Infertility

*

DefinitionInfertility is inability to conceive after one year of conjugal life without use of contraceptive methods.The term "primary infertility" is applied to the couple who has never achieved a pregnancy."secondary infertility" implies that at least one previous conception has taken place.

Causes of infertility -Female factors(single)

Tubal factors-------------- 30% - 40%Endometriosis --------------6%Ovulatory dysfunction ---- 30% -40%Diminished ovarian reserve --- 8%Uterine factors -------------- 1%

Major CausesMale factor( single) ---19%Other causes ---- 7%Unexplaind causes 12%Multiple factors (female only) 12%Multiple factors (female + male) -18%

*

Etiology of Male InfertilityMulti-factorialPrevalenceVaricocele 35%Idiopathic 25%Infection/injury genito-urinary tract 10%Genetic/systemic disease 10%Endocrine 1 - 5%Immunologic 1 - 5%Obstruction 1 - 5%Developmental 1 - 5%Lifestyle: smoking, diet, heat ???%

*

Aetiological Classification1.Disorders of spermatogenesis:A)Hormonal Hypothalamic disorderPituitary secretion of FSH and LHHyperprolactinaemia causing Impotence or diminished libido.B) Primary testicular disorders:Idiopathic, VaricoceleChromosomal defect, i.e. klinefilters syndromeCryPto-orchdism

Drugs,radiationsOrchitis (traumatic,mumps, TB,gonorrhoea)Chronic illnessImmunological disorders.2) Duct obstruction:Congenital absence, inflammatory block, surgical trauma,3)Accessory glands disorders:Prostitis, vasiculitis, congenital absence of vas in cystic fibrosis.

4.Disorders of sperms and vesicular fluid: Sperms antibodies and low fructose in seminal plasma.Sperms acrosome defectZona pellucida binding defectZona penetrations defectOocyte fusion defect5. Sexual dysfunctions:Low frequency coitus- wrong timeImpotence, hypospadiasPremature Ejaculation, retrograte ejaculation

6.Psychological factors and environmental factors like smoking,alcohol consumption,tobacco chewing,diabetes,Drugs: antihypertensive,antipsycotis,sex steroids, chemotherapy, beta-blockers, spirolactone,oestrogen

Female Infertility EtiologiesUnexplainedCervical/mucusEndometrial/uterinePelvic/peritonealTubalDevelopmental/genetic

10%2-3%2-3%5-10%30-50%40%

Other EtiologiesPIDCx conization/cauterySmokingIUDEndometriosisGenetics

Aetiology1.dyspareunia and vaginal causes2.Congenital defect in the genital tract.3.infection in the lower genital tract.4.Cervical factors5.Uterine causes6.Tubal factors7.Ovaries8.Peritoneal causes 9.Chronic ill health especially thyroid dysfuntion

The Most Important Factor in the Evaluation of the Infertile Couple Is:HISTORY

*

History-GeneralBoth couples should be presentAgePrevious pregnancies by each partnerLength of time without pregnancySexual history Frequency and timing of intercourseUse of lubricantsImpotence, anorgasmia, dyspareuniaContraceptive history

*

Male Infertility: EvaluationHistory (Questionnaire)Physical examinationStandard semen analysisHormonal evaluationGenetic counseling and evaluationImaging studies

*

History-MaleHistory of pelvic infectionRadiation, toxic exposures (include drugs)Mumps Testicular surgery/injury Excessive heat exposure (spermicidal)

*

Physical Exam-MaleSize of testiclesTesticular descentVaricocoeleOutflow abnormalities (hypospadias, etc)

*

Male Factors-Semen AnalysisCollected after 3 days of abstinenceEvaluated within one hour of ejaculationIf abnormal parameters, repeat twice, 2 weeks apart

*

Semen Analysis:World Health Organization Guidelines ParametersNormal range Volume 1.5 - 5 mLSperm conc. >20 million/mLSperm motility >50%Sperm morphology>30% normal formsLeukocyte density

