Subfertility

Bryan Goh 191303012

Case
A 36 years old woman and her 39 year old partner came to the fertility clinic
after trying for a baby for 3 years. The referral letter notes that she has
irregular period and her partner had hernia repair done as a child. Neither
have any children.
Index
● Introduction to subfertility
● History and Examination
● Causes of subfertility
● Risk factors of subfertility
● Clinical features
● Investigations
● Management & Treatment
● Complications
Introduction
● Subfertility:
○ Def: failure to conceive after 12 months of regular unprotected intercourse
○ There is reduced fertility or chance of getting pregnant but still possible
○ Affect 1 in 7 heterosexual couples

● Infertility:
○ Def: inability to conceive with regular unprotected intercourse at least 1 year without
using birth control methods

● Types of infertility:
○ Primary - inability of couple to conceive after staying together and having regular
unprotected intercourse for / 2 years (regular => 3 times/week)
○ Secondary - inability of couple to conceive after an initial phase of fertility
History & Examination
HISTORY TAKING:
● In males:
○ Age, duration of infertility, any contraception practiced (if yes, for how long?)
○ Past medical & surgical history:
■ TB, STIs, DM
■ Surgery done on hernia, scrotum, undescended testes

○ History related to external genitalia

■ Any past h/o or U/L coital problems (premature ejacualtion, retrograde ejaculation,
failure to ejaculate)

○ Social history & lifestyle

■ Occupation (frequent traveller/working in hot place)
■ smoking , alcohol consumption, tobacco and drugs
History & Examination
HISTORY TAKING:

● In females:
○ Age
○ past obstetric history
■ Puerperal infections
■ Coital difficulties
■ Menstrual history (LMP, UPT)
■ Previous use of contraceptive (if yes, which type?)

○ Past medical history

■ H/o TB, pelvic infections
■ H/o DM and Thyroid dysfunction

○ Social history & lifestyle

○ Other complaints (dyspareunia, vaginal discharge, galactorrhea/thyroid disease)
History & Examination
CLINICAL EXAMINATION:
● In males: (can be postponed until after semen analysis)
○ In case of abnormal semen analysis,
■ General examination
● height (increased in klinefelter syndrome)
● weight → obesity may be due to hormonal defects
● Hirsutism
● Abnormal 2’ sexual characters (i.e gynaecomastia)
● Thyroid examination
● Blood pressure

■ Examination of the external genitalia

● includes penis, scrotum and surgical scars
● Palpate for testes (well-placed in scrotum)
● Palpate for epididymis (for enlargement & thickness)
● Palpate for vas deferens (thickened in inflamed condition)
History & Examination
CLINICAL EXAMINATION:

● In females:
○ Body size and habitus (heigh, weight)
○ Blood pressure
○ Obesity, acne, hirsutism
○ Thyroid examination
○ Breast examination
○ Abdominal examination - abdominal swelling => uterine fibroid
○ Bimanual pelvic examination - TRO gynaecological causes for infertility (endometriosis,
PID)
Causes
Male factors:
Production of sperm
● Incomplete development of testis
● late/non-descent of testes
● Previous orchitis due to mumps
● Damage to testes due to trauma/heat
● TB, DM, multiple sclerosis
● Lifestyle issues (smoking, alcohol,
electromagnetic radiation from phones)
Transport of sperm Deposition of sperm
● Obstructive azoospermia ● Erectile dysfunction
● Trauma ● Premature ejaculation
● Surgeries (Herniorrhaphy) ● Retrograde ejaculation
● Epididymitis (in TB)
● Congenital obstruction of
epididymis
Causes (contd)
Female factors:
Ovarian factors Tubo-peritoneal factors Others

● PCOS ● Endometriosis ● Uterine

● Hyperprolactinemia ● PID ● Cervical
● Hypothyroidism ● Vaginal
● Premature ovarian failure ● Lubricants
● Anxiety
Risk Factors
● Male> 40 years old
● Female > 35 years old
● Obese
● Tobacco usage
● Alcohol consumption
● Excessive physical and emotional stress
● Exposure to radiation
● Exposure to toxins (leads, pesticides)
● Medications: NSAIDs, Amitriptyline, Fluoxetine
Clinical features
● In females:
○ Irregular periods
○ Pelvic pain/back pain

● In males:
○ Testicular pain
○ Ejacultion problem
○ Erection problem
○ Small testicles

● In both:
○ More acne
○ Changes in sexual desire
○ loss/thinning of hair
Investigations(Male)
1. Seminal fluid analysis
● Obtained by ejaculating into a clean wide mouthed container in a semen collection room
● 3 days abstinence ( avoid any form of ejaculation)
● Normal results:
○ Volume: 1.5 ml
○ Liquefaction: 30 minutes
○ Sperm concentration: > 15 millions/ml (reduced in oligospermia)
■ In severe cases: < 5 millions/ml
○ Sperm count: > 39 millions/ejaculation
○ Sperm motility: > 40% motile (reduced in Asthenospermia)
○ Sperm morphology: >4% normal (reduced in teratospermia)

** Oligoasthenoteratospermia → reduced sperm concentration, sperm motility, and abnormal morphology **

● Abnormal results → repeat after 3 months

● Severely abnormal → repeat after 3-4 days

2. Testicular biopsy: done in the case of azoospermia

Investigations (Female)
1. Transvaginal ultrasound:
● Uterus, ovaries, follicular imaging and endometrial thickness

2. Hormonal assays:
● Free Thyroxine (T4), TSH, Prolactin (PRL), FSH

3. Tubal patency tests:

● Hysterosalpingography (HSG)
○ To assess shape of uterus, patency of fallopian tube, TRO PID, chlamydia infections, endometriosis
○ Done within day 10 of menstrual cycle
○ Idx: in patients with symptoms and absence of peritoneal problems
○ C/I: prior to menses, after curettage, suspected TB/lower genital tract infections

● Sonosalpingography
● Hysteroscopy
● Laparoscopy
Management & treatment
For both:

1. Reassurance
2. Correction of coital difficulties
3. Correction of general health
a. Tribestan
b. Clomiphene citrate

In males:

● Correction of Erectile dysfunction (ED) - Sildenafil citrate (viagra), premature ejaculation

● Improve sperm by clomiphene
● Testicular Sperm Aspiration (TESA), Microsurgical Epididymal Sperm Aspiration (MESA)
● Correction of Varicocele
Management & treatment (contd)
In female:
● Hormone therapy
○ Clomiphene citrate
○ Gonadotropins
○ Bromocriptine

● Operative:
○ Tubal reconstructions
○ Laparoscopic ovarian drilling in PCOS to improve ovulation + adhesiolysis to remove adhesions

If treatment fails, consider artificial reproduction technology (ART)

● Male: intracytoplasmic sperm injection (ICSI) + embryo transfer (ET)

● Female: IVF + ET
Complications
● Psychological problem
● Relationship problem
● Depression
● Anxiety
● Social stigma
● Stress
THANK YOU