OVERVIEW OF MARKUP

OF INFERTILITY
Requirements for Conception
Male role:
 Production of healthy sperms
 Deposition of sperms in vagina

Female role
 Healthy eggs
 Patent healthy tubes
 Healthy uterine cavity
 Healthy cervix and vagina
What is Infertility?
Infertility is defined as inability of a couple to conceive
after regular unprotected sexual intercourse
<35-year -old: Failure to conceive after 12 months of
unprotected intercourse
>35-year-old: Failure to conceive after 6 months of
unprotected intercourse
Causes of Infertility
Male factor
Female factor
Ovarian
Tubal and peritoneal
Uterine
Cervical
Vulval and vaginal
Combined pattern
Infertility affects men and women equally
Unexplained
Thus, there is equal share of male factor
And female factor
Male Factor Infertility
Defective insemination

Abnormal spermatogenesis
Defective Insemination
Impotence

Premature ejaculation

Retrograde ejaculation

Severe hypospadius

Marked obesity
Abnormal Spermatogenesis
Azoospermia
Teratospermia
Oligospermia
Asthenospermia
Teratospermia Necrospermia
Necrospermia
Pyospermia
Hematospermia Hematospermia

Pyospermia
Investigation of Male Factor Infertility
Semen analysis- Single most important diagnostic test
for male infertility
Steps:
Abstain from coitus for 2-3 days
Collect all the ejaculate
Analyze within hour
Normal semen analysis excludes 90% of male factor
Normal Values for Semen Analysis (WHO)
Semen volume ≥1.5 ml
Semen pH ≥7.2
Sperm concentration ≥15 million spermatozoa/ml
Total sperm count ≥39 million spermatozoa per
ejaculate
Total motility: ≥40% sperms motile/≥32% with
progressive motility
Vitality: ≥58% live spermatozoa
Sperm morphology: ≥4% sperms in normal form

NICE Guidelines 2013

Female Factor Infertility
Ovulatory Defects

Anatomical defects of genital tract

Tubal and peritoneal
Uterine
Cervical
Vulval and vaginal
Ovulatory Defects- Symptoms
Ovulation pain
Ovulation bleeding
Ovulation cascade
Premenstrual mastalgia
Premenstrual tension syndrome
Elevated body temperature in second half of cycle
Primary dysmenorrhea
Assessments- Regularity of Menstrual Cycle
Women undergoing investigations for infertility- Blood
test for serum progesterone in mid-luteal phase even
in regular menstrual cycles
Prolonged irregular menstrual cycle- Progesterone test
later in cycle, repeated weekly until next cycle starts.
Irregular menstrual cycle- Test gonadotrophins (LH
and FSH)

NICE Guidelines 2013

Assessment of Ovarian Reserve
Ultrasonography for follicular growth and maturation-
Normally 18-22 mm
NICE recommendations for predicting response to
gonadotrophin stimulation in IVF:
Total antral follicle count
 ≤4 for low response
 >16 for high response

Anti-Müllerian hormone
 ≤5.4 pmol/L for low response
 >25 pmol/L for high response

FSH
 >8.9 IU/L for low response
 <4 IU/L for high response NICE Guidelines 2013
Tubal Factor Infertility
Causes
Congenital Ectopic
Endometriosis pregnancy

Traumatic
Previous ectopic pregnancy
Tubal sterilization
Salpingitis
Peritubal surgery
Salpingitis
Sexually transmitted diseases
TB
Neoplastic
Tubal malignancy Endometriosis
Broad Ligament fibroids
Uterine Factor Infertility
Causes
Congenital
Traumatic
Asherman’s syndrome
Hysterectomy
Endometritis
TB
Neoplastic
Fibroids
Congenital Uterine Abnormalities
Asherman’s Syndrome
Also called intrauterine adhesions
Occurs when scar tissue is formed inside uterus
and/or cervix
Occurs primarily after a dilation and curettage for an
elective termination of pregnancy
Uterine Fibroids
Also called leiomyomas
Most common form of benign uterine tumor
Diagnosis of Tubal and Uterine Factor
Infertility- NICE Says…
Women not known to have co-morbidities-
Hysterosalpingography
Sonosalpingography should be considered if
appropriate expertise is available
Women thought to have co-morbidities- Laparoscopy
to assess tubal and other pelvic pathology at the same
time
Unless clinically indicated, hysteroscopy shouldn’t be
offered on its own for initial investigation.

NICE Guidelines 2013

Diagnosis of Tubal Pathology
Hysterosalpingography
Injection of radio-opaque medium through cervical
canal to uterus
Evaluates uterine cavity and fallopian tube
Done by fluoroscopy
Best done a week after menstruation
Diagnosis of Tubal Pathology
Sonosalpingography
Slow and deliberate injection of about 200 ml of saline
into uterine cavity under ultrasound scanning
Tubal patency can be tested by this
Diagnosis of Tubal Pathology
Laparoscopy
Making small incisions in abdomen through which
laparoscope and surgical instruments are inserted
Recommended for women thought to have co-
morbidities
Diagnosis of Tubal Pathology
Hysteroscopy
A hysteroscope is inserted into vagina to examine cervix
and uterine cavity
Cervical Factor Infertility
Causes
Congenital
Traumatic
Immunologic
Cervicitis
Neoplastic
Fibroids
Cervical cancer
Diagnosis of Cervical Pathology
History
Investigations:
Ultrasonography
Hysterosalpingography
Post-coital test

