OBSTETRICS and

GYNAECOLOGY
jDEPT OF PSYCHIATRY

SHAGUN TYAGI MD2020

SAKSHI CHAUDHARY MD2020
TARISHI SINGH MD2020
TOPIC

INFERTILITY
What is infertility ?

Failure to conceive within one or more years

of regular unprotected coitus. may be that one
partner cannot contribute to conception, or that a
woman is unable to carry a pregnancy to full term
Types of infertility
● Primary
refers to couples who have not become pregnant after at least 1 year
infertility
sex without using birth control
having
methods.
● Secondary
refers to couples who have been able to get pregnant at least once,
infertility
but now are unable .
FECUNDABILITY
the probability of a woman conceiving within a given
period of time, especially during a specific month or menstrual cycle.
INCIDENCE
According to the Indian Society of Assisted
Reproduction, infertility currently affects about 10 to
14 percent of the Indian population, with higher
rates in urban areas where one out of six couples is
impacted. Nearly 27.5 million couples actively trying
to conceive suffer from infertility in India
COMMON FACTORS AFFECTING CONCEPTION IN BOTH PARTNERS

A number of factors affect your chances of conception. They

include the following:
● your age
● the timing and frequency of intercourse relative to ovulation
● the length of time trying to conceive
● whether or not you have been pregnant before
● getting adequate nutrition
● maintaining a healthy body weight
● avoiding excessive smoking, drinking and recreational drugs
● avoiding potential occupational exposures
Increased chance of conception Reduced chance of conception

Woman aged under 30 years Women aged over 35 years

Previous pregnancy No previous pregnancy

Less than three years trying to conceive More than three years trying to conceive

Intercourse occurring during the few days Intercourse incorrectly timed, not
before and/or the day of ovulation occurring within the few days before
and/or the day of ovulation

Woman's body mass index (BMI) 20-30 Woman's BMI < 20 or > 30

Both partners non-smokers One or both partners smoke

Caffeine intake less than two cups of coffee Caffeine intake more than two cups of
daily coffee daily

No use of recreational drugs Regular use of recreational drugs

 ESSENTIAL FACTORS FOR CONCEPTION
● Healthy spermatozoa
● Capacitation acrosome reaction on time changes to be done
● Motile spermatozoa
● Ovulation
● Tube should be healthy
● Fertilization to be done at ampulla
● Uterine cavity should be healthy and embryo to come after 3 or 4 days
● Endometrium be receptive for implantation (by estrogen
progesterone IGF 1 cytokines integrins
● Corpus luteum should work adequately
PHYSIOLOGICAL CONSIDERATION
Anovulation[before puberty or after menopause ] But
a girl may become pregnant before menarche

Because a girl can ovulate before having her first period, it is possible to become
pregnant if she has sex.

Conception not possible during pregnancy [pituitary gonad is suppressed by HCG , no

ovulation ]
During lactation period , amenorrhoea occurs still ovulation and conception can be done

However ,in a fully lactating women breastfeeding 5-6times/day spending 1hour or more
infertility and lactation are relative
Pregnancy is unlikely upto 10 weeks postpartum.
Conception depends upon potential of both partners
M ale is about 30 -40% responsible and female is
about 40-55% , both are responsible in 10% and
remaining 10% causes are unexplained
Its strange that 4 of 10 patients become pregnant
within 3 years without taking proper treatment
Sometimes subfertility of one partner be
counterbalanced by high fertility of other
● Defective spermatogenesis
● Obstruction of the efferent duct
system
● Failure to deposit sperm high in
the vagina
● Errors in the seminal fluid
DEFECTIVE SPERMATOGENESIS
The most common causes of male infertility are called:
● Azoospermia, no sperm cells are produced
● Oligospermia, where few sperm cells are produced
● Teratospermia, where a high proportion of sperm is abnormally
shaped

