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• At the end of the lecture, students
should be able to;
• Define infertility
• State the demographic distribution of
• State the types of infertility
• State the pathogenesis of infertility

• List the risky factors among men and
• List the physical
examinations/investigations carried
out on couples unable to conceive.
• Mention some measures taken to
control infertility/treatment
• State complications of infertility

the number of office visits to the physicians by couples seeking treatment have tripled due to the availability of treatment options for infertility. 2007). INTRODUCTION • ‘Infertility is the inability to conceive after one year of unprotected intercourse.’ (Callahan and Caughey. • Although the overall incidence of infertility remains relatively unchanged over the past thirty years. .

• However. whatever the cause. • Partners may become anxious and marital discords may occur.. • Infertility can result from either female or male related factors. INTRODUCTION CONTINUES. infertility may have profound psychological effects on the couple. .

DEFINITIONS • Infertility is childlessness in a population of women of reproductive age (Mendiola etal. • Infertility is the inability to conceive after 1 year of unprotected intercourse (Callahan and Caughey. 2008). 2007). .

accessory glands and supporting structures. . ductal system. maturation and delivery of spermatozoa in the female reproductive tract are the testes. within which are tightly coiled seminiferous tubules contains primitive sex cells (spermatogonia) present at birth. • Each testis contains 200 to 300 lobes. BRIEF PHYSIOLOGY OF MALE REPRODUCTION • The male reproductive organs responsible for the production.

neck. each with specialized function. BRIEF PHYSIOLOGY CONT…. . • The spermatozoon provides one-half of the genetic material required to create a new life.. the process of spermatogenesis starts and continues throughout life. Each spermatozoon has a head. body and tail. • At puberty.

BRIEF PHYSIOLOGY CONT…. the most important being testosterone which is produced by the interstitial cells (leydig’s cells). • The testes produce androgens. • Testosterone is important for. - • Maleness and male sexual behaviour • The development and maintenance of male secondary sex characteristics and the functions of the accessory organs. .

FSH stimulates the seminiferous tubules of the testes to produce spermatozoa. • The sperms undergo a ripening process as they pass through the ductal system before ejaculation. BRIEF PHYSIOLOGY CONT…. follicle stimulating hormone (FSH) and interstitial cell stimulating hormone. . • Protein anabolism • Inhibition of the anterior pituitary secretion of the gonadotropins.

.. • The seminal vesicles. BRIEF PHYSIOLOGY CONT…. which are two in number are lobulated glands lined with secretory epithelium which lies to the posterior of the bladder.

BRIEF PHYSIOLOGY CONT….. • They secret a thick. This fluid accounts for 30% of the volume of the seminal fluid and contains fructose and protein. nutritive alkaline fluid that mixes with sperm on ejaculation. which is essential to sperm motility and metabolism. .

alkaline fluid that make up 60% of the seminal fluid. BRIEF PHYSIOLOGY CONT… • The prostate glands found in the pelvic cavity. behind the symphysis pubis. surrounding the uppermost part of the urethra secretes a thin. . milky. • The fluid creates an environment more hospitable to sperms by giving protection from the normally acidic environment of the male urethra and female vagina.

. BRIEF PHYSIOLOGY CONT…. • The penis is an important erectile organ which facilitates penetration and ejaculation into the female organ.

.000 by adolescence. though the number reduces to approximately 30.000 follicles. the uterus. the fallopian tubes and the vagina) and the external organs which are the vulva and mammary glands. • A woman is born with approximately 100. BRIEF PHYSIOLOGY OF FEMALE REPRODUCTION • The female reproductive system consists of the internal organs (which are the ovaries.

. 2007). The ovulatory cycle begins at 12 to 13 years of age. luteinizing hormone (LH). oestrogen and progesterone. The hormones responsible for the cyclic changes are FSH. BRIEF PHYSIOLOGY CONT…. • Each follicle contains an immature ovum known as an oocyte (Stellenberg and Bruce.

• The hypothalamus releases gonadotropin-releasing hormone which stimulates the anterior pituitary gland to release FSH and LH responsible for the initial development of ovarian follicles and their secretion of oestrogen. LH further stimulates development of the ovarian follicles. BRIEF PHYSIOLOGY CONT…. initiates ovulation and incites production of .