Semen AnalysisAbnormal semen resultsAzospermiaOligospermiaAthenospermiaTeratospermia

*

Sperm TermsNormozoospermiaNormal ejaculate

Asthenozoospermia

Teratozoospermia

Azoospermia

Aspermia

Normal ejaculate Sperm concentration

Hormonal and others GnRHFSHLHTSHProlactin level

Rule out genetic diseases.Chromosomal studyImmunological study

Imaging StudiesTransrectal Ultrasound (TRUS)VasographyTestis Biopsy

*

Transrectal Ultrasound (TRUS)Seminal vesicle dilatation.Ejaculator ductal stones

*

VasographyIndicationAssessment of vasal obstruction or ejaculatory duct obstruction. An inguinal vasal obstruction should be suspected in an azoospermic patient with normal spermatogenesis and a history of prior inguinal or scrotal surgery.

*

Testis BiopsyIndicationDistinguishing between obstruction and testicular failure.Identification of mature sperm for ICSI

*

Treatment- Male FactorHypogonadotrophism:-GnRHLigation Retrograde ejaculationTestosterone for spermatogenesisClomiphene 50 mg daily for 3 months for oligospermia.

Empierical medical therapy by administration of vit.c , B 12, folic acid.Varicocele:- surgical treatmentObstruction:-short-cut operationIVF/IUI :- last option.

*

Female Infertility: EvaluationHistory (Questionnaire)Physical examinationOvarian factorTubal factorsHormonal analysisImmunological testPostcoital test

*

History-FemalePrevious female pelvic surgeryPID/InfectionMedical diseases:-TB, diabetes,STDIUD use Ectopic pregnancy history Proven fertilityEndometriosis

*

History-FemaleIrregular menses, amenorrhea, detailed menstrual history Vasomotor symptoms StressWeight changesExerciseCervical and uterine surgery

*

Physical Exam-FemalePelvic massesUterosacral nodularityAbdominopelvic tendernessUterine enlargementThyroid examUterine mobilityCervical abnormalities

*

Ovarian factors Fern testEndometrial biopsy in secretory phaseSerial USGSerum progesteroneLaparoscopyD & C.

Tubal factorTubal patency test by:-

Tubal insufflation testHystero-salphingo-graphyLaproscopy dye insufflation testHydrotubation

Hormonal Immunological FSHLHEstrogenProgesteroneTSHProlactinTestosterone

Antisperm antibody

Treatment for female factorAnovular :- clomiphene citrate

bromocriptine

D&C:- histopathology, bacteriologyReconstructive surgery:- developmental defect Surgery:- tubal blockIf all method fails, then go for.

Assisted Reproductive Technologies

Intrauterine Insemination(IUI)In Vitro Fertilization(IVF)IVF and Intra Cytoplasmic Injection of Sperms(ICSI)

*

Intrauterine insemination (artificial insemination)definition: Artificial introduction of semen into the vagina, cervix or uterus by means other than coitus to produce pregnancy is called artificial insemination.sperm can come from husband or donor or pool donor.

*

IUI, contd.6000 babies / year born in US. as result of artificial insemination

INDICATION OF ARTIFICIAL INSEMINATION:-

Impotent husband.Sterile husband.Husband suffering from hereditary disease.Rh-incompatibility between husband and wife.

*

In vitro fertilizationtest - tube babies1st performed in 1978 (Louise Joy Brown)often performed on infertile women with tubal blockage

*

Test tube babies/ in-vitro fertilizationTechniques:-The ovum is removed from ovary through abdominal wall and is fertilized with the sperm in a small laboratory dish in artificial medium..At the stage of blastocyst, the embryo is return to uterus through cervix.Blastocyst is implanted in endometrium.

Artificial insemination in laboratory discBlastocyst

Thank you

*

**

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*