INFERTILITY

Max Brinsmead MB BS PhD

March 2017
 What is Infertility?

• After 12 months of regular sex without contraception...

• 85 – 90% of couples will achieve pregnancy
• Another 5% will be pregnant in the next 12 months

• The age of the woman has a major influence

• Because of the quality of eggs in the ageing ovary
• But semen quality also diminishes with age
 Primordial follicle numbers in the Human Ovary throughout Life
[from de Bruin and te Velde (2004)].

Broekmans F et al. Hum. Reprod. Update 2006;12:685-718

© The Author 2006. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org
Semen Quality and Age
 So most “infertility” is really
subfertility
• Or failing to conceive when the couple expect to

• They expect to “switch on” fertility in the same way that

contraception switches it off
Principal Causes of Infertility
• Ovulation problem
• Sperm Problem
• Tubal problem
• Cervical factor
• Endometriosis
 Taking the history
 Do not ask “How long have you been trying to get pregnant”
 Ask instead: “How long have you been in your current
relationship”
 What methods of contraception or avoiding pregnancy have
you used and…
 When did you stop using it?
 Have you ever been pregnant?
 Or tried in any previous relationship?
 Have you ever fathered a pregnancy before (or tried in any
other relationship).
 Has that person subsequently proven fertile (become
pregnant or fathered a pregnancy) in any subsequent
relationship(s)?
 Infertility Questions
 Have you ever been treated for inflammation of the pelvis or
tubes? Chlamydia?
 A sexually transmitted infection?
 Genital Herpes? Wart virus? Pre-cancer of the cervix?
 Do you know if any of your partners have been treated or
suffered from any of these conditions?
 Have you ever used an intra uterine contraceptive device?
 When you say your periods are “irregular” does that mean
that they are coming more or less often than once in each
four weeks?
 How much earlier? How much later?
 Most patients with “regular” cycles will be ovulating normally
 Infertility Questions

 How often is intercourse occurring?

 This is better than...
 How often are you trying each month!

 Do either of you have any problems?

 Coital problems are rarely a cause of infertility

 But impotence is a common problem in older males
 Who may have some difficulty admitting to this problem
 Tests of Ovulation
• A basal body temperature chart (BBT)
• Accurate body temperature measured once daily after
>8 hours at rest
• Progesterone (released only after ovulation) raises
BBT by 0.3 – 0.50C
• S Progesterone luteal phase of the cycle
• Preferably 7 days before menstruation
• LH surge in urine
• False positives can occur
• Endometrial biopsy 2nd half of the cycle
• Look for secretory changes on histology
 Tests of Tubal Patency
• The simplest test is insufflation with CO2
• Listen with a stethescope
• Shoulder pain when the patient sits up
• Hysterosalpingogram
• Passage of radio-opaque dye from the cervix with
pressure and fluoroscopy or still images
• Laparoscopy with dye studies
• The best test because it involves direct observation
• And the only way of diagnosing endometriosis
• All of these tests have potential for therapy if there is
minor tubal obstruction
• And diathermy of minimal endometriosis reduces
“reproductive toxins”
 Testing the Cervical Factor

• Requires careful cycle timing

• Because it has to be done when the cervical mucous is
receptive
• This is Day 12 or 13 in a 28 day cycle
• Take a sample of the mucous 4 – 20 hours after intercourse...
• And examine microscopically for evidence of progressively
motile sperm
• This is a good backup test for men who cannot or will not
produce a semen sample
• But is uncommonly performed in modern practice
 Semen Analysis
• Requires 48 – 72 hours of abstinence
• Must collect the whole semen sample
• Must be examined within 1-2 hours kept at room
temperature
• Count
• Should be > 20 million/ml
• Motility
• Should be >50%
• Morphology
• Should be >15% completely normal
• If abnormal it should be repeated
• Preferably after a number of weeks
 ANY QUESTIONS OR
COMMENTS?

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