Female Infertility

Definition of terms
• Fecundability: probability of achieving a
pregnancy within 1 menstrual cycle (25%)

• Fecundity: the ability to achieve a live birth

within 1 menstrual cycle (6%)
 Evaluation of Female factors
• We will evaluate causes under the following
female factors;
1. Ovulatory Factors
2. The Pelvic Factors
3. Cervical Factors
 1. Ovulatory Factors
• Ovulatory dysfunction is responsible for
approximately 20-25% of infertility cases
• Any deviation in the menstrual cycle could
lead to infertility
• Below are some of the causes that affect the
ovulation;
a) Central Defects;
• Chronic hyperandrogenic anovulation
• Hyperprolactinemia – impairs GnRH secretion
• Hypothalamic insufficiency
• Pituitary insufficiency
• Hypothalamic-pituitary dysfunction
Hypothalamic-Pituitary-Gonadal Axis
b) Peripheral Defects;
• Gonadal dysgenesis (Turner syndrome) –
abnormal development of ovary
• Polycstic ovarian syndrome – hormonal
imbalance, ireegular periods, excess androgen
levels
• Premature ovarian failure
• Ovarian tumor
• Ovarian resistance
c) Metabolic Diseases;
• Thyroid disease – hyperprolactinemia, anovulation
• Liver disease – metabolism of estrogen is impaired,
hence high circulating estrogen
• Renal disease – impairs hypothalamic-pituitary-gonadal
axis
• Obesity – high chances of menstrual disorders and
anovulation
• Androgen excess – affects follicular development hence
anovulation
• Too much exercise – suppress hormones responsible for
ovulation
• Others e.g. drugs – certain antidepressants, medications
with estrogen or progestin
 2. Pelvic Factor
• This includes abnormalities of the uterus,
fallopian tubes, ovaries and adjacent pelvic
structures
• They can be ruled out with patient’s history
and investigations
• The causes can include the following;
a) Infection;
• Pelvic inflammatory disease – causes scarring
of fallopian tubes
• STI’s – chlamydia and gonorrhea can damage
uterus, ovaries and fallopian tubes
• Uterine adhesions (Asherman’s syndrome) –
• Appendicitis (ruptured appendix)
b) Endometriosis
• Distorts anatomy of pelvis, adhesions, scarred
fallopian tubes, pelvic structure inflammations,
ovarian problems hence affect ovulation
c) Structural abnormalities
• Failure of normal fusion of the reproductive
tract
• Myoma ( fibroids) – may block fallopian tubes,
or stops a fertilized egg from implanting in the
uterus
• History of ectopic pregnancy
• Lower abdominal surgeries leading to pelvic
adhesions
• Intrauterine polyps
 3. Cervical factor
• Abnormalities in the cervix can cause infertility
• Cervical mucus is normally stimulated to change
from thick to thin and stretchable to allow entry of
sperms
• Abnormal cervical mucus may:
– Remain impenetrable to sperm around the time of
ovulation
– Promote sperm destruction by facilitating influx of
vaginal bacteria (e.g. due to cervicitis)
– Contain antibodies to sperm (rarely)
• Mullerian duct abnormality – hence no
development of cervix, uterus, fallopian tubes
• Surgical treatment
• Infections e.g. cervicitis may cause cervical
problems
 Diagnosis of infertility in females
• The goal of evaluation is to determine the
causative factor, to provide accurate
information regarding prognosis, to provide
counseling, support and education throughout
the process of evaluation and to provide
guidance regarding options for treatment
• Female infertility evaluation is done based on
the individual factors required for successful
reproduction, i.e. ovulatory, pelvic and cervical
 1. Evaluation of Ovulatory factors
• Detailed history should be taken f
• To include; onset of menarche, present cycle
length, presence of premenstrual syndromes
conditions like amenorrhea, oligomenorrhea,
abnormal uterine bleeding
• Signs and symptoms of systemic disease (thyroid
problems) and endocrine disease should be noted
• Also the degree and intensity of exercise, history
of weight loss and complaints of hot flushes
Investigations;
• Hormonal tests – oestrogen, progesterone,
FSH and LH
• Basal body temperature monitoring
• Ultrasonography – to monitor increase in
ovarian follicle diameter, PCOS
 2. Evaluation of pelvic factors
• History – to include history of ectopic pregnancy, lower abdominal
surgeries, STI’s, appendicitis, endometriosis, PID
• Tests for STI’s – gonorrhea and chlamydia
• Saline infusion sonohysterography (SIS) – injection of isotonic fluid
through the cervix into the uterus during ultrasonography
• Hysterosalpingography (HSG) – fluoroscopic imaging of the uterus and
fallopian tubes after injection of radiopaque agent into the uterus
• Both of the above are done 2 to 5 days after cessation of menstrual
flow
• Hysteroscopy
• MRI – to rule out endometriosis
• Laparascopy (rare)
 3. Evaluation of cervical factors
• History
• Pelvic examination to check for cervicitis and
cervical stenosis
