2. INFERTILITY
Defined as 1 year of unprotected
intercourse without pregnancy
Classified as primary or secondary
infertility
Fecundability- probability of achieving
pregnancy within a single menstrual
cycle
Fecundity- probability of achieving a live
birth within a single menstrual cycle
3. INFERTILITY (contd.)
Fecundability of normal couple is
estimated at 20 to 25%
Time of exposure and pregnancy rate –
3months=57% , 6months= 72%,
1year = 85% , 2years = 93%.
4. INFERTILITY (contd.)
Evaluation for infertility is after 1 year
Exceptions are
1) women above 35 years.
2) couples with obvious pathology that
is associated with infertility.
5. INFERTILITY (contd.)
At age 35years and above, fertility
decreases due to
1) decrease in number of ovarian follicle,
which becomes rapid after 36 years.
2) ovarian follicles becomes less
sensitive to GNT stimulation.
3) rate of estradiol rise and peak
concentration is low.
6. INFERTILITY (contd.)
Infertility affects 10 – 15% of couples
in the U.S and about 20 to 30% in
Nigeria.
Couples who have conceived before
have a better prognosis
7. CAUSES (contd.)
Infrequent coitus due to separation,
erectile dysfunction, dyspareunia
Age. Female- as stated above. Male-
semen volume, sperm motility and
percentage of normal sperm gradually
decrease with age especially from 45 to
50 years.
8. CAUSES (contd.)
• MALE
• 1. Abnormality of sperm production –
• 1A. Primary testicular failure
(hypergonadotrophic hypogonadism) due
to
• a) genetic causes like klinefelter
syndrome and Y-chromosome
microdeletion.
• b) damage to the testis anatomy
like in cases of cryptochidism,
varicocele.
9. CAUSES (contd.)
• c) infections like viral and bacterial
orchitis
• d) gonadotoxins-lead, agricultural
spray, x-ray, radioactive substance,
heat ,febrile illness, tight nylon
underwear, smoking, alcohol and
drugs like cimetidine, nitrofurantoin
and tetracycline.
10. CAUSES (contd.)
• 1B. Inadequate GNT stimulation from
• a) genetic causes like isolated GNT
deficiency.
• b) direct and indirect effect of
hypothalamic/ pituitary tumour.
11. CAUSES (contd.)
• 1C. Exogenous androgen use thus
suppressing GNT secretion.
• 2. Abnormality of sperm function –
antisperm antibody , prostatitis, seminal
vesiculitis , varicocele , failure of
acrosome reaction, problems with sperm
binding and penetration of zona
pellucida.
12. CAUSES (contd.)
• 3. Obstruction in the ductal system-
vasectomy, congenital absence of vas
deferens in patients with cystic
fibrosis, congenital or acquired
obstruction of the epididymis or
ejaculatory ducts.
•
• 4. Idiopathic due to poor understanding
of mechanism of testicular function.
14. CAUSES (contd.)
4) Cervical/ immunological – antisperm
antibody, hostile cervical mucus,
abnormality of the cervix.
5) Systemic conditions – chronic
infections, chronic disease including
auto-immune conditions.
15. CAUSES (contd.)
Unexplained infertility – applies to
couples that have failed to establish a
pregnancy despite
(a) evaluation uncovering no obvious
cause of infertility OR
(b) after correction of identified
cause(s) responsible for infertility.
16. PREVALENCE
Male factor – 25 -40 percent
Male and female – 10%
Female factor – 40-50%
Unexplained – 10%
18. CLINICAL EVALUATION (female)
Gravidity, parity, pregnancy outcome
and associated complication
Menstrual Hx – cycle length ,flow,
dysmenorrhoea, intermenstrual
bleeding.
