SUBFERTILITY IN NIGERIA

1. INFERTILITY
DR. IBEANU

2. OUTLINE
DEFINITION
INCIDENCE
CLASSIFICATION
FACTORS FOR FERTILITY
ETIOLOGY
INVESTIGATION
MANAGEMENT

3. DEFINITION
 Failure of a couple of reproductive age that live together to
conceive despite:
 Regular (2/3times a week with spaced intervals(alternate days))
 Unprotected coitus
 Peniovaginal intercourse
 Leading to ejaculation
 Absence of contraception
 Time

4. INCIDENCE
 In developed countries, infertility affects about 10% - !5% of married
couples.
 In Nigeria, the incidence varies from 25% – 30%. Despite growing concern
about overpopulation and under nutrition in Africa, It is estimated that
about 30% - 40% of women in sub-Saharan Africa, would complete their
reproductive years without a child.

5. CLASSIFICATION
Primary: Denotes couples who have never conceived
Secondary: Indicates previous pregnancy but failure to conceive
subsequently

6. FACTORS RESPONSIBLE FOR FERTILITY
 Healthy Spermatozoa
 Ovulation
 Spermatozoa should fertilize the oocyte at the ampulla of F.tube
 Embryo should reach the uterine cavity after 3 – 4 days of
fertilization
 Endometrium should be receptive for implantation and corpus
luteum should function adequately

7. ETIOLOGY
 Causes of Infertility includes:
 Male factor (40%)
 Female factor (40%)
 Combined (10%)
 Unexplained factor (5% - 10%)

8. MALE FACTOR
PRE - TESTICULAR
 Endocrine:
 Gonadotropin deficiency
 Thyroid dysfunction
 Hyperprolactinemia
 Psychosexual:
 Erectile dysfunction
 Impotence
 Drugs:
 Antihypertensive
 Antipsychotics
 Genetic:
 47 XXY
 Y chromosome deletions
TESTICULAR
 Immotile cilia (kartagener syndrome)
 Cryptorchidism
 Infection (mumps, orchitis)
 Toxins: drugs, radiation
 Varicocele
 Immunologic
 Sertoli-cell-only syndrome
 Primary testicular failure
 Oligoasthenoteratozoospermia

9. POST - TESTICULAR
 Congenital:
 Absence of Vas deferens (cystic
fibrosis)
 Young's syndrome
 Acquired infections:
 TB
 Gonorrhoea
 Surgical:
 Herniorrhaphy
 Vasectomy
 Others:
 Ejaculatory failure
 Retrograde ejaculation
 Hypospadia
 Bladder neck surgery

10. FEMALE FACTOR
OVARIAN
 Anovulation or oligo-ovulation
 Decreased ovarian reserve
 Luteal phase defect (due to
defective folliculogenesis)
 Luteinised unruptured follicular
syndrome (trapped ovum)
TUBAL & PERITONEAL
FACTORS
 Pelvic infections causing:
 Peritubal adhesions
 Endosalpingeal damage
 Previous tubal surgery or sterilization
 Salpingitis isthmica nodosa
 Tubal endometriosis
 Polyps

11. UTERINE
 Congenital malformation
 Uterine fibroid
 Chronic endometritis
 Endometial damage
CERVICAL
 Chronic cervicitis
 Cervical stenosis
 Immunological factor (antisperm
antibody)
VAGINA
 Congenital (atresia, transverse
vaginal septum, narrow introitus)
 Vaginism

12. COMBINED
 Age (F > 35 years)
 Infrequent sexual intercourse, lack of knowledge of coital technique
& timing of coitus
 Apareunia and dyspareunia
 Anxiety and apprehension
 Use of lubricants which maybe spermicidal
 Immunological factor

13. INVESTIGATION
OBJECTIVES
 To detect the aetiological
factor(s)
 To rectify the abnormality in an
attempt to improve the fertility
 To give assurance with
explanation to the couple if no
abnormality is detected
WHAT TO INVESTIGATE ?
 Semen analysis
 Confirmation of ovulation
 Confirmation of tubal patency

14. MALE
PROPER HISTORY
 Age
 Prev. marriage
 STI
 Prev. surgery
 Occupational hx (exposure to
excessive heat or radiation)
 Sex hx (frequency, erection,
penetration, orgasm, satisfaction)
 Social habits etc
PHYSICAL EXAMINATION
 Inspection and palpation of the
genitalia.
 Size and consistency of testicles
 Testicular volume (measured by
an orchidometer) should be at
least 20 cm3

15. SEMINAL FLUID ANALYSIS
Volume 2 – 5ml
Count > 20 million
Morphology > 30%
Motility > 50%
pH 7.5 - 8
Viability > 75% living
TRANSRECTAL US
 Indications include:
 Azoospermia or severe
oligospermia with normal
testicular volume
 Abnormal DRE
 Ejaculatory duct abnormality
 Genital abnormality
(hypospadias)

16.  OTHERS:
 Testicular biopsy
 Vasogram
 Blood and urine tests
 Hormone profile; serum FSH, LH, testosterone, prolactin & TSH
 Karyotype analysis
 Immunological tests

17. FEMALE
PROPER HISTORY
 General medical history
 Surgical history
 Menstrual history
 Previous Obstetric history
 Contraceptive practice
 Sexual problems
EXAMINATIONS
 General examination
 Systemic examination
 Gynecological examination
 Speculum examination
 Vaginal examination

18.  Basal body temperature
 Abdomino-pelvic US
 Hysterosalpingography (HSG)
 Hormone profile
 Laparoscopy and chromopertubation (NB: precisely diagnose
peritubal adhesions, pelvic endometriosis. Chromopertubation with
methylene blue reveals patency and nature of tubal motility)
 Immunological test
 Post-coital test

19.  Hormone profile:
 S. Progesterone: done 21th day mid cycle. > 25 ng/ml suggests ovulation
 S. LH: Daily estimation of serum LH at midcycle can detect LH surge.
Ovulation occurs about 34-36 hours after beginning of the LH surge. It
coincides about 10 -12 hours after LH peak.
 S. oestradiol: attains the peak rise approximately 24 hours prior to LH surge
and about 24 – 36 hours prior to ovulation

20. MANAGEMENT
 Assurance
 Control risk factors:
 Body weight
 Smoking and alcohol
 Psychosocial
Treat etiological factor

21. SURGICAL: Vaso-vasostomy, varicocelectomy
CONSERVATIVE:
Ovulation induction; clomiphene citrate, Letrozole, hMG (Humegon,
Pergonal)
Antiprolactin agent; bromocriptine
Antibiotics
Steriods

22.  ARTIFICIAL REPRODUCTIVE TECHNIQUE:
 Artificial Insemination
 In vitro fertilization and embryo transfer
 Intracytoplasmic sperm injection

23. THANK YOU
FOR YOUR ATTENTION