BRIEF PHYSIOLOGY CONT…. control of fluid and electrolyte balance and increases protein anabolism. . • Oestrogens are responsible for development and maintenance of female reproductive structures..

BRIEF PHYSIOLOGY CONT…. . • Progesterone is important for secretory changes in the lining of the uterus when the endometrium develops tortuous glands and an enriched blood supply in redness for possible arrival of fertilized ovum. It is also important in maintenance of pregnancy.

2008). approximately 10% of couples are infertile (Mendiola etal. with the incidence similar in most countries independent of the level of the country’s development • . DEMOGRAPHIC DISTRIBUTION • Generally. . Fertility problems affect one in seven couples in UK. worldwide it is estimated that one in seven couples have problems conceiving. In Sweden.

• The remaining 10% couples tend to have no identifiable cause for their infertility (Callahan and Caughey. DEMOGRAPHIC DISTRIBUTION CONT… • Among couples who undergo evaluation of infertility. . • While factors which are a combination of both male and female causes are at 10% of the patient population. 40% are attributed purely to male factors and 40% purely to female factors. 2007).

TYPES OF INFERTILITY • Primary Infertility This is infertility which is found among couples who have never been able to conceive. . • Secondary Infertility This is failure to conceive after already having conceived or carried the pregnancy to term or had a miscarriage.

. FACTORS LEADING TO INFERTILITY • FEMALES • Defective Ovulation • Ovarian disorders such as failure of ovarian hormonal release. presence of ovarian cysts or tumours. polycystic ovary disease and ovarian endometriosis may affect the growth and release of ovaries.

anovulation. 2001). . FACTORS LEADING TO INFERTILITY CONT… • These are grouped in three (WHO. luteal phase defects. • Hypothalamic-pituitary dysfunction (polycystic ovarian syndrome (PCOS) is characterized by oligomenorrhea. hyperprolactinemia and thyroid dysfunction). - • Hypothalamic-pituitary failure (hypothalamic amenorrhea).

. • In diabetes mellitus. FACTORS CONT… • Ovarian failure (premature ovarian failure. • Systemic diseases such as diabetes mellitus. coeliac disease and renal failure can have a negative effect on fertility once not controlled. high insulin levels leads to increased production of androgens which leads to reduction in the production of follicle stimulating hormone. advanced maternal age).

• Excessive exercise may also hinder ovulation as they are associated with metabolic alterations. . FACTORS CONT… • Physical disorders such as obesity. anorexia nervosa or strict dieting.

. FACTORS CONT… • Defective Transport • Ovum -Tubal obstruction can occur due to infections such as gonorrhea. • Previous tubal surgery can also lead to obstruction during the healing process. • Fimbrial adhesions occurs secondary to previous surgery or endometriosis. peritonitis and pelvic inflammatory disease.

presence of an infection (can lead to dyspareunia and altered sperm motility). • Sperm transportation may be hindered in situations where there are defects in the vagina such as vaginismus (psychosexual problems). FACTORS CONT…. .

• Cervical trauma or surgery (cone biopsy) may lead to altered cervical function in the reproductive process.. Also presence of infection or hormonal defects may lead to hostile cervical mucus which tends to destroy sperms. Antisperm antibodies in mucus tend to destroy sperms before ascension. . FACTORS CONT.

. intrauterine adhesions and multiple curettages and submucosal fibroids. pelvic inflammatory diseases and chronic salpingitis. congenital anomalies. fibroids and infection such as endometriosis. pelvic or tubal surgery. • Other factors are cigarette smoking. FACTORS CONT… • Defective Implantation occurs in cases of hormonal imbalance.

adrenal hyperplasia and thyroid disease. pituitary failure (tumor. surgery). FACTORS LEADING TO INFERTILITY MALE FACTORS 1. radiation. Defective spermatogenesis • Endocrine disorders such as dysfunction of the hypothalamus (Kallman). .

