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Dr. Azdihar Sahmi

University of Karbala
Medical college
Obstetrics and
Learning Objectives
❖Objectives that you must know:
• Definition and types
• Factors affect fertility & causes
• Assessment

❖Objectives that are nice to know

• Management
• A woman of reproductive age who has not conceived after 1-2 years
of unprotected, regular, vaginal sexual intercourse, in the absence of
any known cause of infertility.

• Primary infertility; couple have failed to conceive before.

• Secondary infertility; woman has previously been pregnant regardless

of the outcome of the pregnancy and now unable to conceive.
Chances of conception
• People who are concerned about their fertility should be informed that
over 80% of couples in the general population will conceive within 1
year if:
• - the woman is aged under 40 years
• - they do not use contraception and have regular sexual intercourse.
• Half of those who do not conceive in the first year will do so in the
second year
(cumulative pregnancy rate over 90%)
Factors affecting Fertility
1. Frequency/Timing of sexual intercourse
➢Every 2 to 3 days optimizes the chance of pregnancy.
-Frequency -Probability of conception
of intercourse (within 6 months)

• 1 time per week 17 %

• 3 times per week 50 %
Factors affecting Fertility
2. Obesity:
• Women who have BMI of over 30 should be informed that they are
likely to take longer time to conceive and will affect treatment success

3. Low body weight

• Women with BMI less than 19 and irregular menstruation should be
counselled to gain weight.
Factors affecting Fertility
4. Smoking
• Strong association between smoking and fertility in both partners.
• Affects success rates of ARTs. ( assisted reproductive technology).
5. Alcohol
• Female patients: alcoholism can lead to amenorrhea. This in part
caused by hypothalamic dysfunction and in part caused by the
associated general lifestyle and nutritional problems.
• - Intoxication may affect semen quality.
Factors affecting Fertility

6. Drugs: Corticosteroids, beta- blockers, antidepressants and

7. Occupation: exposure to heat, radiation and chemicals.
8. Age, Stress, Poor diet, Athletic training, STD’s, Health problems.
• In about 40% of cases disorders are
found in both the man and
the woman.
Pathogenesis of male subfertility
➢Semen abnormality ( 85%)
- Idiopathic
- Testis cancer
- Drugs, including alcohol and nicotine
- Genetic
- Varicocele
Pathogenesis of male subfertility
➢Azoospermia (5%)
- Pretesticular; anabolic steroid abuse; idiopathic hypo gonadotrophic
hypogonadism; Kalman’s; pituitary adenoma.
- Non- obstructive; cryptorchidism; orchitis; 47XXY; chemoradiotherapy
- Obstructive; CBAVD; vasectomy; STD, Chlamydia and Gonorrhea; CF.

CBAVD= congenital bilateral absence of vas deference.

CF= cystic fibrosis
47XXY= Klinefelter's syndrome
Pathogenesis of male subfertility
➢Immunological ( 5%)
• Antisperm antibodies
➢Coital dysfunction (5%)
• Mechanical cause with normal sperm function
• Ejaculation normal (hypospadias, phimosis)
• Retrograde ejaculation (diabetes, bladder neck surgery,
• Failure in ejaculation (MS, spinal cord/ pelvic injury)
MS= Multiple sclerosis
Female subfertility

❖Causes of anovulation
➢Primary ovarian failure
• Premature ovarian failure. POF
• Genetic; Turners syndrome.
• Autoimmune.
• Iatrogenic
- Surgery
- Chemotherapy.
Female subfertility
➢Secondary ovarian disorders
• Excessive weight loss or exercise
• Hypopituitarism
- Tumor
- Trauma
- Surgery
• Kalman's syndrome
• Hyperprolactinemia
• Hypothyroidsm
Female subfertility
❖Tubal damage:
• Infection
• Endometriosis
❖Uterine factors;
• Infection
• Asherman's syndrome
• Submucous fibroids
• Congenital uterine anomalies.
• Stenosis or abnormalities of the mucus-sperm interaction
• Infection
• Female sperm antibodies
Evaluation of the
Infertile couple
• History taking (female)
• frequency of intercourse
• menstrual history: irregularities
• surgical history: abdominal / pelvic surgery
• history of weight changes,
• hirsutism and acne
• contraception :IUCDs
• cervical smear
• symptoms (past or present) : STD , galactorrhea, thyroid symptoms
• obstetric history
Evaluation of the
Infertile couple
• History taking (male)
• Genital tract infection : mumps. Orchitis, prostatitis
• History of impotence, premature ejaculation, change inlibido,
• Surgical history of testicular torsion, undescended or maldescended testis,
prostate surgery, hernia repair
• Trauma: genital or inguinal region
• Exposure to lead, cadmium, mercury
• Drug history: Sulphasalazine ’impairs spermatogenesis’
Phenothiazine/ antipsychotics/metoclopramide ‘increase prolactin levels’
Medical history
• In both
• Smoking
• Alcohol intake
• Psychological factors
Evaluation of the
Infertile couple
• Examination for infertility (female)
• blood pressure, pulse, and temperature
• Body mass index BMI: <19 OR > 30
• Head and neck assessment:
• Exophthalmos (hyperthyroidism)
• Epicanthus, lower implantation of ears and hairline, and webbed
neck (chromosomal abnormalities)
• Exclude thyroid gland enlargement/nodules (thyroid dysfunction )
Examination for infertility (female) cont.

