Infertilité: facteur tubaire,

endométriose, myomes
utérins, infertilité inexpliquée

Presented by

Dr. E. NKWABONG
Obstetrician & Gynecologist
Senior lecturer
FMBS/ CHU Yaoundé
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 Plan :
1. Objectives
2. Introduction
3. Tubal factors inclusing endometrioisis
4. Uterine factors (myomes, adenomyosis)
5. Ovulatory factors
6. Unknown infertility
7. Management of an infertile couple
8. Conclusion
9. References

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1. Objectives:

At the end of the lecture, the student should :

1. Define infertility
2. List the tubal causes
3. Enumerate the uterine factors
4. List the ovulatory factors
5. Define unknown infertiility
6. Have an overview on the management of infertility

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2. Introduction (1)

Infertility is a serious concern for couple. Absence of

conception is a common cause of divorce, especially in
Africa.

This subject, therefore, should be well known by the

gynecologist.

Moreover, each GP should have at least an idea on the

pathology, in order to refer the patient in time.

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 Introduction (2)

Declining female fertility with age

• Reduced quality of oocytes

• Ovulatory disorders
• Longer exposure to the risk of genital
infections and iatrogenic infertility causes
• Increased uterine pathology
• Decreased frequency of intercourse
• Decreased partner's fertility
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 Introduction (3)
Some definitions:

• Infertility : absence of conception after 12 months of

regular (3 to 4 days/week), unprotected intercourse
(without any contraception). Inability to conceive within two years of exposure to
pregnancy is the epidemiological definition recommended by the World Health Organization.

• Primary infertility means that the couple has never

conceived, despite regular unprotected intercourse for
a period of 12 months.

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 Introduction (4)
Some definitions:

• Secondary infertility means that the couple has

previously conceived, but is subsequently unable to
conceive despite regular unprotected intercourse for a
period of 12 months.

If the woman has breastfed a previous infant, then

exposure to pregnancy is calculated from the end of
lactational amenorrhea

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 Introduction (5)

Origin of infertility

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 Introduction (6)
East
Latin Mediterrane
Categories Developed Africa Asia America an
Female diagnosis
No demonstrable cause 40 16 31 35 26
Bilateral tubal occlusion 11 49 14 15 20
Pelvic adhesions 13 24 13 17 13
Acquired tubal
12 12 12 12 9
abnormality
Anovulatory regular cycles 10 14 9 9 15
Anovulatory
9 3 7 9 11
oligomenorrhea
Ovulatory oligomenorrhea 7 4 11 5 8
Hyperprolactinemia 7 5 7 8 6
Endometriosis 6 1 10 3 1
Male diagnosis
No demonstrable cause 49 46 58 41 28

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3. Tubal factors:
In this case, the tubes have been damaged.

• Infections:
– Maladies sexuellement transmissibles (mycoplasmes,
chlamydiae, gonocoques)
– Infections du post-partum ou du post-abortum
– Après manipulations endo-utérines (stérilet, curetage, etc.)
– Appendicite avec péritonite
– Tuberculose

• Causes iatrogènes (après interventions chirurgicales

pelviennes)
• Endométriose
• Anomalies congénitales des trompes

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4. Facteurs utérins

• Malformations congénitales
• Infections (endométrites, cervicites)
• Fibromes ou polypes
• Causes iatrogènes (chirurgicales:
Ashermann syndrome)
• Adenomyose

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Endometriosis (1)

It is the extra uterine presence of functioning

endometrial glands and stroma.
Ovaries (44%), Pouch of Douglas and vesicouterine
space (34%), Uterosacral ligaments (20%), and
Surrounding pelvic peritoneum (22%).
The exact incidence of endometriosis (estimated 3% to
10%) is uncertain because the disease process exists in
several states from microscopic lesions to macroscopic
disease.
The incidence is believed to be 20% to 40% among
infertile couples

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Endometriosis (2)

Studies have shown that activated leukocytes and

macrophages produce Vascular endothelial growth
factor (VEGF) in endometriosis →new blood vessels.

Impaired immune response (natural killer cells activity

may be reduced due to expression of HLA-B7 allele,
deficient cellular immunity).

Endometriosis can be asymptomatic. The rate of

ovulation among endometriosis patients is 11–27%.

