The most commonly prescribed fertility drugs include:
Clomid, Serophene - The risks of side effects, like multiple
pregnancy and ovulation hyper stimulation syndrome (OHSS), are less
with Clomid, when compared to gonadotropins (FSH, hCG, and hMG).
Femera - Femera, or letrozole, isn't actually meant to be a fertility
drug, but is intended to treat postmenopausal women with breast
cancer. Still, Femera has been shown to be as effective as Clomid
when inducing ovulation.
Follistim, Gonal-F - Follistim and Gonal-F

26. TRANSCERVICAL
BALLOON TUBOPLASTY
ARTIFICIAL
INSEMINATION
SURROGATE
PARENTING

27.  May be used to unblock a woman’s fallopian
tubes without more invasive procedures.

28.  This technique is used either the partner’s
sperm (Intrauterine Insemination) or that of
a donor (Artificial Therapeutic Insemination)
to overcome a low sperm count.
 Sperm that are to be placed directly in the
uterus or the fallopian tube are prepared by
washing and spinning the semen in a
centrifuge to remove seminal fluid.
 A technique called sperm swin-up uses a
suspension to concentrate sperm having the
best motility.

29.  A surrogate mother may enter the picture
if the woman is infertile or if she cannot
carry a fetus to live birth.
 The surrogate mother may supply her uterus
only, with the infertile couple supplying the
sperm and ovum or she may inseminated
with the male partner sperm and carry the
fetus to birth thus supplying both her genetic
component and gestational component.

30.  It bypasses many natural obstacles to
conception by placing intact gametes
together to allow fertilization. This class
includes in vitro fertilization, gamete
intrafallopian transfer and tubal embryo
transfer.
 Another class involves assisting fertilization
with microsurgical techniques. These
techniques bypass obstacles to fertilization
by penetrating the ovum with tiny needles to
allow placement of sperm within the ovum or
its surrounding zona pellucida.

31. IN VITRO
FERTILZATION
GAMETE
INTRAFALLOPIAN
TRANSFER
TUBAL EMBRYO
TRANSFER

32. MICRO
SURGICALLY
ASSISTED
FERTILIZATION
EPIDIDYMAL
AND
TESTICULAR
SPERM
EXTRACTION
BLASTOMERE
ANALYSIS

33.  The technique of IVF involves bypassing
blocked or absent fallopian tubes.
 The physician removes the ova by laproscope
or by ultrasound-guide transvaginal retrieval
and mixes them with prepared sperm from
the woman’s partner or a donor.
 Two days later, up to four embryos are
returned to the uterus to increase the
likelihood of a successful pregnancy.
 The woman receives supplemental
progesterone to enhance the receptivity of
her endometrium to implantation.

34.  It is used in cases where the women have
cervical problems or mild endometriosis or
male factor fertility, and require that a
woman have at least one unobstructed
fallopian tube.
 The retrieved ova are drawn into a catheter
that also carries prepared sperm.
 Sperm and up to two ova per tube are
injected into each fallopian tube through a
laproscope in which fertilization may occur.
 Progesterone is often given to enhance
implantation of any fertilized ova.

35.  It is also known as zygote intrafallopian
transfer (ZIFT) is a hybrid of IVF and GIFT.
 The woman’s ova are fertilized outside her
body, but the resulting fertilized ova (single-
celled embryo or “zygote”) are placed in the
fallopian tubes and the uterus naturally for
implantation.
 The woman must have at least one patent
fallopian tube.

36.  It involves making small slits in the zona pellucid cells
that surround the ovum to allow sperm to access the
ovum itself to achieve fertilization.
 A similar technique injects sperm into the space just
under the zona pellucida. Direct injection of a
spermatozoon into the cytoplasm of the ovum is called
intra cytoplasmic sperm injection (ICSI).
 Intra Cytoplasmic Sperm Injection (ICSI) is a laboratory
procedure developed to help infertile couples
undergoing In Vitro Fertilization (IVF) due to severe
male factor infertility. ICSI can facilitate fertilization by
sperm that will not bind to or penetrate an egg

37.  Sperm are removed from the epididymis or
directly from the testis using a needle.
 Fertilization is performed by ICSI. This
treatment is used in cases of male infertility
such as azoospermia and spermatic cord
abnormalities.