Ultrasonography of cervix
Post-Coital Test
Scheduled close to ovulation when mucus is abundant
The couple is asked to have sexual intercourse,
preferably early in morning.
After a few hours (usually 2), cervical mucus is
collected and spread on a glass slide.
Normal: 10-15 motile sperms per high power field.
Rotatory/shaky sperm motion: Anti-sperm antibodies
Not recommended for routine use
Management of Infertility
 General Principles
Involve both the partners in evaluation and management
Counsel both the partners
Perform fertility evaluation as per established guidelines
Identify the cause of infertility
Reversible- Medical or surgical management
Irreversible- Assisted reproductive technology, surrogacy,
adoption
Managing Male Factor Infertility (NICE Guideline)
Medical Management
Hypogonadotrophic hypogonadism- Gonadotrophins
improve fertility
Idiopathic semen abnormalities- Don’t offer:
Anti-estrogens
Gonadotrophins
Androgens
Bromocriptine
Kinin-enhancing drugs
Pyospermia- No antibiotics unless infection is
identified NICE Guidelines 2013
Managing Male Factor Infertility (NICE Guideline)
Surgical Management
Azoospermia- Surgical correction of epididymal
blockage when expertise is available
Alternative to surgical sperm recovery and IVF

NICE Guidelines 2013

Management of Ejaculatory Failure
Treatment of ejaculatory failure can restore fertility
without the need of invasive procedures

Further evaluation of different treatments is needed

NICE Guidelines 2013

Treating Female Factor Infertility
Ovulation Induction
Ovulation induction is one of the first options
recommended for treating infertility.
Fertility medications are used to induce ovulation and
stimulate the development of egg production in
women who have had difficulty in conceiving.
Ovulation inducers- Clomiphene citrate and letrozole
Human chorionic gonadotrophin (hCG) can also be
used
Classification of Ovulatory Disorders
Group 1- Hypothalamic-pituitary failure (hypothalamic
amenorrhoea or hypogonadotrophic hypogonadism)

Group 2- Hypothalamic-pituitary-ovarian dysfunction

(predominately polycystic ovary syndrome)

Group 3- Ovarian failure

 Group-1 Ovulation Disorder
Advice:
Increasing the body weight if BMI is <19 and/or
Moderating exercise levels if exercise is high
Offer pulsatile administration of GnRH or gonadotrophins
with LH activity to induce ovulation

NICE Guidelines 2013

 Group-2 Ovulatory Disorder
Advice to lose weight of BMI is >30
Offer:
Clomiphene citrate (NMT 6 months) or
Metformin or
Combination of the two
For those taking clomiphene citrate, offer ultrasound
monitoring during at least first cycle of treatment to ensure
that the dose minimizes the risk of multiple pregnancies

NICE Guidelines 2013

Group-2 Ovulation Disorders
Clomiphene-Resistant Women
One of the following second-line treatments:
Laparoscopic ovarian drilling
Clomiphene citrate + Metformin (if not already a part of
first-line treatment)
Gonadotrophins

Laparoscopic ovarian drilling NICE Guidelines 2013

Hyperprolactinemic Amenorrhea
Ovulatory disorders due to hyperprolactinemia-
Dopamine agonist like bromocriptine

Consider safety in pregnancy and minimize the cost

while prescribing
Monitoring Ovulation Induction During
Gonadotrophin Therapy

Inform the women about risk of multiple pregnancy

and ovarian hyperstimulation

Ovarian ultrasound to measure follicular size and

number should be an integral part to minimize this
risk
 Surgical Treatment of Female Factor
Infertility
Tubal microsurgery may be considered a treatment option to
deal with tubal obstruction
In proximal tubal obstructions:
Selective salpingography plus tubal catheterization or
Hysteroscopic tubal catheterization,
Assisted Reproductive Technology (ART)
IVF* is most effective strategy and is recommended
when both fallopian tubes are blocked
ART works best when:
Woman has healthy uterus
Responds well to fertility drugs
Ovulates naturally or uses donor eggs

*IVF- In-vitro fertilization

Simple Ovulation with In-Vitro Fertilization
(IVF)

• A woman’s eggs are

removed from the ovary
and mixed with sperm in
a laboratory. Then once
fertilized, the embryos
are placed into the
woman’s uterus.
Steps in IVF
Pre-stimulation treatment
Ovarian stimulation with gonadotrophins
Monitor follicle development
Final oocyte maturation and hCG administration
Trans-vaginal oocyte retrieval
Insemination
Embryo transfer
Progesterone supplementation
Pregnancy test and early pregnancy follow-up
Process of IVF
Intra-Uterine Insemination (IUI)
Placing sperm into woman’s uterus to facilitate
fertilization
The goal is to increase the number of sperms that reach
the fallopian tube, increasing the chances of fertilization
Process of IUI
• IUI is performed when a women is releasing eggs (ovulation).

•Sperm is collected from the man prior to the procedure and it

is washed with a special solution in the laboratory.

• It is then injected into the uterus using a thin tube (catheter)

attached to a plastic syringe.

• IUI is also used if sperm shows poor motility (swimming

ability) or if there is an ejaculatory problem, but the
effectiveness of IUI is naturally higher if sperm parameters are
within the normal limits.

• Results depend on the diagnosis and the treatments done in

conjunction with IUI.
Summary
Infertility is defined as inability to conceive after 12
months (<35 years) or 6 months (>35 years) of
unprotected intercourse
Affects men an women equally
Semen analysis is single most important assessment of
male factor infertility
Female factor infertility is caused by ovulatory defects
as well as anatomical defects of genital tract
Different methods are available for diagnosing female
infertility
Summary
Gonadotrophins are available for medical management of
male infertility
Clomiphene citrate, metformin or gonadotrophins can be
used in female infertility
Surgical procedures are also available, ex.
Surgical correction of epididymal blockage (male)
Tubal surgery (female)
Assisted reproductive techniques (ARTs) is an effective
option for conception
IVF, intrauterine insemination are some important
techniques in ART
Thank You….