INFERTILITY

Learning objectives

1. Define the term infertility.

2. List at least eight causes of infertility in both men and women.
3. Mention the investigations carried out to diagnose infertility.
4. Describe the management of infertility.
Definition

Infertility refers to the inability of a couple to achieve a pregnancy after repeated

unprotected sexual intercourse without contraception for more than a year.

Types of infertility

Primary infertility is the inability to conceive in a couple who have had no

previous pregnancies.

Secondary infertility is the inability in a couple who have had at least one
previous pregnancy, which may have ended in a live birth, still birth, miscarriage,
ectopic pregnancy or induced abortion.

Incidence

1 out of 5 couples in USA are affected.

Causes of infertility

The cause can be from male, female or both.

Male causes

1. Low sperm count (oligospermia). This could be due to some drugs like anti-
hypertensives, antidepressants or some sedatives, or acute / chronic
infections of the male genital tract.
2. No sperms (azoospermia). This could be due to bilateral cryptochidism
(undescended testes)
3. Abnormal sperms like those without tails which makes them difficult to
swim.
4. Testesterone hormone insufficiency,
 5.Inflamed epididymis; storage and maturation of the sperms will not happen.
6.High levels of female hormones (hormonal imbalance)
7.Blocked vas deferens; Transportation of sperms will not take place.
8.Too much exposure of testes to heat; this affects spermatogenesis
(production of sperms).
9. Diseases like diabetes mellitus, hypertension, and mumps. These lead to
testicular atrophy.
10.Auto immune disorder may result in production of antisperm antibodies.
11.Obesity may result in testicular atrophy.
12.Smoking and or alcoholism affects spermatogenesis resulting into low sperm
count.
13.Exposure to chemicals like asbestos affects spermatogenesis resulting into
low sperm count.
14.Exposure to radiations also affects spermatogenesis.
15.Premature ejaculation resulting into immature and non motile sperms,
16.Malformations of seminal vesicles and prostate gland,
17.Retrograde ejaculation; this when a man ejaculates into sperms into the
bladder instead of the penis,
18.Conge5nital abnormalities of the penis like hypospadias and abnormal
urethra.
19.Varicocele affects the movement of sperms.
20.Urethral stricture affects the way of the sperms.
21.Failure to maintain an erection, a condition known as erectile dysfunction,
22.Some medications like anti-convulsants and anti-depressants depress sperm
count and motility.
Causes in females

1. Pelvic inflammatory diseases accounts for over 65%. This results into
healing by fibrosis (scar tissue formation), narrowing or blocking the
fallopian tubes making fertilization impossible.
2. Pituitary tumors leading to production of high levels of prolactin hence
inhibiting ovulation,
3. Ovarian cysts may hinder ovulation.
4. In ovulation; this is when ovulation does not take place.
5. Absence of ovaries (Turner’s syndrome); No ova will be produced.
 6. Fibroids; These tend to occupy a greater part of the uterine cavity making
implantation impossible.
7. Hormonal imbalance may also hinder ovulation.
8. Hostile environment to sperms or thick cervical mucus,
9. Severe vaginal infection which interferes with sperm transport,
10.Transverse septum in the vagina or uterus which makes sperms unable to
reach the fallopian tubes where fertilization takes place,
11.Un controlled diabetes mellitus, active goiter and hypertension also affects
the fertility rate of a mother.
12.Severe hypertension and some drugs like Methyldopa.
13.Excessive alcohol and smoking; this affects the production of ova.
14.Obesity; this also affects the fertility rate.
15.Increased maternal age that is, over 35 years. The rate of productivity
decreases with an increase in age.
16.Hypersensitivity to man’s sperms, whereby man’s sperms get killed by
antibodies in cervical mucus,
17.Endometriosis; This is the presence of endometrial tissue outside the uterine
cavity like in fallopian tubes which may result into implantation in the tubes
resulting into habitual ectopic pregnancy.
18.Tub ligation. This is a permanent form of family planning by which the
fallopian tubes are tied such that the sperms do not go through to reach the
ova for fertilization.
19.Adhesions or kinked tubes; these block the fallopian tubes making it
impossible for the sperm to reach the ova.
20.Pseudo menorrhoea; this is when a woman perceives that she is pregnant yet
she is not resulting into absence of menstruation
Causes in both males and females

