INFERTILITY ,MALE AND FEMALE

CAUSES AND DIAGNOSIS

DEFINITION
 Infertility is defined as a failure to
conceive within one or more years of
regular unprotected intercourse.
 Primary infertility denotes, those

patients who have never

conceived.Secondary infertility
indicates previous pregnancy but
failure to conceive subsequently.
INCIDENCE
80 Percentage of the couples achieve
conception if they so desire,within one
year of having regular intercourse with
adequate frequency(4-5 times a
week). Another 10% will achieve the
objective by the end of second year.As
such 10% remain infertile by the end
of second year.
FACTORS RESPONSIBLE FOR FERTILITY
 Healthy spermatozoa should be deposited
high in the vagina.
 The spermatozoa should undergo

changes(capacitation,acrosome reaction) and

acquire motility.
 The motile spermatozoa should ascend

through the cervix in to the uterine cavity and

the fallopian tubes.
 There should be ovulation.
 The fallopian tubes should be patent and the
oocyte picked up by the fimbriated end of the
tube.
 The spermatozoa should fertilize the oocyte

at the ampulla of the tube.

 The embryo should reach the uterine cavity

after three to four days of fertilization.

 The endometrium should be prepared for

implantation and the corpus luteum should

fuction adequately.
ETIOLOGY
 Infertility can be attributed to any
abnormality in female or male reproductive
system. In most cases, the etiology is
distributed fairly equally among male
factors, ovarian dysfunction and tubal
factors. A smaller percentage of cases are
attributed endometriosis, uterine or cervical
factors, or other causes.
 Infertility can be primary (couple has never

conceived) or secondary (where the couple

has conceived before).
 CAUSES OF INFERTILITY:
 The male is directly responsible in about 30-
40%, the female in about40-50% and both are
responsible in about10% cases.
 FAULTS IN THE MALE:
 Defective spermatogenesis.
 Obstruction of the efferent duct system.
 Failure to deposit sperm high in the vagina.
 Errors in the seminal fluid.
 Defective spermatogenesis:
 The causes of defective spermatogenesis are:
CONGENITAL:
 Undescended testes.
 Kartagener syndrome(autosomal disease)-

There is loss of ciliary function and sperm

motility.
 Hypospadias- causes failure to deposit sperm

high in the vagina.

 Thermal factor:
 The scrotal temperature is raised in
conditions such as varicocele, big hydrocele
or filariasis.Other causes are using tight
undergarment or working in hot atmosphere
 General factors:

Chronic debilitating diseases, malnutrition or

heavy smoking reduces
spermatogenesis.Alcohol inhibits
spermatogenesis
 Genetice
Common chromosomal abnormality in
azoospermic male is klinefelters
syndrome(47XXY).Gene deletion have been
detected in the long arm of Y chromosome for
patients with severe oligospermia.
 Iatrogenic

Radiation,cytotoxicdrugs,nitrofurantoin,cimatedin
e,antihypertensive,anticonvulsant and
antidepressant drugs are likely to hinder
spermatogenesis.
 OBSTRUCTION OF EFFERENT DUCT:
CONGENITAL:
 Absence of vasdeferens(cystic fibrosis)
 Young’s syndrome
 ACQUIRED:
 Infective(tuberculosis,gonorrhea)
 Surgical trauma(herniorrhaphy,vasectomy)
FAILURE TO DEPOSIT SPERM HIGH IN THE
VAGINA
 Impotency.
 Ejaculatory failure.
 Retrograde ejaculation.
 Hypospadias.
 Bladder neck surgery.
 Psychosexual.
 Drug related.
 DEFECT IN SPERM AND SEMINAL FLUID
 Immotile sperm(kartagener syndrome).
 Oligo astheno teratozoosermia
 Low fructose content.
 Sperm antibodies.
 Abnormal sperm morphology,Unusually high

or low volume of ejaculate, low fructose

content,High prostaglandin content, Undue
viscosity.
CAUSES OF FEMALE INFERTILITY:
Causes are :
 Tubal and peritoneal factors(25-30%)
 Ovulatory factor(30-40%)
 Endometriosis.

