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Introduction

to Infertility

Division of Reproductive Endocrinology Department of Obstetrics and Gynecology Gadjah Mada University

Introduction
The inability to create a desired pregnancy that culminates in the birth of a child is likely to create a life crisis for women and their partners. Women seeking fertility treatment looking for care, counsel and health teaching. Infertility is more common in older women. Moreover, increased age reduces the efficacy of treatment.
© 2008, March of Dimes Foundation

Infertilty
Infertility is inability of a couple to conceive after one year of sexual intercourse without contraception
 Primary infertility: The inability to conceive

after 1 year of unprotected intercourse for a woman younger than 35, or after 6 months of unprotected intercourse for a woman 35 or older (Speroff & Fritz, 2005).  Secondary infertility: The inability of a woman to conceive who previously was able to do so (Speroff & Fritz, 2005).

Causes of Infertility
Couples

(Speroff & Fritz, 2005)
© 2008, March of Dimes Foundation

2005) . March of Dimes Foundation (Speroff & Fritz.Causes of Infertility Women © 2008.

INCIDENCE AND TREAMENT The overall incidence of infertility has remained relatively unchanged over the past 3 years.  However.  . the evaluation and treatment of infertility has changed dramatically during that time.

The introduction of IVF (Invitro Fertilization) and other ARTs. Changes in population demographic The advances in ART and concerns about the age-related decline in fertility Consequently. . 2. evaluation andtreatment.THREE MAJOR DEVELOPMENT 1. infertile couples are now more likely to seek medical advice. 3.

Which Investigations!! There is a very long list of investigations for the diagnosis of infertility. unfortunately there is no consensus on which tests are essential before reaching the exact diagnosis .

Infertility investigation            Semen analysis Tubal patency by hysterography or laparoscopy Mid luteal progesterone for the diagnosis of ovulation Ultrasound Postcoital test Antisperm antibodies assays Endometrial dating Varicocele assessment Chlamydial testing Hysteroscopy Hydrolaparoscopy .

Basically there are 4 factors required for getting pregnant :  Sperm  Ovum  Conception  Implantation Investigations of infertility .

Sperm transport to the side of fertilization .

FERTILIZATION – TRANSPORTATION – DEVISION .OOCYTE BLASTO CYST OVULATION .

When should woman go to see a doctor?   Women in their 30s who've been trying to become pregnant for six months should speak to their doctors as soon as possible. Women with the following issues should speak to their doctors:      irregular periods or no menstrual periods very painful periods Endometriosis pelvic inflammatory disease more than one miscarriage .

What Increases the Risks?           Age Stress Poor diet Smoking Alcohol STDs Overweight Underweight Caffeine intake Too much exercise .

a woman's fertility potential gradually declines.Many of the risk factors for both male and female infertility are the same. . they include:   Age. After about age 32. Infertility in older women may be due to :    A higher rate of chromosomal abnormalities that occur in the eggs. The risk of miscarriage also increases with a woman's age. Older women are also more likely to have health problems that may interfere with fertility.

Tobacco smoking.  Alcohol use. For women. Miscarriages are more frequent in women who smoke.  Being overweight. Among American women. infertility often is due to a sedentary lifestyle and being overweight. Men and women who smoke tobacco may reduce their chances of becoming pregnant and reduce the possible benefit of fertility treatment.  . there's no safe level of alcohol use during conception or pregnancy.

not enough exercise can contribute to obesity. On the other hand. exercising more than seven hours a week has been associated with ovulation problems. zinc. Women at risk include those with :    eating disorders. Strenuous exercise may also affect success of in vitro fertilization.  Too much exercise. which also increases infertility. iron and folic acid. Strict vegetarians also may experience infertility problems due to a lack of important nutrients such as vitamin B-12. . such as anorexia nervosa or bulimia women following a very low-calorie or restrictive diet.    In some studies. Being underweight.

 Caffeine  Studies intake.  If there are effects. .  High caffeine intake does appear to increase the risk of miscarriage. it's likely that caffeine has a greater impact on a woman's fertility than on a man's. are mixed on whether drinking too much caffeine may be associated with decreased fertility.  Some studies have shown a decrease in fertility with increased caffeine use while others have not shown adverse effects.

and with time. .The Age Factor    A woman's fertility naturally starts to decline in her late 20's. the supply diminishes. A woman is born with all the eggs she'll have. After age 35 a woman's fertility decreases rapidly.

000 300.000 – 500.2.000 .000 .000.000 1.000 400 – 500 oocytes will (Over the next 35-40 years of reproductive life) 37 YEARS ovulate. the rest are lost through atresia. 25.000 Menopause 1.000.000 – 7.000.000.PHYSIOLOGY OF REPRODUCTIVE AGING During fetal life. germ cells rapidly proliferate by mitosis AGE 16-20 WEEKS GESTATION AT BIRTH PUBERTY READY TO DEVELOP  GERM CELLS 6.

 .MENSTRUAL CHARACTERISTIC Menstrual characteristics in older women correlate with number of follicles remaining.  The ovaries of regularly menstruating contain 10-fold more follicles than those of peri-menopusal women having irregular and infrequent menses.  Follicles are virtually absent in the ovaries of postmenopausal women.

Time required for conception in couples who will attain pregnancy Time of exposure 3 months % Pregnant 57% 6 months 1 year 2 years 72% 85% 93% .