. FACTORS CONT… • Systemic disease • Diabetes mellitus (there is an increase in release of glucagon and other stress hormones like cortisone and catecholamine leading to suppression of reproductive hormone).

distended abdomen and failure to grow). • Coeliac disease (a disease condition of early childhood characterized by steatorrhoea. altered hormonal function and anaemia). This is caused by folic acid deficiency. FACTORS CONT…. . • Renal failure (leads to alters metabolism.

. • Environmental factors such as. FACTORS CONT… • Testicular disorders • Trauma to the testis may alter their function. high temperatures for men working as furnace men in industries and putting on tight clothes that which prevents free air circulation. • Congenital defects like hydrocele and undescended testes.

• Toxins such as glues. physical agents. FACTORS CONT…. • Exposure to radiotherapy in cancer treatment alters hormonal function and sperm production. . chemical dusts. volatile organic solvents or silicones. and pesticides tend to alter the production and morphology of sperms.

hernia repair. . mumps. and impotence. Men with a history of varicocele. anabolic steroid use. testicular injury. FACTORS CONT… • Tobacco smokers due to nicotine intake are 60% more likely to be infertile than non-smokers. pituitary tumor.

• Certain drugs have also been found
to depress semen quantity and
quality (cimetidine, sulfasalazine,
spironolactone, anabolic steroids,
nitrofurans, erythromycin,
tetracyclines and heavy
marijuana/alcohol use). (Callahan
and Caughey, 2007).

• Defective Transport
• Obstruction or absence of seminal
ducts due to infection, congenital
anomalies or trauma.
• Impaired secretions from prostate or
seminal vesicles due to infection or
metabolic disorders.

• Sexual Dysfunction/ineffective delivery
• Psychosexual problems (impotence)
• Drug induced sexual potency where
ejaculatory dysfunction exists.
• Physical anomalies such as hypospadias,
epispadias and retrograde ejaculation
(ejaculation into the bladder).
• Impotence.
• Decreased Libido

CLINICAL MANIFESTATIONS • In men the main clinical manifestation is inability to father a child. hernia repair or trauma to the genitals is other signs. • Abnormal findings during physical examinations and laboratory investigations. • History of sexually transmitted diseases. . mumps. orchitis.

inability to get pregnant despite several months of unprotected sexual intercourse. pelvic pain associated with movement or lifting. . or menorrhagia. Others include. CLINICAL MANIFESTATIONS • In females. dyspareunia. history of dysmenorrhea. There may be reports of amenorrhea. oligomenorrhea.

or unusual stress (Tamara and Callahan. CLINICAL MANIFESTATIONS CONT… • Also. weight gain. headaches. there may be history of spontaneous abortions due to premature ovarian failure. extreme exercise. . galactorrhea. or hot flashes. A detailed social history might reveal reasons for centrally mediated ovulatory dysfunction including eating disorders.

EXAMINATIONS/INVESTIG ATIONS • Both partners should undergo physical examinations to eliminate presence of some physical abnormality. .

• Examine for presence of varicocele • Look for presence of lesions which could indicate history or presence of a sexually transmitted infection. • Identification of the urethra meatus to rule out hypospadias or epispadias.EXAMINATIONS/INVESTIG ATIONS • MEN • Measurement of testicular size and presence of two testicles. .

pH. Sperm count. and white blood cell count are analyzed. morphology.EXAMINATIONS/INVESTIGATIONS CONT… • Laboratory investigations include. semen analysis which is the primary investigative tool for male infertility. . volume. motility.

. sperm concentration> 20 million/ml. morphology> 30% normal forms and white blood cells< 1 million/ml (WHO. .EXAMINATIONS/INVESTIGATIONS CONT. motility> 50% progressive motility. 1992). • Normal values semen volume > 2- 5mls.

and follicle stimulating hormone. • These may indicate an imbalance in hormonal functions. prolactin. an endocrine evaluation should be done which include thyroid function tests. • In case of abnormal sperm analysis. .EXAMINATIONS/INVESTIGATIONS CONT…. serum testosterone.

• Screening for chlamydia should be . A healthy interaction occurs when a large number of forwardly moving sperm are seen in a thin acellular mucus. • Urine can be taken for microscopy and blood for presence of STIs like syphilis.EXAMINATIONS/INVESTIGATIONS CONT… • Post-coital test done to examine the interaction between sperm and cervical mucus.