• Breast evaluation:
• Assess breast development
• abnormal masses or secretions, especially galactorrhea
• Abdominal evaluation:
• abnormal masses
• Speculum examination:
• Obtain a Papanicolaou test and cultures for gonorrhea, chlamydia.
• assess for cervical stenosis.
Examination for infertility (female) cont.

• Bimanual examination:
• Establish direction of the cervix + size/position of the uterus to
exclude the presence of uterine fibroids, adnexal masses Tenderness,
or pelvic nodules.
• Assess for defects (absence of vagina and uterus, vaginal septum)
• Extremities evaluation:
• Exclude malformation (cubitus valgus), which can indicate
chromosomal abnormalities and other congenital defects
• Dermatologic evaluation:
• Assess for the presence of acne or hirsutism.
Examination for infertility (male)
• General examination:
• Blood pressure, pulse, and temperature
• Body mass index BMI: > 30
• Secondary sexual character
• Local examination:
• Hypospadias
• Size and consistency of each testicle, epididymis and prostate
Presence of varicocele or hernia
• Gynaecomastia
Investigations for men
• Primary care
• Semen analysis
• Hormone testing
- testosterone
- prolactine
• Secondary care
• Testicular ultrasound
• T. Biopsy
• Genetic testing : karyotype
Investigations for women
• Evidence of ovulation:
▪ serum progesterone in the mid-luteal phase of their cycle (day 21 of a 28-day cycle) even if they
have regular menstrual cycles.
▪ Serum gonadotrophins (follicle-stimulating hormone and luteinising hormone) on Day2-3
especially in irregular periods.
▪ (N.B.: No role for basal body temperature charts)
• Ovarian reserve
• -More important in >35 years old, suspected ovarian failure and to detect response to ovulation
• 1. Total antral follicle count.
• 2. Anti-Müllerian hormone of less than or equal to 5.4 pmol/l for a low response and greater than
or equal to 25.0 pmol/l for a high response
• 3. Follicle-stimulating hormone greater than 8.9 IU/l for a low response and less than 4 IU/l for a
high response.
Investigations for women
• Other Hormone testing:
• Prolactin
• Thyroid test
• Genetic testing

• Further investigations
• Pelvic ultrasound
• Laparoscopy
• Hystero-salpingography
Investigations for women
• Investigation of suspected tubal and uterine abnormalities:
• 1. Hystersalpingography (HSG):
• - usually after failed successive cycles of ovulation induction, and in
some centres after failed IUI.
Investigations for women
• 2. Hysterosalpingo-contrast-ultrasonography
• TVS scan during which air and saline or a solution of D-galactose is
• infused into the uterine cavity and observed to flow along the
fallopian tubes.
• Requires more expertise.
• Less invasive.
Investigations for women
• Laparoscopy:
• Invasive procedure.
• to check for pelvic disease; such as endometriosis
• check tubal patency.
• therapeutic as in laparoscpic myomectomy and ovarian drilling.
• Hysteroscopy:
• to evaluate uterine cavity.
• In case of repeated failed IVF cycles.
• therapeutic as in intrauterine septum.
1. Counselling and waiting.
• Lifestyle changes
• Folic acid supplementation
• Rubella status
• Cervical screening
2. Treatment of the cause.
• Ovulation induction.
3. Artificial insemination (IUI/ICI)
Treatment of the cause:
• Male Factor:
1. Medical management:
• Men with hypogonadotrophic hypogonadism should be offered
gonadotrophin drugs.
• Men with idiopathic semen abnormalities
should not be offered anti-oestrogens,
gonadotrophins, androgens, bromocriptine
or kinin-enhancing drugs.
Treatment of the cause:
• Surgical management:
• Surgical correction of epididymal block in obstructive azoospermia.
• No evidence for surgical treatment of varicocele in infertility.

3. Management of ejaculatory failure:

• - Can be of great value as in retrograde ejaculation.
Treatment of the cause:
• Female Factor:
• Ovulation disorders:
• The WHO classifies ovulation disorders into 3 groups:
• 1. Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea
or hypogonadotrophic hypogonadism).
• 2. Group II: hypothalamic-pituitary-ovarian dysfunction
• (predominately polycystic ovary syndrome).
• 3. Group III: ovarian failure.
Treatment of the cause:
➢Ovulation disorders: (Group I)

• Weight gain if BMI less than 19.

• pulsatile administration of gonadotrophin-releasing hormone or

gonadotrophins with luteinising hormone activity to induce ovulation.
Treatment of the cause:
➢Ovulation disorders: (Group II “PCO”)
1. Weight loss to BMI <30
2. Clomiphene citrate and/or Metformin.
• folliculometry via TVUSS should be done to avoid multiple pregnancies
and risk of OHSS.
• Not for more than 6 months.
3. If resistant to the above, offer:
• laparoscopic ovarian drilling, or,
• ovulation induction via gonadotrophins.
Treatment of the cause:
➢Ovulation disorders: (Hyperprolactinaemic amenorrhoea)
• Women with ovulatory disorders due to hyperprolactinaemia
should be offered treatment with dopamine agonists such as
➢Tubal and uterine factors:
• Tubal microsurgery and laparoscopic tubal surgery:
• Uterine surgery, hysteroscopic adhesiolysis
• Surgery for hydrosalpinges before in-vitro fertilization
Treatment of the cause:
• Medical management
• Surgical ablation:
➢Unexplained infertility:
• Ovarian stimulation should not be considered as does not improve
pregnancy or birth rates.
• Advise to try to conceive for two years of unprotected sexual
intercourse before other options.
• After two years of failure to conceive, consider IVF/ICSI.