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Endometriosis (3)
Pathophysiology of infertility:
– Inflammatory Factors: There is elevated levels of
interleukin-6 (IL-6 suppress blastocyte formation).
and of tumor necrosis factor in the peritoneal fluid of
endometriosis patients (TNF decreases tight sperm
binding to the zona pellucida).
– Implantation defects: integrin needed for
implantation has been shown to be decreased in
the endometrium of infertile women with E.
– Moderate and severe endometriosis is associated
with pelvic adhesions that distort pelvic anatomy,
prevent normal tubo-ovarian apposition.
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5. Facteur ovulatoire (1)

• Causes suprahypothalamiques (dans la plupart des

cas de cause psychogène et/ou nutritionnelle),
• Causes hypothalamiques (causes congénitales ou
tumorales prédominantes),

• Causes hypophysaires (dans la plupart des cas de

cause tumorale)
• Ovaires polykystiques

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 Facteur ovulatoire (2)

• Tumeurs ovariennes
• Insuffisance gonadique primaire:
– Anomalies chromosomiques (syndrome de
Turner 45 X0, mosaïques, etc.)
– Ménopause précoce

• Pseudohermaphrodisme masculin
• Endocrinopathies périphériques extragonadiques

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 Screening du cycle
Dosages hormonaux (1)

• J3-5: réserve ovarienne

FSH, LH et E2

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 RAPPEL: FOLLICULOGENESE

FSH Sélection
Recrutement

Phase tonique de Phase de croissance régulée

croissance par Gn

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6. Unexplained Infertility (1)

In certain cases (10-30%), no cause is found (semen,

tubal evaluation, tests of ovulation normal).
At least 3 years of unexplained infertility is accepted
as a minimal duration before active intervention is
considered.

Invasive assisted reproductive techniques offer fairly

modest pregnancy rates.
However, spontaneous conception can occur

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 Unexplained Infertility (2)
The causes include:
1.Subclinical pregnancy loss
2.Mild endometriosis (without gross pelvic distortion)
3.Occult infection (tubal)
4.Anatomical abnormalities (tubo cornual polyps)
5.Sperm dysfunction (subtle)
6.Luteal phase deficiency
7.Immunological causes (antiphospholipid Ab)
8.Psychological causes (stress level increased)
9.Luteinized unruptured follicle (LUF) syndrome
10.Hyperprolactinemia (→ deficient luteal function)

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7. Management of an infertile couple

The investigation should concern the two partners.

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Interrogatoire de la femme (1)

• Age: Mariés/vie commune depuis: Désir d’enfants

depuis:
• Grossesses conçues dans ce mariage; mariages
et/ou grossesses antérieures.
• Antécédents familiaux: stérilité, avortements
spontanés, maladies héréditaires.

• Antécédents médicaux: maladies chroniques,

tuberculose, endocrinopathies, médicaments.
• Antécédents chirurgicaux: appendicectomie,
péritonite.

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Interrogatoire de la femme (2)

• Antécédents gynécologiques:
– Contraception antérieure; MST, MIP (PID),
vulvovaginites, cervicites; opérations
gynécologiques abdominales; curetages,
opérations cervicales et vulvovaginales.
– Puberté; modifications du cycle, cycle actuel,
signes d’accompagnement.

• Habitudes de vie: profession, exercices physiques;

tabac, alcool; fréquence et qualité des rapports;
troubles sexuels.

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Interrogatoire de l’homme (1)

• Age: Mariages et/ou grossesses antérieures:

• Antécédents familiaux: stérilité, avortements
spontanés.
• Antécédents médicaux et chirurgicaux: maladies
chroniques; infections récidivantes, états fébriles,
allergies; médicaments, radiothérapie.
• Troubles urogénitaux: cryptorchidie; orchite
(oreillons); torsion du cordon spermatique;
épididymite, prostatite, urétrite, cystite; traumatisme
testiculaire.

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Interrogatoire de l’homme (2)

• Opérations urogénitales: orchidopexie; hernie

inguinale; orchidectomie; varicocèle; opérations
prostatiques, vésicales, urétrales.

• Habitudes de vie: profession; exercices physiques;

tabac, alcool; troubles sexuels; bains chauds.

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 Semen analysis: description
• Normal semen quality Normospermic

• No ejaculate Aspermia

• No spermatozoa Azoospermia

• Low spermatozoa concentration Oligozoospermia

• Low spermatozoal motility Asthenozoospermia

• Low normal morphology Teratozoospermia

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 Investigation of the infertile couple

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8. Conclusion

Infertility is a serious concern for couple. Absence

of conception is a common cause of divorce,
especially in Africa.

This subject, therefore, should be well known by

the gynecologist.

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 9. References:
* Current Obstetrics & Gynaecologic diagnosis &
treatment
* Williams Obstetrics
* Dewhurst’s textbook of Obstetrics &
Gynaecology, 7th edition
*Johns Hopkins Manual of Gynaecology and Obstetrics,
3rd edition
* Others
• Modalités de l’évaluation: QCM, QROC,
Questions rédactionnelles
• Conseils: Consulter la bibliographie
• Contact: Dr Nkwabong, service de gynécologie,
CHU Yaoundé, Tel. 699663843

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 Thanks for your kind
attention

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