.EXAMINATIONS/INVESTIG ATIONS FEMALES • Inspection of the genital area for lesions indicating history or presence of STIs • Visualization of cervix to rule out stenosis. infection and malformations • Examination of breast development as a sign of previous estrogen function.

.EXAMINATIONS/INVESTIGATIONS CONT… • Evaluation of thyroid function by observing changes in goiter. • Current estrogen secretion can be observed by a well rugged. moist vagina with abundant clear stretchable cervical mucus. hair. • Pap smear and cervical cultures for gonorrhea and chlamydia should be done in all women undergoing infertility evaluation. nails and presence of tachycardia.

and the presence of ferning. • Pelvic ultrasound can be done to rule out tumors and cysts. fluidity.EXAMINATIONS/INVESTIG ATIONS • Cervical mucus can be evaluated for quantity. color. spinnbarkeit. • Post-coital test to evaluate quality and quantity of cervical mucus. .

. Best done in follicular phase. • A saline sonohysterogram can complement the pelvic ultrasound by allowing better visualization of the uterine cavity.EXAMINATIONS/INVESTIGATIONS CONT. • Magnetic resonance imaging can be done to rule out adenomyosis and uterine anomalies. . • Hysterosalpingogram performed for visualization of tubal patency.

.EXAMINATIONS/INVESTIGATIONS CONT… • Hysteroscopy and laparoscopy can also be done to visualize the uterus when need arise. • Blood hormonal activity estimation.

MEASURES TO CONTROL INFERTILITY • It is important that both partners should be involved in the management of their infertility and that full explanations are given to the couple at each stage in the investigation and treatment. A range of assisted reproductive techniques is available to treat infertile couples and it is important that appropriate treatment option is offered (Myles. . 2003).

.. • Treatment should be focused on elimination of the identified cause. MEASURES TO CONTROL INFERTILITY CONT. • The first most important primary treatment of infertility is counseling to couples to help them improve on communication and support each other to minimize stress.

• Measures to correction conditions such as diabetes mellitus. MEASURES TO CONTROL INFERTILITY • It is important to treat any sexually transmitted infection. if any. renal failure and coeliac disease should be carried out. . before attempting any conception measures.

• Couples should be encouraged to improve their coital practice. . more especially every other day near ovulation with female partner at the bottom. MEASURES TO CONTROL INFERTILITY CONT. The woman should lie on her back with her knees to her chest for at least 15 minutes after intercourse.. placing more semen in contact with the cervix.

and unnecessary • environmental exposures such as radiation. excess heat. MALES • Men should avoid the use of tight underwear. • Treatment of low sperm density or motility depends on the causal agent. . and certain medications as discussed earlier.. MEASURES TO CONTROL INFERTILITY CONT…. saunas and hot tubs.

. • This medicine is used to increase sperm production in men who have low sperm count as a result of low hormone levels. • Hypothalamic-pituitary failure can be treated with injections of Menopur (human menopausal gonadotropins. MEASURES TO CONTROL INFERTILITY CONT….

• It can also be used in combination with human chorionic gonadotropin (HCG). which increases the production of testosterone in the testicles and helps the FSH to work.MEASURES TO CONTROL CONT…. .

• In cases of low semen volume treatment is by washed sperm for intrauterine insemination. • Varicocele can be repaired by ligation. MEASURES TO CONTROL CONT…. . and then placing the fertilized egg inn the uterine cavity or fallopian tube). • Intracytoplasmic sperm injection (ICSI) is another option for patients with low sperm density or impaired motility (injection of a single sperm into an egg.

MEASURES TO CONTROL/TREAT CONT…. 90% of infertility cases are corrected by treating the underlying cause. . • FEMALES • In cases where etiology of ovulatory dysfunction is identified.

testosterone.MEASURES TO CONTROL/TREAT CONT… • In patients with polycystic ovarian syndrome (PCOS) related to obesity and diabetes mellitus. . and androsteindiones which tend to be higher in diabetes mellitus. even just weight loss is enough to lower fasting insulin levels.