Sometimes, sperm cells are malformed or die before they can reach the egg.
In rare cases, a genetic disease such as cystic fibrosis or a chromosomal
abnormality can cause male infertility.
Around one in three cases of male infertility are caused by blockages or
absence of tubes which prevent sperm passage. This could be caused by
injury, genetic abnormality, or a vasectomy.
Congenital
Undescended testes-hormones are normal, defect in spermatogenesis, vas deferens absent 1%
sufferers

Kartagener syndrome- loss of ciliary function and sperm motility

Hypospadias -failure to deposit sperm to vagina
Thermal factor
Sperm need cool temperature , in disease like varicocele it disturbs
Infection
Mumps orchitis , chronic systemic illness like bronchiectasis affects quality of sperm,
t. Mycoplasma, chlamydia trachomatis

Endocrine
Kallmann syndrome , its rare causing testicular failure , Sertoli-cell-only-syndrome
-FSH level raised with germ cell hypoplasia
Genetic
Klinefelter syndrome in oligospermia and azoospermia gene deletion [Yq] is seen
Iatrogenic
Radiations , cytotoxic drugs, beta blockers, antidepressants etc
Immunological
Antibodies against spermatozoal surface antigen causing clumping after
ejaculation

Obstruction of efferent duct

By infection like TB,gonococcal, surgical trauma following
vasectomy ,young’s syndrome [epididymal obstruction]
Coital problems [failure to deposit sperm high in
vagina]
❖ Erectile dysfunction
❖ Ejaculatory dysfunction-premature or retrograde or
absence
❖ Hypospadias is a condition in which the opening of the urethra is on the
underside of the penis instead of at the tip.
Errors in the seminal fluid
❖ Unusual high or low volume of ejaculate
❖ Low fructose content
❖ High prostaglandin
❖ Undue viscosity
ANOVULATION
● Anovulation is the lack or absence of ovulation (the release of an egg). It is a common
cause of infertility.
● Anovulation is often the result of an imbalance of the hormones that cause a woman to
ovulate and may be part of the condition polycystic ovary syndrome (PCOS).
● Irregular menstruation can also indicate anovulation, and we have a variety of
diagnostic tools to help determine the cause of irregular cycles.

Ovulation depends on gonadotropins which depend on GnRH released by

hypothalamus

Primary or secondary thyroid or adrenal dysfunction lead to disturbed

hypothalmo-pit.-ovarian axis
Leading to ovulatory problems
LUTEAL PHASE DEFECT
Due to inadequate progesterone it leads to improper function and
growth of corpus luteum

Leading to Life of corpus luteum less than 10 days

Which lead to inadequate endometrial filling which hinder implantation
This defect is due to changes in folliculogenesis caused by -

Drug induced ovulation, less FSH , less LH ,increased prolactin,

endometriosis ,dysfunctional uterine bleeding
,hypothyroidism[subclinical]
LUTEINIZED UNRUPTURED FOLLICULAR
SYNDROME

Ovum is trapped in follicle

Cause associated with pelvic endometriosis,
hyperprolactinemia
PERITONEAL FACTORS

● Peritoneal inflammation - septic , aseptic

inflammations
● Abdominal or pelvic surgery
● Organized pelvic haematoma
● Pelvic irradiation
UTERINE CAUSES
CERVICAL FACTORS

ANATOMIC
● Congenital elongation of cervix
● Cervical stenosis

PHYSIOLOGICAL
● Fault in composition of cervical mucous
● Antisperm antibiotics
VAGINAL FACTORS
ATRESIA OF VAGINA [PARTIAL OR TOTAL ]

TRANSVERSE VAGINAL SEPTUM

NARROW INTROITUS causing DYSPAREUNIA is the term for recurring pain in

the genital area or within the pelvis during sexual intercourse. The pain can
sharp or intense. It can occur before, during, or after sexual intercourse.
be

VAGINITIS

PURULENT DISCHARGES