 
 Ovarian factors:
 Anovulation or oligoovulation
 Decresed ovarian reserve.
 Luteal phase defect.
 Luteinised unreptured follicle.
 ANOVULATION OR OLIGOOVULATION:
 The ovarian activity is totally dependent on

the gonadotrophins and the normal secretion

of gonadotrohins depends on the pulsatile
release of GnRH from heypothalamus.As such
ovarian dysfunction is likely to be linked with
disturbed hypothalamo-pituitary-ovarian axis
either primary or secondary from thyroid or
adrenal dysfunction
LUTEAL PHASE DEFECT:
 In this condition there is inadequate growth

and function of the corpus luteum.There is

inadequate progesterone secretion.The life
span of corpus luteum is shortened to less
than 10 days.As a result there is inadequate
secretory changes in the endometrium which
hinder implantation.
LUTEINISED UNREPTURED FOLLICULAR
SYNDROME:
 In this condition the ovum is trapped inside

the follicle which gets luteinized.The cause is

obscure but may be associated with pelvic
endometriosis or with hyperprolactinaemia.
TUBAL AND PERITONEAL FACTORS
Tubal factors
 The impaired tubal function includes

defective ovam pick up , impired tubal

mortility, lose of cilia and partial to compelte
obstruction of the tubal lumen
Peritoneal factors
 In addition to peri tubal adhesions , even

minimal endometriosis may produce

infertility. Deep dyspareunia too often
troubles the patients.
Uterine factors
 The endometrium must be sufficiently

receptive enough for effective nidation and

growth of the fertilized ovum . the possible
factors that hinder nidation are utrane hypo
plasia , inadequate secretary endometrium ,
fibroid uterus , endometritis, uterine
synechiae or congenital malformation of the
uterus.
Cervical Factors
 Anatomic defects preventing sperm ascent

may be due to congenital elongation of the

cervix, second degree uterine prolapsed and
acute retroverted uterus.
 Physiologic:
 The fault lies in the composition of the

cervical mucucus, so much that the

spermatozoa fail to penetrate the mucus.
Vaginal factors:
 Atresia vagina,transverse vaginal

septum,septate vagina or narrow introitus

causing dyspareunia are included in the
congenital group
COMBINED FACTORS:
General factors:Advanced age of the wife
beyond 35 is related but spernatogenesis
continues throughout life although ageing
reduces the fertility in male also.
 Infrequent intercourse, lack of knowledge of

coital techinique and timing of coitus to

utilize the fertile period are very much
common even amongst the liberate couples.
 Apareunia and dyspareunia
 Anxiety and apprehension.
 Use of lubricants during intercourse.
 Immunological factors.
INVESTIGATIONS OF INFERTILITY:
Objectives of investigation:
 To discover any aetiological factor.
 To rectify the abnormality in an attempt to

improve the fertility

 To give assurance with explanation to the

couple if no abnormality is detected.

 MALE
History:
 Age, duration of marriage, history of previous

marriage and proven fertility if any are to be

noted. A general medical history including
sexually transmitted diseases, mumps orchitis
after puberty, diabetes, recurrent chest
infection or bronchiectasis.Relevant surgery
such as herniorrhaphy, operation on testes or
other surgery in the genital area are to be
enquired.
 EXAMINATION:

Examination of the reproductive

system includes inspection and
palpation of the genitalia,size and
constituency of the testicles.Testicular
volume should beat least 20 cm3.
Presence of varicocele should be
elicited in the upright position.
INVESTIGATIONS
Rutine investigations include urine and blood
examination including post prandial sugar.
SEMINAL FLUID ANALYSIS:
 Collection

The collection is best done by masturbation

failing which by coitus intruptus. The semen is
collected in a clean wide mouthed dry glass jar.
The sample so collected should be send to the
laborotry as early as possible. The coitus should
be avoided for two to three days prior to the
test.
NORMAL VALUES

 Volume-2mL or more
 PH 7.2 to 7.8
 Sperm concentration -20 million /mL or more
 Total Sperm count ≥ 40 million per ejaculate
 Motility – 50% or more progressive forward motility
 Morphology-30% or more normal form
 Vitality- 75% ore more living
 Leucocytes – Less than 1 million per ml
 Total fructose - >13µ mol per ejaculate
Testicular biopsy- is done to differentiate
primary testicular failure from obstruction as
a cause of azoospermia or severe
oligospermia. The biopsy material is to be
send in Bouin’s solution and not in formol
saline.
 Transrectal Ultarsound (TRUS)-is done to
visualize the seminal vesicles, prostate and
ejaculatory duct obstruction. Indications of
TRUS are:
Azoospermia or severe oligospermia with a
normal testicular volume.
Abnormal digital rectal examination.
Ejaculatory duct abnormality
Genital abnormality (Hypospadias)
 Vasogram is a radiographic study done to
evaluate the ejaculatory duct obstruction. It is
mostly replaced by TRUS.
 Karyotype analysis- this is to be done in

cases with azoospermia or severe

oligospermia and raised FSH. Klinefelter’s
Syndrome (XXY) is the commonest.
 Immunological tests- Two types of antibodies

have been described- Sperm agglutinating

and sperm immobilizing.
FEMALE
HISTORY:
 Age , Duration of marriage, history of previous

marriage with proven fertility if any are to be

noted.
 A general medical history
 Should be taken with special reference to

tuberculosis, sexually transmitted disease, features

suggestive of pelvic inflammation or diabetes.
 The surgical history should be directed specially

towards abdominal or pelvic surgery.