. ovulation induction and pregnancy can be tempted with a combination of human gonadotropins and other reproductive technologies. If these treatments are do not succeed.MEASURES TO CONTROL/TREAT CONT… • PCOS are treated with Clomid and metformin to establish ovulation and producing viable pregnancies.

or adoption. gestational surrogacy. . ovulation can usually be achieved with pulsatile gonadotropin releasing hormonal therapy or human gonadotropins.MEASURES TO CONTROL/TREAT CONT… • In hypothalamic-pituitary failure (WHO Group 1). The only recommended help is egg donation. • Patients with ovarian failure have no treatment because they lack viable oocytes.

Fertilization occurs outside and then the embryo is transferred into the mother’s womb after hormonal treatment to prepare the mother for implantation. .MEASURES TO CONTROL/TREAT CONT… • Some of the recommended procedures by the Human Fertilization and Embryology Authority (HFEA) set up in 1991 to license and regulate clinics are: - • In vitro fertilization (IVF) treatment.

• Gamete intrafallopian transfer (GIFT) where donated sperm or eggs are used in treatment. . CONTROL/TREAT CONT… • Donor insemination (DI) treatment. clinics licensed by HFEA have well selected counseled donors who donate sperms and eggs which are frozen and later used for artificial insemination and then zygote intrafallopian transfer (ZIFT). GIFT and Intracytoplasmic sperm injections (ICSI) are done respectively. Here. • Storage of gametes or embryos.

SOME DRUGS USED IN TREATMENT OF INFERTILITY • Clomid • Glucophage • Pergonal • Gonal-F • Lutrepulse • Lupron • Danocrine .

COMPLICATIONS OF INFERTILITY • Failure to correct infertility has resulted in many couples left unhappy. • Psychosocial trauma • Multiple gestation pregnancy • Ovarian hyperstimulation syndrome • Abandonment of sexual intimacy • Ethical issues associated with infertility . dejected and isolated.

provision of written information that should include a list of addresses of organizations offering infertility treatment. . THE ROLE OF THE MIDWIFE • The main role of the midwife in couples with infertility problem is counseling of the couple to allay anxiety.

THE ROLE OF THE MIDWIFE • Taking of a detailed history of lifestyle. . drug abuse. occupation. previous and present disease conditions which could have affected their fertility is important for ongoing counseling and support.

THE ROLE OF THE MIDWIFE • When a successful conception has been achieved. . The midwife will be needed for psychological care throughout the pregnancy to allay anxiety. then maternity services will be offered by the midwife.

In both cases it is important that the couples are both involved and cooperative in investigations and correction of the problem. 2007). CONCLUSION • Infertility is caused by a number of factors from either the male or female. . In order to effectively treat couples with infertility it is essential that male infertility be considered in parallel to evaluation for female factor infertility (Callahan and Caughey.

It is therefore. CONCLUSION • Treatment of infertility is done in line with the underlying cause. . the duty of the midwife to offer guidance and psychological support throughout the couple’s treatment.

L and Caughey A. Baltimore. Blueprints. M. African edition. Churchill Livingstone. M. • Fraser . Mosby. (2003) Myles Text book for midwives 14th Edition Elsevier. Lippincott Williams and Wilkins.(2006). . 4th Edition.A. D. B. A. M. and Cooper. REFERENCES • Callahan T. Philadelphia. (2007).D and Cooper. • Fraser. Myles Text Book for Midwives. Obstetrics & Gynecology.M.

Torres-Cantero AM. "Exposure to environmental toxins in males seeking infertility treatment: a case-controlled study" . L. Philadelphia . (Jun 2008). (2007) Nursing Practice. PMID 18549695. and Bruce J. African Edition. Reprod Biomed Online 16 (6): 842–50.ingenta. REFERENCES • Mendiola J.1016/S1472-6483(10)60151-4 . et al. Medical-Surgical Nursing for Hospital and Community. doi: 10. Moreno-Grau article&issn=1472-6483&volume=16&issue=6&spag e=842&aulast=Mendiola extracted on 04/01/12 at 10:08hrs • Stellenberg E. Elsevier. http://openurl. C..