1. Poor timing; this when the couple decides to have intercourse when a
woman is in her safe days,
2. Lack of relaxation; when a couple have intercourse while tied, this can result
into production of weak or immature sperms,
3. Stress; This can also result into production of weak sperms.
4. Excessive alcohol and or smoking; this affects spermatogenesis and
production of ova.
 5. Incompatibility, that is, woman may destroy man’s sperms due to variability
in Ph.
Diagnosis/ Investigations

1. History taking from both partners; Personal and family history about
frequency of sex, duration of sex, infertility in family, alcoholism and
smoking, nature of the job, marital status whether monogamy or polygamy,
social relationship and others.
2. Examination of the man and woman to rule out abnormalities like
Varicocele and hydrocele in men which affect fertility, and hirsutism
(excessive facial hair growth in women) and obesity in women which may
be suggestive of endocrine disorders.
Specific investigations in men

Semen analysis; this is the basic test for male infertility. It should be carried out
before any further investigations on the couple. Average values are assessed on 3
samples produced over several weeks, as quality is variable.

Specimen are produced by masturbation after 2 – 3 days abstinence and examined

in the laboratory within 1 hour.

If satisfactory, the man is assumed to be potentially fertile.

Normal values

Volume 2 – 6 mls per ejaculation

Total sperm count > 40 million per ml

Mortality more than 60% moving forward;

Morphology > 60% should appear normal.

Post coital test

A specimen of aspirated cervical mucus from the female partner is examined at the
fertile time of the cycle within 6 hours of intercourse. The ability of the sperm to
penetrate the mucus can be observed. This determines whether sperms can survive
in the cervical mucus.
Specific investigations in women

1. History of menstruation to determine ovulation,

2. Hysterosalpingiogram to rule out obstruction, abnormal tubes and fibrous
masses in the uterus and adhesions,
3. Blood for hormones analysis, that is, prolactin, oestrogen, and progesterone
levels; this will show fluctuations in the circulating levels.
4. X-ray of the pituitary gland and hypothalamus to rule out tumors and other
abnormalities.
5. High vaginal swab to rule out infection,
6. Ovulation tests to confirm if ovulation occurs or not, and if not more
investigations are carried out to identify the cause.
7. Ultra sound scan to confirm whether there is growth of ovarian follicles to
20mm and then the release of oocyte at ovulation.
8. Endometrial biopsy to rule out endometrial change following ovulation, the
presence of secretory endometrium confirms that ovulation has taken place.
9. Hysteroscopy, this views the uterus to rule out adhesions and septum in the
uterus and fallopian tubes.
10.Laparoscopy; this views the uterus, tubes, and ovaries to rule out any
abnormalities,
11.Crossed hostility test, this observes the behavior of the partner’s sperm and
fresh donor sperm in the woman’s cervical mucus.
12.The sperm penetration test; this demonstrates the behavior of sperm
alongside a sample of mucus taken at a fertile time on a glass slide. It
determines whether sperm functions or mucus hostility is the problem.
Treatment of infertility in men

1. Oligospermia may be improved by attention to diet and general health,

particularly reducing smoking and alcohol intake.
2. Azoospermia is usually untreatable.
3. Reducing high temperatures of the testicles may encourage sperm
development.
4. Administer corticosteroids to any man who presents with mumps as soon as
there is a hint of the infection.
Treatment of infertility in women

1. Clomiphene citrate is usually used to induce ovulation. It stimulates the

hypothalamic – pituitary system, permitting follicle stimulating hormone
(FSH) and so inducing ovulation.
2. GnRH (gonadotrophin releasing hormone) drug may be used to induce
ovulation if hypothalamus has a problem in release of the hormone.
3. HCG can be used to trigger ovulation, often in conjunction with clomiphene
or some other forms of ovulation induction.
4. Bromocriptine is used to inhibit the synthesis and release of prolactin by the
pituitary in case of hyper prolactinaemia.
5. In case of hostility, that is, if the mucus or the woman is producing anti
sperm antibodies to her partner’s sperms, steroids in short courses may be
helpful, or intra- uterine insemination may be successful.
6. Artificial reproduction