INFERTILITY

A report presented to the department of Gynecology

PRESENTED BY

‫سفيان معاوي سليمان‬

University of mosul

College of medicine

Department of Gynecology

Supervised by

‫ أسماء عبدالرزاق حسن‬: ‫الدكتورة‬

contents

Introduction
Definition
Types of Infertility
Conception and Fertility
Factors Affecting Fertility
Requirements for Female and male Fertility
Causes of Female and male Infertility
Basic Work-up for Infertility
Treatment Possibilities : female and male
infertility
Summary
References
Introduction
Significant social and medical problem affecting couples worldwide Average
incidence of infertility is about 15% globally
- varies in different populations
-Some causes can be detected and treated, whereas others cannot
- unexplained infertility constitutes about 10% of all cases

Definition
Inability to conceive after 12 months of having sexual intercourse with average
frequency (2 to 3 times per week), without the use of any form of birth control

Types of Infertility
-Primary infertility: couple has never produced a pregnancy
-Secondary infertility: woman has previously been pregnant, regardless of the
outcome, and now is unable to conceive

Conception and Fertility

• The chances of conceiving in any given menstrual cycle is less than 20%
• Main events necessary for pregnancy to occur are:
−ovulation
− fertilization
− implantation
Any condition that interferes with these events may result in infertility

Factors Affecting Fertility:

1- Frequency of Intercours : Coital frequency is positively correlated with
pregnancy rates
Frequency of intercourse Probability of conception
(within 6 months)
1 time per week 17%
3 times per week 50%

2-Timing of Intercourse : Intercourse just before ovulation maximizes the

chance of pregnancy
- Sperm survives as long as 5 days in the female genital tract
- Ovum life expectancy is about 1 day if not fertilized
- Sperm should be available in the female genital tract at or shortly before
ovulation
3-STIs and Other Infections :
➢ Gonorrhea and chlamydia can cause:
✓ in women: pelvic inflammatory disease (major cause of
tubal infertility) and cervicitis
✓ in men: urethritis, epididymitis, accessory gland infection
➢ Mumps, leading to orchitis, may cause secondary testicular atrophy
➢ Other infections that may affect fertility include tuberculosis,
toxoplasmosis, malaria, schistosomiasis and leprosy

Age of the woman

− after 40 the fertility rate decreases by 50% while the risk of miscarriage
increases
Age of the man
− increased age affects coital frequency and sexual function
Nutrition
− for women, weight 10% to15% below normal or obesity may lead to less frequent
ovulation and reduced fertility
Factors that can contribute to fertility problems include:
− toxic agents, such as lead, toxic fumes and pesticides
− smoking and alcohol
All these factors may cause:
− in women: reduced conceptions and increased risk of fetal wastage
− in men: reduced sex drive and sperm count
Female and Male Factors
-Infertility may be a result of one or more male or female factors
- Female and male factors are equally responsible for infertility (30% to 40% each)
− in 20% of cases there is a combination of both factors
- Evaluating both partners is essential

Requirements for Female Fertility

✓ Vagina capable of receiving sperm
✓ Normal cervical mucus to allow sperm passage
✓ Ovulatory cycles
✓ Patent fallopian tubes
 ✓ Uterus capable of developing and sustaining pregnancy
✓ Adequate hormonal status to maintain pregnancy
✓ Adequate sexual drive and sexual function
✓ Normal immunologic responses to accommodate sperm and conceptus
✓ Adequate nutritional and health status to maintain nutrition and oxygenation
of placenta and fetus

Requirements for Male Fertility

✓ Normal spermatogenesis in order to fertilize egg: sperm count , motility ,
biological structure and function
✓ Normal ductal system to carry sperm from the testicles to the penis
✓ Ability to transmit sperm to vagina achieved through:
− adequate sexual drive
− ability to maintain erection
− ability to achieve normal ejaculation
− placement of ejaculate in vaginal vault

Causes of Female Infertility

✓ Pelvic inflammatory disease (PID) leading to blocked or damaged fallopian
tubes
− may interfere with fertilization and transport of egg
✓ Ovarian dysfunction resulting in absent or diminished egg production
✓ Local factors in the uterus and cervix
− may interfere with implantation and woman’s ability to carry pregnancy to
term
✓ Luteal phase defect
− results in low production of progesterone
− may lead to early miscarriage
✓ Production of anti-sperm antibodies
− can interfere with fertilization

Causes of Male Infertility

✓ Conditions that affect quality or quantity of sperm may lead to infertility
✓ These conditions include:
− varicocele
− primary testicular failure
− accessory gland infection
− idiopathic low sperm motility
Causes of Infertility Affecting Both Partners:
✓ Psychological: sexual behavior may reflect couple’s desire not to have
children
✓ Immunological incompatibility: may cause sperm agglutination
✓ Unknown causes
Basic Work-up for Infertility
Evaluating both partners is essential
• Detailed history and physical examination for both
• Semen analysis
• Evidence of ovulation
• Evidence of fallopian tubes patency
• Postcoital test
− still performed by some clinicians
− not found valid by some studies
General and Sexual History
General history
− occupation and background
− use of tobacco, alcohol and drugs
− history of abdominal surgery and earlier diseases/infections
Sexual history
− sexual disturbances or dysfunction such as vaginismus, dyspareunia or erectile
dysfunction
− sexually transmitted infections
Obstetric and Gynecological History
• Reproductive history
• Gynecological history
• Age at menarche
• Menstrual periods: duration and intervals
• Previous contraceptive use
• Previous testing and treatment for infertility

