Marie Antonette H.

Calinawagan, MD, FPOGS, FPSMFM

Introduction
■ Significant social and medical problem affecting
couples worldwide
■ Average incidence of infertility – 15% globally; may
vary in different populations
■ Some causes can be determined and treated, while
others cannot
Definition
■ WHO
– “a disease of the reproductive system defined by
the failure to achieve clinical pregnancy after 12
months or more of regular unprotected sexual
intercourse
Types of Infertility
■ Primary Infertility

■ Secondary Infertility
Conception and Fertility
■ The chances of conceiving in any given menstrual
cycle is less than 20%
■ Main events necessary for pregnancy to occur
– Ovulation
– Fertilization
– Implantation
■ Any condition that interferes with any of these events
can cause infertility
Conception and Fertility
■ Since approximately 85% of couples will achieve
pregnancy within a period of 1 year of unprotected
intercourse, workup for couples after such time is
recommended
■ Earlier work up (after 6 mos)
– If the woman is older than 35 years old
– Presence of oligo/amenorrhea
– known tubal obstruction, uterine disease, or severe
endometriosis
– Known male factor
Factors Affecting Fertility: Frequency of
Intercourse
■ Coital frequency is positively correlated with
pregnancy rates
1x per week 17%

3x per week 50%

Factors Affecting Fertility: Timing of
Intercourse
■ Intercourse right before ovulation maximizes the
chances of pregnancy
– Sperm survives as long as 5 days in the female
genital tract
– Ovum life expectancy is about 1 day if not
fertilized
– Sperm should be available in the female genital
tract at or shortly before ovulation
Factors Affecting Fertility: STIs and other
Infections
■ Gonorrhea and Chlamydia can cause:
– PID and cervicitis
– Urethritis, epididymitis, accessory gland infection
■ Mumps (orchitis) → secondary testicular atrophy
■ Other infections: TB, toxoplamosis, malaria,
shistosomiasis, leprosy
Factors Affecting Fertility
■ Age of the woman
– Decreased fertility rate by 50% at age 40 and increase in
miscarriage rate
■ Age of the man
– Increased age affects coital frequency and sexual
function
■ Nutrition
– For women, weight 10-15% below normal and obesity may
lead to less frequent ovulation and reduced fertility
Factors Affecting Fertility
■ Substances that can affect fertility
– Lead, toxic fumes, pesticites
– smoking and alcohol
■ May cause:
– In women: conceptions and increased risk of
fetal wastage
– In men: reduced sex drive and sperm count
Causes of Infertility
Evaluation of the Infertile Male
■ Male factor: independently responsible for approx.
20% and contributes to another 30-40% to infertility
in couples
■ Main causes of male infertility:
– Hypothalamic-pituitary disorders (1-2%)
– Primary gonadal disorders (30-40%)
– Disorders of sperm transport (10-20%)
– Idiopathic (40-50%)
Evaluation of the Infertile Male
■ History
– Complete review of systems
– Family reproductive history
– Detailed social history: use of anabolic steroids,
recreational drugs, tobacco and alcohol use
– Reproductive history:
■ Coital frequency and timing
■ Duration of infertility & previous fertility
■ Childhood illnesses and developmental history
■ Systemic medical illnesses ( DM, URT diseases)
■ Previous surgeries
■ Medications and allergy
■ Sexual history
■ Exposure to gonadotoxins
Evaluation of the Infertile Male
■ Physical examination:
– General physical exam
– Examination of the male genitalia
■ Examination of the penis, noting the location of the
urethral meatus
■ Palpation and measurement of the testes
■ Presence and consistency of both vasa and
epididymides
■ Presence/absence of varicocoele
■ Secondary sex characteristics, including body habitus,
hair distribution and breast development
■ Digital rectal exam when indicated
Evaluation of the Infertile Male
■ Semen analysis
Evaluation of the Infertile Female
■ History:
– Duration of infertility and results of any previous evaluation and
treatment
– Menstrual history
– Pregnancy history
– Previous methods of contraception
– Coital frequency and sexual dysfunction
– Past surgery
– Thyroid disease, galactorrhea, hirsutism, pelvic and abdominal pain
and dyspareunia
– Previous abnormal Pap smear and any subsequent treatment
– Current medications and allergies
– Family history of birth defects, developmental delay, early menopause
or reproductive problems
– Occupation and exposure to known environmental hazards
– Use of tobacco, alcohol and recreational or illegal drugs
Evaluation of the Infertile Female
■ Physical Exam:
– Weight, BMI, BP, and pulse
– Thyroid enlargement and presence of any nodules or
tenderness
– Breast characteristics and evaluation for secretions
– Signs of androgen excess
– Vaginal or cervical abnormality, secretions or discharge
– Pelvic or abdominal tenderness, organ enlargement, or
masses
– Uterine size, shape, position, and mobility
– Adnexal masses or tenderness
– Cul de sac masses, tenderness or nodularity
Evaluation of the Infertile Female
■ Tests for ovulation
– Transvaginal sonography
■ 12th day of cycle
■ Mature follicle: 1.8 cm, Endometrium ideal for implantation:
>0.8 cm
■ Limitation: cost and invasive nature
– Serum progesterone
■ 7 days prior to expected menses
■ Value of >3ng/ml presumptive of ovulation
– Urinary LH determination
■ May detect LH surge
■ Start testing 2-3 days prior to expected date of ovulation
Evaluation of the Infertile Female
■ Ovarian reserve testing
– Should be assessed in selected women at
increased risk for diminished ovarian reserve
■ >35 years old
■ Family history of early menopause
■ Single ovary or history of previous ovarian surgery,
chemotherapy or pelvic radiation therapy
■ Unexplained infertility
Evaluation of the Infertile Woman
■ Ovarian reserve testing
1. Cycle day 3 serum FST and estradiol
- Day 3 FSH values greater than 10-20 IU/ml have been
associated with poor ovarian stimulation and failure to
conceive
- Day 3 Estradiol: when FSH levels are normal but
estradiol levels during the early follicular phase are
elevated → associated with poor response to
gonadotropin stimulation and lower pregnancy rates
Evaluation of the Infertile Woman
■ Ovarian reserve testing
2. Antral Follicle count
- sum of antral follicles (2-10mm in mean diameter) in
both ovaries by TVS
- low AFC (3-10 follicles) associated with poor response
to ovarian stimulation
3. Serum Anti-Mullerian hormone
- AMH: secreted by granulosa cells, does not vary
during the cycle
- low AMH (<1ng/ml): associated with poor response to
stimulation and poor pregnancy outcomes with IVF
Evaluation of Infertile Women
■ Hormonal Assays
– Serum TSH and Prolactin measurements should
be limited to women with symptoms of thyroid
disease, galactorrhea or pituitary tumor or
anovulatory probmens
Evaluation of Infertile Women
■ Tests for tubal patency
– Hysterosalpingogram
■ Use of fluoroscopy and contrast media to document proximal
and distal tubal occlusion, demonstrate salpingitis isthmic
nodosa, and reveal tubal architecture
■ Day 8-10 of cycle
– Saline infusion hysterography (SIS)
■ TVS
■ Instilling saline inside the uterine cavity
– Laparoscopy with chromotubation
■ Instillation of dilute methylene blue or indigo carmine through
the cervix during laparoscopy to demonstrate tubal patency and
to demonstrate proximal or distal obstruction
Evaluation of the Infertile female
■ Evaluation of uterine factors:
– Transvaginal sonography
– Sonohysterography
– 3D ultrasound
– MRI
– Hysteroscopy
Management of Infertility
■ Management would depend on the different causes of
infertility
■ General advice:
– Diet
– Lifestyle modification
– Supplements: folate
– Stress reduction
– Coital frequency
Treatment for Anovulation
■ Clomiphen citrate
– First line treatment for oligo/anovulation
– Estrogen antagonist
– Competes with endogenous estrogens for estrogen
binding sites on the hypothalamus → blocking
negative feedback on endogenous estrogens
– Dosage: 50 to 150 mg per day for 5 days beginning 3-
5 days after the onset of menses
Treatment for Anovulation
■ Metformin
– Biguanide
– Has a role in ovulation induction in women with PCOS
– Decreases hepatic glucose production; some minor
peripheral action → decrease in insulin resistance
– Direct role in inhibiting ovarian androgen steroidogenesis
– Inferior to clomiphene in terms of livebirth rates in
women with PCOS; adjunct therapy
– Typical dosage: 1500mg/day
Treatment of Anovulation
■ Gonadotropins
– Indicated for ovulation induction when estrogen levels
are low & when there is no response to CC or
letrezole.
– Recombinant FSH preparations (75 IU/ml)
– Monitor treatment carefully with frequent
measurements of estrogen levels and ovarian
ultrasonography to assess the adequacy of response
and avoid ovarian hyperstimulation
Treatment for Anovulation
■ Letrezole
– Aromatase inhibitor
– Inhibits E2 production during the 5 days of
administration → negative feed back causing
increase in FSH
– Dosage: 2.5 – 5 mg for 5 days beginning on cycle
days 3-5
Treatment of Male factor Infertility
■ Evaluation by an
andrologist / urologist
■ Rule out medical problems
■ Intrauterine insemination
– Higher pregnancy rates
if with COS
■ IVF-ICSI
■ Donor sperm
Treatment of Uterine causes of infertility
■ Intrauterine adhesions
– Lysis of adhesions
■ Leiomyoma
– If no other case of infertility is found, and myomas of
moderate size and position are present, a
myomectomy is justified
■ Tuberculosis
– antiTB drugs
– Women with pelvic TB usually sterile
Treatment of Tubal causes of Infertility
■ Tubal reconstruction
■ IVF

