Infertility

By : Dr Endalew
Definition
• Infertility - is inability to conceive after 1 year of unprotected sexual
intercourse of reasonable frequency or therapeutic donor insemination
in women < 35 yr and 6 months in >/= 35 yr.

• Sterility: incapable of becoming pregnant or of inducing pregnancy

• About 90% of couples should conceive within 12 months of
unprotected intercourse
• Affects 10-15% in the general population
....

Two types of infertility

• Primary infertility: no prior pregnancies
• Secondary infertility: infertility following at least one prior
conception.
 Etiology of Infertility
Successful pregnancy requires a complex sequence of events
including:
Patent out flow tract
Ovulation
Sperm of adequate number & quality
Ovum pick-up by a fallopian tube
Fertilization
Transport of a fertilized ovum into the uterus
Receptive endometrial cavity.
Infertility can be seen as male & female infertility
 Etiology contd.
Female infertility Male factors
Ovulatory Dysfunction Pre-testicular
Tubal /Peritoneal Factor Testicular
Uterine Factor Post-testicular
Cervical Factors
Idiopathic
Vaginal Factors
Chronic systemic diseases
Social personal habit(illicit
drugs)
Unexplained
 Ovulatory Dysfunction
Ovulation may be perturbed by abnormalities within
the hypothalamus, anterior pituitary, or ovaries.
Hypothalamic disorders may be due to lifestyle, for
example, excessive exercise, eating disorders, or
stress.
Alternatively, idiopathic hypothalamic hypogonadism
(IHH) or Kallman syndrome may be the cause.
Thyroid disease and hyperprolactinemia may also
contribute to menstrual disturbances
Causes ovarian dysfunction
• Pituitary adenoma
• Genetic causes like Turner, kallmann syndrome
• PCOS
• Obesity
• CKD/CLD
• Chung syndrome
• Premature ovarian failure - chemotherapy, radiation
 Ovulatory contd.
Methods used to document ovulation include:
1. Indirect
Menstrual pattern
Basal body temperature
Ovulation predictor kits
Endometrial biopsy
Serum progesterone
Sonography
2. Direct: laparoscopic visualization of recent corpus luteum or
detection of ovum from aspirated peritoneal fluid
3. Conclusive: pregnancy
 Tubal/Peritoneal Factor

Damage or obstruction of fallopian tube

Previous PID
Previous tubal surgery
Ectopic pregnancy
Benign polyps
Tubal endometriosis
Mucus debris
Tubal damage of unknown cause-sub clinical infection
 Tubal/ peritoneal contd
HSG (hysterosalpingography):
Done on day 6-10 of cycle
Advantage: site & side of blockade
determination, detection of uterine
malformation and as treatment
Contraindicated in presence of pelvic
infection & undiagnosed adnexal mass
Could be oil based or water based
Tubal abnormalities on HSG
 Tubal/ peritoneal Contd.
Laparoscopy & chrome pertubation
Indications:
Abnormal HSG
Failure to conceive after 6 months with normal
HSG
Unexplained infertility
Age above 35 years
Better done in secretary phase
Drawbacks: more invasive and couldn’t detect uterine
cavity problems & tubal lumen
 Uterine Factor

Uterine causes of infertility include

Congenital malformation –didelphys, unicornute, septate
Luteal phase defect
Endometritis –Tuberculosis
Endometrial polyps
Leiomyoma – large, solitary, submucous, distorting cavity
Asherman’s syndrome
In utero exposure to DES
 Cervical Factors
Abnormalities in mucus production are secondary to
Cryosurgery, cervical conization, or LEEP
Cervical infection (Chlamydia trachomatis, Neisseria
gonorrhoeae & Ureaplasma urealyticum)
Abnormalities of cervical factor can be assessed by
postcoital test
Cervical Factors
Normal finding are:
1. Mucus is copious, stretchy
2. At least five motile sperm per
high-power field,
3. There should be a minimal
number inflammatory cells.
4. When dried, the mucus should
form a ferning pattern
 Male factor
The hypothalamic-pituitary-testicular axis
Male factors
Semen Analysis Terminology

• Normozoospermia: All semen parameters normal

• Oligozoospermia: Reduced sperm numbers
• Mild to moderate: 5–20 million/mL
• Severe: <5 million/mL
• Asthenozoospermia: Reduced sperm motility
• Teratozoospermia: Increased abnormal forms of sperm
• Oligoasthenoteratozoospermia: Sperm variables all subnormal
• Azoospermia: No sperm in semen
• Aspermia (anejaculation): No ejaculate (ejaculation failure)
• Leucocytospermia: Increased white cells in semen
• Necrozoospermia: All sperm are nonviable or nonmotile
Investigation
• Hormonal test - FSH, LH, Testosterone
• prolactin, TSH
• Testicular u/s, biopsy
• Trans rectal ultrasound
• Fructose content in seminal fluid
• Karyotype
Reading
• Assisted Reproductive Technology
• Ovarian reserve assessment
Thank you!