General and Gynecological Examination

Visual evaluation and pelvic exam Visual evaluation and penile exam for
for women to rule out: men to rule out:
Endocrinopathy Hypogonadism
Congenital anomalies Tumors
Uterine hypoplasia Epididymal cysts
Cervical lesions Cryptorchidism
Dyspareunia Hydrocele
Varicocele

Fertility Evaluation of Female Partner: Evidence of Ovulation

• Urine test measures the LH in urine to detect if and when ovulation occurred
 • Basal body temperature chart  temperature is measured every morning,
before woman gets out of bed elevation in temperature indicates ovulation

• Progesterone test: progesterone level in blood is measured on days 21 or 22

of 28-day cycle
• Endometrial biopsy: done during premenstrual phase , detects if
endometrium undergoes expected changes (consistent with ovulation and
production of progesterone)
• Hysterosalpinogram (HSG)− to determine whether fallopian tubes are
blocked
• Laparoscopy: to evaluate for pelvic disease, such as endometriosis, and
check patency of fallopian tubes
• Hysteroscopy : to evaluate condition of uterine cavity (polyps, fibroids)

Fertility Evaluation of Male Partner: Semen Analysis

• Volume (1.5 cc to 5.0 cc)
• Number of sperm present (> 20 million/ml)
• Sperm motility (> 60%) and forward progression(more than 2 on scale 1 to 4)
• Morphology (> 60% normal forms)
• Presence of any infection
• Urine analysis: to rule out infection
• Endocrine tests: to measure concentrations of hormones testosterone, FSH
and LH
• Anti-sperm antibodies
• Sperm penetration assay: to establish ability of sperm to penetrate egg
• Postcoital test (low validity): to establish ability of sperm to penetrate
cervical mucus

Treatment Possibilities:
Female Infertility:
Ovulation disorders
Hyperprolactinemia
Uterine and tubal abnormalities
Cervical mucus problems
Endometriosis
Ovulation-inducing drugs
Prolactin-suppressing drugs
Surgical procedures
Intrauterine insemination
Suppressing hormones or
surgical procedure

Induction of Ovulation
• Involves the use of medication to stimulate development of one or more
mature follicles
• Success rates vary considerably and depend on age of the woman, the type
of medication used,whether there are other infertility factors present in the
couple and other reasons
Ovulation Induction Agents: Clomiphene citrate, Gonadotropin releasing hormone
analogs, Gonadotropins, Bromocriptine
Intrauterine Insemination
• A fertility procedure in which sperm are washed, concentrated and injected
directly into a woman’s uterus
• Increases the number of sperm in the fallopian tubes
• Not recommended in cases of tubal blockage, poor egg quality, ovarian
failure and severe male factor infertility
• Most successful when coupled with drugs inducing ovulation (success rates of
5% to 20% per cycle)
Assisted Reproductive Technology (ART)
• Noncoital methods of conception
• Includes all fertility treatments in which both eggs and sperm are manipulated
• Types of ART include:
− In Vitro Fertilization (IVF)
− Zygote Intrafallopian Transfer (ZIFT)
− Gamete Intrafallopian Transfer (GIFT)
In Vitro Fertilization(IVF)
• Involves retrieving eggs and sperm from female and male partners and
placing them in a lab dish to enhance fertilization
• Fertilized eggs are transferred several days later into the uterus
• Ovarian stimulation drugs are used prior to procedure in order to retrieve
several eggs and maximize chances for successful fertilization
• Success rates are about 20% per egg retrieval
Gamete Intrafallopian Transfer (GIFT)
• GIFT is a procedure that involves:− ovarian stimulation− retrieval of eggs
− placing a mixture of sperm and eggs directly into the woman’s fallopian tube
• GIFT does not allow visual confirmation of fertilization
• Success rates per egg retrieval are about 28%(higher than for IVF)
Zygote Intrafallopian Transfer (ZIFT)
• ZIFT, also called tubal embryo transfer, is another variation of IVF
• As with IVF, the actual fertilization takes place in a lab dish
• Fertilized eggs are placed directly into a fallopian tube
• Success rate is about 29% per egg retrieval
Male Infertility treatment;
• Surgical treatment in some cases (varicocele)
• Intrauterine insemination can be performed either with patient’s or donor’s
sperm
• ART procedures:
− GIFT
− IVF
− ICSI
Donor semen should be free from STDs/HIV
Intracytoplasmic Sperm Injection (ICSI)
• Involves injection of single sperm into the egg
• The woman is administered fertility drugs prior to the procedure to aid in the
production of multiple eggs
• Only active undamaged sperm are selected for injections
• Eggs are observed to see if fertilization takes place− average fertilization rate
is 65%
• Implantation into the uterus takes place within 72 hours after ICSI
• Success rates range from 15% to 35% per egg retrieval
Summary
• Infertility is a significant social and medical problem affecting couples
worldwide
• Female and male factors are equally responsible
• Evaluation of both partners is essential
• Treatment depends on the cause of infertility and varies from ovulation-
inducing drugs to surgery to ART

References
1. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA.
National, regional, and global trends in infertility prevalence since 1990: A
systematic analysis of 277 health surveys. PLoS Med. 2012;9(12):e1001356.
2. World Health Organization. Infertility. 2013.
3. WHO. Sexual and reproductive health. 2013.
4. Taylor A. Extent of the problem. ABC of subfertility. 2003;327(7412):434-436.
5. Kakarla N, Bradshaw K. Evaluation and Management of the Infertile. Glowm.
2008.