– the extent and location of the intrinsic and

extrinsic tubal disease should be ascertained by
HSG and possibly laparoscopy in an effort to
determine whether tubal reconstruction or IVF
offers the better prognosis
Treatment of Infertility with Endometriosis

■ Mild lesions seen at the time of laparoscopy:

ablation by electrocauterization or laser
■ Surgery in the setting of infertility reserved for those
patients with pain and if large endometriomas are
present
■ Moderate to severe disease: surgery (operative
laparoscopy
Treatment of Unexplained Infertility
■ Routine empirical treatment : COS + IUI
■ For good prognosis patients (based on age and
shorter duration of infertility): EXPECTANT
MANAGEMENT (continued TIMED intercourse for
another 6 mos before proceeding to treatment
■ After 3-6 cycles of COS+IUI→ IVF
■ For women >40 years old→ IVF
Simplified Algorithm for Subfertility
Management Azoospermia – surgical sperm
retrieval then IVF - ICSI

Male – Semen OAT – IUI , IVF-ICSI,

Analysis varicocoelectomy,
antioxidant/hormonal treatment
Inability to
conceive for 1
year or earlier
if with risk
factors for Ovulation induction + IUI
subfertility Female –
pelvic
ultrasound,
test for Tuboplastay or IVF
ovulation, test
for tubal
patency Pelvic surgery of IVF
Counseling and Emotional Support
■ Address the emotional and social needs of couples
undergoing treatment
■ Individual counseling
■ Support groups
■ Patient information sessions