38.  It is a related technique to genetically
analyze the conceptus that results from
assisted reproduction.
 One or two cells from the 4-8 cell stage
conceptus are withdrawn for analysis.
 The DNA from the cell is amplified to allow
genetic analysis. If a genetic defect is
identified, the couple has the option of not
implanting the conceptus.

39.  Whole area of artificial conception is a
potential vulnerable area regarding
medicolegal problems whereas third party
assisted reproduction is a minefield.
Although the ethical issues are essentially
the same throughout the world, the law will
vary from country as will religious and social
attiudes.

40.  Demand for donor insemination is
considerably increased in all countries. In
view of this, several countries have
established a nation-wide system of Semen
Banks as well as to store semen as ‘Fertility
Insurance’ before male partner undergoes
chemotherapy, radiotherapy or vasectomy.

41.  Donor should be healthy preferably with proven fertility record.
 Donor should be screened for HIV, Hepatitis B, C, and STDs.
 Blood group and typing should be done.
 A detailed history of genetic disorder, sexual history, drugs used
should be recorded.
 Complete physical examination should be done.
 Age of the donor should be 21-45 years.
 Written informed consent should be taken from the donor that he
will not attempt to find out the identity of persons who are
inseminated.
 Relative or friends of couple are not permitted as donor to avoid
claims of inheritance rights.
 One donor sample should not be used for more than 5 successful
pregnancies.
 The recipient couple will pay the ART clinic for all the screening
tests including DNA fingerprint.

42.  Designed for women who have premature ovarian
failure, genetic diseases. Oocytes donation is clearly
different from sperm donation since the donor
receives drug treatment makes several visits to clinic
and undergoes invasive procedures for egg retrieval.
 Egg donors should be young (21-35 years) and
healthy with previous proven fertility record.
 Free of genetic or virus diseases.
 Recipient should be medically fit for gestation and
less than 45 years.
 All relevant information should be recorded and
preserved.
 Baby born after egg donation is registered as child of
carrying mother and her husband.

43.  Legal and ethical problems associated with
embryo donation are greater than those with
sperm or oocytes donation. The growing
number of frozen stored embryos in most IVF
centres is giving concerns for their future
management.
 Couples need to give specific consent for
donation of excess frozen embryos.
 Screening
 Embryos are not to be preserved for more
than 5 years.

44.  The surrogate should be the one who has had her
own children and living in a satisfied family unit.
 Should be young female, preferably less than 35
years and healthy to go through a successful
pregnancy.
 Surrogate should be in sound state of mind.
 Should be screened.
 Payment for surrogate should include all genuine
expenses.
 Birth certificate of the child born to surrogate
shall be in name of genetic parents.

45.  Prospective adoptive parents should register
themselves with the local licensed Adoption
agency or voluntary coordinating agency.
 Prospective adoptive parents submit the
documents related to their financial and
health status.
 A child is then showed to the parents. The
agency takes care to match a child meeting
the description, if any, desired by the
parents.

46.  Once a successful matching is done the agency
then files a petition in the court for obtaining
the necessary orders under HAMA or any other
relevant Act.
 Fees as prescribed will be charged by the
licensed adoption agency for the cost of caring
of the child and the legal procedures.
 The above process is normally completed in 6-8
weeks. Once the child has been matched with
the parents, there are regular follow up visits
and post adoption counseling by the social
worker till the child adjusts in his/ her
environment.

47. Complete and accurate information about the diagnosis and
treatment options available, including adoption or child free living.
Education about human reproduction, including factors that
interfere with normal conception.
Providing support and counseling to the couple during the diagnostic
and decision making process.
Assisting the couple during the process of treatment for fertility.
Evaluating the need for referrals to other resources such as
psychological or pastrol counseling

48. Anxiety related to unknown outcome of diagnostic
workup
Disturbed body image or situational low self esteem
related to impaired fertility
Risk for ineffective individual coping related to
methods used in the investigation of impaired
fertility.
Risk for ineffective individual coping related to
alternates to therapy: child free living or adoption

49. Interrupted family processes related to unmet
expectations for pregnancy
Acute pain related to effects of diagnostic
tests (or surgery).
Ineffective sexuality patterns related to loss
of libido related to medically imposed
restrictions

50. Deficient knowledge related to preconception
risk factors
Deficient knowledge related to factors
surrounding ovulation
Deficient knowledge related to factors
surrounding fertility.