Dr Atin Singhai

Assistant Professor
Department of Pathology
KGMU, Lucknow
 Definition:
1 yr unprotected coitus without conception
 10-15% couples affected
 Etiology
Couples:
○ 35% Tubal and pelvic pathology
○ 35 % Male problems
○ 15% Ovulatory dysfunction
○ 10% Unexplained
○ 5% unusual causes
 Etiology
◦ Women:
 40% Tubal and pelvic pathology
 40% Ovulatory dysfunction
 10% Unexplained Infertility
 10% Unusual causes
 Normal couple:
◦ 25-30% chance of pregnancy per ovulatory cycle
 Fertility decreases with age
Time of Exposure % Pregnant

3 months 60%
6 months 70%
1 year 85%
18 months 90%
 DDX
 Tests/Inv
 Dx
 Rx
 Production
 Storage
 Delivery
1. Production:
◦ Hypothalamus
◦ Anterior Pituitary
◦ Testes
 1. Production
◦ Hypothalamus
 Congenital abnormalities of hypothalamus
 e.g. Kallman’s syndrome
 Starvation, stress or severe illness
 Tumors (craniopharyngioma, metastatic tumor)
 Head injury
 Inflammation (sarcoidosis)
 Infection (tuberculosis)
 Drugs: marijuana
 1. Production:
◦ Pituitary
 Endocrine: thyroid, prolactin
 Tumors
 Inflammation: sarcoidosis, meningitis
 Infiltration
 Infarction
 Trauma/XRT
 Drugs: anabolic steroids
 Production:
◦ Testes:
 Congenital: Klinefelters (XYY), developmental
disorders
 Disorders of gonadal steroidgenesis
 Infection: chlamydia, prostatitis, mumps orchitis
 Autoimmune
 Cryptorchidism
 Tumors; chemo/XRT
 Drugs / alcohol
 Vascular: testicular torsion
 2. Storage:
◦ Temperature
 Rise in scrotal temperature
 Occupation
 Varicocoele
 3. Delivery:
Impotence/Ejaculation
○ Neurogenic: medications (α-blockers,
methyldopa)
○ Endocrine: diabetes
○ Congenital: absence vas deferens (CF)
○ Genetic: cystic fibrosis
○ Primary ciliary dyskinesia: Kartagener syndrome
○ Hypospadia
○ Vasectomy
 History:
Previous children
Infections: prostatitis, STD, mumps orchitis
Trauma to head or testicles
Surgery to testicles or hernia
Occupation (sitting, bio hazards)
Chemo or Radio therapy
Ethanol or Smoking
Medication
Medical history (DM, HTN)
Previous investigations
 Physical
◦ Anatomy (meatus)
◦ Testicular size
◦ Varicocele (valsalva)
◦ Rectal exam (protatitis, discharge)
 Investigations:
◦ semen analysis
 Abstain 2-4 days prior
 At least 2 samples over different period of time
◦ If abnormal:
 Blood work: FSH, LH, TSH, testosterone, PRL
 Testicular U/S
 Chromosomal analysis
 Semen analysis:
◦ WHO (1992)
 Volume > 2.0 mL
 Sperm > 20 million/mL
 Motility > 50% forward progression or
> 25% rapid progression within
60 min
 Morphology > 30% normal forms
 WBC < 1 million/mL
 Tx / Interventions:
◦ Treat underlying causes
◦ Intrauterine Insemination (IUI)
◦ Intracytoplasmic Sperm Injection (ICSI)
 Fecundability: probability of achieving a
pregnancy within 1 menstrual cycle (25%)

 Fecundity: ability to achieve a live birth

within 1 menstrual cycle (6%)
 Production
 Storage
 Delivery
 Production:
◦ Hypothalamus
◦ Pituitary
◦ Ovary
 Hypothalamus:
◦ Stress
◦ Exercise
◦ Eating disorders
◦ Psychogenic
◦ Congenital/genetic: Kallman’s syndrome (hyposmia &
hypoplasia olfactory lobes of brain)
◦ Starvation/stress or severe illness
◦ Tumors (craniopharyngioma, metastatic tumor)
◦ Head injury
◦ Inflammation (sarcoidosis)
◦ Infection (tuberculosis)
◦ XRT
◦ Drugs
 Pituitary:
Sheehan syndrome
Tumors: Pituitary adenoma, metastatic
Empty sella syndrome
Inappropriate gonadal steroid feedback:
○ estrogen excess: obesity/ tumors
○ estrogen deficiency: aromatase deficiency/ ER gene
mutation
○ androgen excess: adrenal or ovarian
○ PCOS
Testicular feminization (46 XY) - absence
androgen receptors
 Ovary
◦ Gonadal dysgenesis - Turner’s Syndrome 45XO or
mosaics 46 XX/45 XO
◦ Testicular feminization
◦ XRT / Chemo for childhood malignancies
◦ Premature ovarian failure
 Storage (R.P.L. unless severe)
◦ Uterine abnormalities
◦ Mullerian Agenesis: Mayer-Rokitansky-Kuster-
Hauser syndrome
◦ Leiomyoma
◦ Luteal phase deficiency
 Delivery:
◦ Uterine abnormalities
◦ Vaginal septum
◦ Tubal Disease
 Infections/ STD/PID
 Ruptured appendix
 Septic abortion
◦ Endometriosis
 History:
Age
GTPAL
Regulatory of period
Prolactin S/S
Thyroid S/S
Infections, Surgeries
Medication, Smoking, Ethanol
Medical history
Previous investigations
 Examination:
◦ Thyroid
◦ Breast (milk)
◦ Abdomen (masses, scars)
◦ Vaginal (abnormalities)
◦ Bimanual (Uterus, masses)
 Blood work:
TSH
PRL
D3 FSH
D3 LH
Luteal phase Progesterone
 Imaging:
Pelvic Ultrasound
HSG
 Diagnostic
Laparoscopy (later)
 Treat the underlying cause
 Medical
 Surgical
 Anovulation:
◦ Clomiphene induction  IUI
◦ Gonadotropin  IUI
 IVF
◦ Bilateral tubal disease
◦ Unexplained infertility after Gonadotropin + IUI
failure.
◦ Failure of the above
 ICSI
◦ Male factor
◦ Unexplained infertility
 DDx – Hx – Px – Inv - Rx
 Age is important factor for female
 Hypothalamic-Pituitary-Gonadal axis central

in working up both male and female infertility

 Investigations:

◦ Male: Sperms
◦ Female: Tubes (HSG) + Ovaries (FSH, LH, PRL, TSH)
 Infertility is defined as unprotected coitus for
___ months, without conception :
a. 3
b. 6
c. 9
d. 12
 Spermatogenesis and sperm maturation is
regulated by :
a. Leydig Cells
b. Sertoli Cells
c. Vas Deferens
d. Intermediate Cells
 Cause/s of male infertility is / are :
a. Kallaman’s syndrome
b. Craniopharyngioma
c. Marijuana abuse
d. All of the above
 Normal semen count is ___ million / ml
a. ≥ 15
b. ≥ 20
c. ≥ 25
d. ≥ 30
 Indication/s for semen analysis is / are :
a. Investigation for infertility
b. to check effectiveness of vasectomy
c. for selection of donor for artificial
insemination
d. All of the above
Thank you