Coital frequency and sexual dysfunction
19. CLINICAL EVALUATION (female)
Duration of infertility, results of
previous evaluation and treatment
Past surgery – indication and outcome
Past and current illness
20. CLINICAL EVALUATION (female) contd.
Previous pap smear and treatment
Drug Hx, smoking, alcohol ingestion,
smoking
Occupation
Family Hx of early menopause and
reproductive failure
21. CLINICAL EVALUATION (female) contd.
Symptoms of thyroid disease
Pelvic pain, abdominal pain,
galactorrhoea, hirsutism and
dyspareunia
Weight and BMI
23. CLINICAL EVALUATION (female) contd.
Vaginal/cervical abnormality, secretion
or discharge
Mass , tenderness, nodularity in
adnexia or cul de sac
24. CLINICAL EVALUATION (male)
Duration of infertility /previous fertility
Coital frequency, sexual dysfunction
Result and treatment from previous
evaluation
26. CLINICAL EVALUATION (male) contd.
Exposure to toxin including heat
Drug Hx
Smoking , alcohol ingestion
Examination of penis and urethral
meatus
Testicular size
27. CLINICAL EVALUATION (male) contd.
Presence and consistency of vas
deferens
Varicocele
Secondary sexual xtics
Digital rectal examination
28. INVESTIGTIONS (male)
Semen analysis – 3 to 5 days
abstinence, semen better collected by
masturbation , Volume 2 to 6mls , ph
greater than 7.2 , sperm concentration-
greater than 20million per ml , total
sperm number greater than 40million
per ejaculate , actively motile greater
than 50% , normal morphology , greater
than 50% , WBC count – less than 1
million per ml , round cell – less than 5
million per ml.
29. INVESTIGTIONS (male)
Endtz test is an immuno-peroxidase
staining technique to identify WBC.
What is oligospermia , teratospermia ,
azoospermia , aspermia ,
asthenospermia,leucocytospermia ,
necrospermia.
30. INVESTIGATIONS (male) contd.
Hormone profile – FSH,LH, Prolactin,
thyroid function test
Testicular biopsy
Semen m/c/s
Vasography
Detection of antisperm antibody
Sugar profile
31. INVESTIGATIONS (female) contd.
Test for ovarian reserve – day 3
menstral cycle FSH, clomiphene citrate
challenge test , serum inhibin-B level,
serum anti-mullerian hormone,
sonographic antral follicular count,
mean ovarian volume measurement.
32. INVESTIGATIONS (female) contd.
INDICATIONS- women greater than
35years, unexplained infertility, family
Hx of early menopause, previous
ovarian surgery e.g –ovarian
cystectomy,ovarian drilling,
ophorectomy, chemotherapy or
radiation treatment, smoking and poor
response to exogenous GNT
stimulation.
33. INVESTIGATIONS (female) contd.
Test for ovulation-
1) Basal body temperature- rise of 0.5
to 1degree Farenheit in 2nd half of
MC
2) Pre-menstrual endometrial biopsy
3) Serum progesterone on 21st day of
MC- greater than 10nmol/l
34. INVESTIGATIONS (female) contd
4) Serial TVS for folliculometry
5) Serial LH monitoring for surge.
Ovulation occurs 34 to 36 hours after
the onset of LH surge and 10 to 12
hours after LH peak.
6) Cervical mucus for spinnbarkeit (8-
10cm) and ferning on dried
specimen.
37. INVESTIGATIONS (female) contd.
Assessment of cervical factor
1) Kremer’s test or Postcoital test –
abstinence for 2 to 3days, intercourse
around ovulatory period, aspirate
endocervical mucus for microscopic
examination. Positive test – 6
spermatozoa phf with forward
progression and spinnbarkeit of
greater than 6cm
39. TREATMENT (male)
Surgery – varicocelectomy , vaso-
vasostomy
Medical – antibiotic, clomiphene citrate,
Tamoxifen , FSH, HMG ,testosterone ,
bromocryptine and other.
Assisted reproduction – artificial
insemination by spouse or donor
sperm, intracytoplasmic sperm
injection (ICSI) with spouse or donor
sperm
40. TREATMENT (female)
Ovulatory disorder
1) Clomiphene citrate, Tamoxifen
2) HMG and HCG
3) Insulin sensitizer like metformin
for PCOS
41. TREATMENT (female)
4) Ovarian drilling for PCOS
5) Bromocryptine, cabergoline for
hyperprolactinaemia
6) Assisted reproduction-IVF plus ET,
GIFT , ZIFT with patient or donor
egg
42. TREATMENT (female) contd.
Tubo-peritoneal problems
1)Tubal surgery
2)Assisted reproduction-IVF plus ET
Uterine factor – Myomectomy for fibroid,
Adhesiolysis/insertion of inert IUD or
inflated foley catheter balloon/oestrogen
therapy for Asherman’s syndrome