Common Causes of Infertility Severe endometriosis  Pelvic Inflammatory Disease (PID)  Ovulation disorders  Elevated prolactin  Polycystic ovary syndrome (PCOS)  Early menopause  Benign uterine fibroids  Pelvic adhesions  .

There is a 25-35% rate of infertility in moderate to severe cases of Endometriosis . Scar tissue can block the fallopian tubes and prevent the egg from entering the uterus.Endometriosis    Occurs when the uterine tissue implants and grows outside of the uterus. uterus and fallopian tubes. affecting the function of the ovaries.

The incidence of infertility attributable to endometriosis is difficult to assess. It is estimated that between 30% and 50% of women with endometriosis have some degree of infertility Severe disease may distort pelvic anatomy Impaired egg release Distortion of the fallopian tubes Inhibited ovum pick up .

In very rare cases it may be found in the lungs. bladder and intestines.  Can Endometriosis cause infertility ?   . Adhesions (scar tissue) can block the fallopian tubes and prevent the egg from entering the uterus. resulting primarily from damage incurred to the ovaries and fallopian tubes. brain tissue and the vaginal wall. There is a 25-35% rate of infertility in moderate to severe cases of Endometriosis. and the lining of the pelvis. surgical wounds (cesarean section scars). The most common places for implantation are:   the ovaries. fallopian tubes. uterine wall.

PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. fallopian tubes and other reproductive organs is a common and serious complication of some sexually transmitted diseases (STDs). Untreated PID can lead to serious consequences including infertility. tuboovarian abscess. and peritonitis. salpingitis. especially chlamydia and gonorrhea.    Infection of the uterus (womb).Pelvic Inflammatory Disease  Pelvic inflammatory disease (PID) is a spectrum of infections of the female genital tract that includes endometritis. ectopic pregnancy. and chronic pelvic pain. abscess formation. .

or abdominal or pelvic surgery This scar tissue formation may impair fertility. . appendicitis.Pelvic Adhesions   Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection.

UTERINE FIBROID   Fibroids are benign tumors in the wall of the uterus May cause infertility by blocking the fallopian tubes .

 Ovarian failure can also occur as a result of treatments such as chemotherapy and pelvic radiotherapy for cancers in other body areas. These therapies destroy eggs in the ovary.Ovarian failure/ovarian dysfunction : Ovarian failure can be a consequence of medical treatments.  . or the complete failure of the ovaries to develop (Turner's Syndrome).

2. Investigation of infertility in the female should not be commenced until the male has been evaluated.Guidelines of infertile investigations 1. There should be discussion with both parters so that the outline of the investigation is understood. . 3. Sexuality patterns of the couples should be discussed as it is quite surprising at times how little an infertile couple know about this subject.

 2.  .1. hamster egg penetration test and post coital test. Assessment of ovulation Basal body temperature  Mid luteal serum progesterone  Endometrial biopsy  Ultrasound monitoring of ovulation. Male investigations conventional semen analysis  A variety of sperm function tests such as in vitro mucous penetration test.

 .3. Tubal factor (Possibility of conception) Hysterosalpingography (HSG)  Laparoscopy  Falloscopy  Hysterosonography  Hydrolaparoscopy.

Hysteroscopy (HSC)  HSC is not a routine investigation of infertile couples as there is no evidence linking treatment of uterine abnormalities with enhanced fertility.Other more specific inverstigations :    The peritoneal factors are assessed by laparoscopy The uterine factor by hysterosalpingography and hysteroscopy. (RCOG.1999) . Immunological factors are evaluated by a variety of special tests.

(Strandell 2000) . Take Care Care must be taken to avoid exploitation of the infertile couple with expensive unnecessary tests ( ESHRE Capri Workshop 1996) 2. Concept to keep in mind A simplified approach will lead to a significant reduction in both the time and cost of investigating an infertile couple.1.

 Note : As many as 25% of proven fertile men have sperm concentration below 20 million/ml  .Collection of semen sample by masturbation Temp (15C to 38C) deliver quickly Husband should not have sexual intercourse 3 to 4 days before essesment.

Hysterosalpingography (HSG)   Although HSG is of low sensitivity. makes it a useful screening test for ruling in tubal obstruction. 1995) HSG is cheaper Performed as an outpatient procedure Although often painful has a low incidence of complications ( RCOG. diagnostic laparoscopy with dye transit is the procedure of choice (Swart et al. its high specificity. In case of abnormal finding. 1999 ) Advantages    .

1979). (Maas et al. the outcome of normal HSG adds little to predicting the occurrence of pregnancy.1999 ) .Conception after HSG    HSG has a low prognostic value. after a normal HSG 40% become pregnant (Mackey. However. Supprisingly. when HSG shows bilateral obstruction. 1997) Precaution  Before uterine instrumentation (as HSG or HSC) appropriate antibiotic prophylaxis against chlamydia should be given ( RCOG. the chance of getting pregnant is only minimal.

Summary From the above data.  Other tests may have a role in special situations or as a part clinical trials. it seems that serum progesterone for detection of ovulation. hysterosalpinghography for tubal patency and semen analysis are the basic essential tests for diagnosis of infertility.  Laparoscopy should be reserved as a further diagnostic procedure or in combination with endoscopic surgery  .