• If cervicitis is suspected, cervical swab taken
to test for gonorrhea or chlamydia
• Complete cervical stenosis is diagnosed if a 1-
2 mm diameter probe cannot be passed into
the uterine cavity
 Management
• Management is based on the findings of the
causative factors
• Medical management may include;
– Hormonal medications in cases of ovulatory factors or
endometriosis
– Letrozole – induce ovulation
– Clomiphene - induce ovulation
– Metformin – for those with PCOS, induces ovulation
– Gonadotropins – containing FSH and LH, hCG
– Antibiotics if cervicitis or PID is present
• Another form of management might be
cervical dilation incase of cervical stenosis
• Tubal surgery can also be done in younger
women
 Assisted Reproductive Technologies
• They involve manipulation of sperm and ova or embryos in
vitro with the goal of producing a pregnancy
• Oocytes and sperm are collected from the intended parents
or donors, and an embryo or the gametes are transferred to
the woman’s reproductive tract after culture in vitro
• If the risk of genetic defects is high, the embryo can often
be tested for defects before transfer and implantation –
preimplantation genetic testing
• The common methods are intra uterine insemination, in
vitro fertilization (IVF) and intracystoplasmic sperm
injection (ICSI)
 Intrauterine insemination (IUI)
• Intrauterine insemination (IUI), also known as
artificial insemination, involves inserting
sperm into the womb via a thin plastic tube
passed through the cervix.
• Sperm is first collected and washed in a fluid.
The best quality specimens (the fastest
moving) are selected.
Intra Uterine Insemination
 In Vitro Fertilization (IVF)
• Used to treat infertility due to oligospermia, sperm
antibodies, tubal dysfunction or endometriosis and
also unexplained infertility
• The procedure is as follows;
1. Controlled ovarian stimulation
• A gonadotropin-releasing hormone agonist or
antagonist is given to premature ovulation.
• When the follicular growth is sufficient, human
chorionic gonadotropin (hCG) is given to trigger
follicular maturation and ovulation
2. Oocyte retrieval
• About 34 hours after hCG is given, oocytes are
retrieved by direct needle puncture of the
follicle, usually transvaginally with ultrasound
guidance or less commonly laparoscopically.
• Natural cycle IVF (in which a single oocyte is
retrieved) can be offered as an alternative;
pregnancy rates with this technique are lower
than those with retrieval of multiple oocytes,
but costs are lower and success rates are
increasing.
3. Fertilization:
• The oocytes are inseminated in vitro.
• The semen sample is typically washed several
times with tissue culture medium and is
concentrated for motile sperm, which are then
added to the medium containing the oocytes.
• At this point, intracytoplasmic sperm injection
—injection of a single sperm into each oocyte
—may be done, particularly if
spermatogenesis is abnormal in the male
partner.
4. Embryo culture:
• After sperm are added, the oocytes are
cultured for about 2 to 5 days.
5. Embryo transfer:
• Only 1 or a few of the resulting embryos are transferred
to the uterine cavity, minimizing the chance of a
multifetal pregnancy, the greatest risk of IVF.
• The number of embryos transferred is determined by the
woman’s age and likelihood of response to IVF.
• Some or all embryos (especially if women are at high risk
of ovarian hyperstimulation syndrome) may be frozen in
liquid nitrogen for transfer in a subsequent cycle.
• There is an increasing tendency to place only 1 embryo at
each transfer and to freeze the remaining embryos for
use in subsequent cycles if pregnancy does not result.
 Intracytoplasmic sperm injection (ICSI)
• ICSI is useful when other technologies are unsuccessful
or are likely to be so or when a severe sperm disorder
is present.
• Oocytes are obtained as for IVF.
• A single sperm is injected into each oocyte to avoid
fertilization by abnormal sperm.
• The embryo is then cultured and transferred as for IVF.
• There is no benefit to using intracytoplasmic sperm
injection in couples with low oocyte yield or advanced
maternal age.
• If a couple's infertility involves the woman, more
than 30 of these procedures must be done to
make one additional pregnancy likely.
• Thus, the additional costs and risks of
intracytoplasmic sperm injection must be
considered when deciding whether to use it.
• Risk of birth defects may be increased after ICSI,
possibly because of the following:
– The procedure itself can damage the sperm, egg, or
embryo.
– Sperm from men who have mutations of the Y
chromosome may be used. Most reported birth
defects involve the male reproductive tract
 Other technologies

• They include the following:

– Use of donor oocytes or embryos
– Transfer of frozen embryos to a gestational carrier
(surrogacy)
 Prevention of infertility
• Class discussion
• Thank You!!!