 Menstrual history should be taken in details.
 Previous c\obstetric history- including
number of pregnancies, the interval between
them and pregnancy related complications
are to be enquired.
 Contraceptive practice should be elicited.
 Sexual problems such as dyspareunia, and

loss of libido are to be enquired.

 EXAMINATIONS
 General systemic and gynecological

examinations.
 General examination must be thorough special

emphasis being given to obesity or marked

reduction in weight. Underdevelopment of
secondary sex characters are to be noted.
Physical features pertaining to endocrinopathies
are carefully evaluated to detect features of
PCOD, hirsutism and inappropriate
galactorrhoea.
 Systemic examination may accidentally detect
such abnormalities like hypertension, organic
heart disease, chronic renal lesion,
endocrinopathies and alike.
 Gynecological examination
 Speculum examination may reveal abnormal

cervical discharge. This discharge is to be

collected for Gramstain and culture.
 OVARIAN FACTORS:
 Anovulation or oligoovulation
 Luteal phase defect
 Luteinised unreptured follicle
DIAGNOSIS OF OVULATION

 Indirect,Direct,Conclusive.
 INDIRECT:
 Menstrual history.
 Evaluation of peripheral or endorgan changes

BBT.
Cervical mucus study.
Vaginal cytology.
Hormone estimation.
Serum progesterone
Serum LH
Serum estradiol
Endometrial biopsy.
Sonography.
 Direct:
Laproscopy
Conclusive:
Pregnancy.
 MENSTRUAL HISTORY:
 Regular normal menstrual loss between the

age of 20-35.
 Midmenstrual bleeding(spotting) or pain or

excessive mucoid vaginal

discharge(mittelschmerz syndrome)
 Features suggestive of premenstrual

syndrome or primary dysmenorrhoea.

EVALUATION OF PERIPHERAL ENDORGAN CHANGES
Basal body temperature(BBT)
 There is biphasic pattern of temperature variation

in the ovulatory cycle.The rise of temperature is

secondary to progesterone output. The patient is
instructed to take her oral temperature daily on
waking in the morning before rising out of the
bed.
 The body temperature maintaining throughout

the first half of the cycle is raised to 0.5 to 1F

following ovulation.
 The rise sustains through out the second half
of the cycle and falls about two days prior to
the next period called biphasic pattern.
 There may be a drop in the temperature to

about0.5F before the rise and almost

coinsides with either LH surge or ovulation.
 The demonstrable rise actually occurs about

2 days after the LH peak and with a

peripheral level of progesterone to greater
than 4ng/ml.
CERVICAL MUCUS STUDY:
 Alteration of the physic- chemical properties

of the cervical mucus occurs due to the

effect of oestrogen and
progesterone.Disappearance of the fern
pattern beyond 22nd day of the cycle which
was present in the midcycle is suggestive of
ovulation.Persistance of fern pattern even
beyond 22nd day suggest anovulation.
 Vaginal cytology:
 Maturation index shifts to the left from the

midcycle to the mid second half of the cycle

due to the effect of progesterone.However a
single smear on day 25 or 26 of the cycle
reveals features of progesterone effect, if
ovulation occurs.
HORMONE ESTIMATION:
 Serum progesterone:

Estimation of serum progesterone is done on

the day 8 and 21 of a cycle.An increase in
value from less than 1 ng/ml to greater
than6ng/ml suggest ovulation.
 Serum LH:

Daily estimation of serum LH at midcycle can

detect the LH surge.
 Serum oestrdiol attains the peak rise
approximately 24 hours prior to LH surge and
about 24-36 hours prior to ovulation.
 The serum LH and oestradiol estimation is

used for in vitro fertilization.

ENDOMETRIAL BIOPSY:
 Endometrial tissues to detect

ovulation(endometrial sampling) can easily be

obtained as an outpatient procedure using
instruments such as sharman curette or
pipelle endometrial sampler.
SONOGRAPHY:
 Serial sonography during midcycle can

precisely measure the graafian follicle just

prior to ovulation.It is particularly helpful for
confirmation of ovulation following ovulation
induction, artificial insemination and invitro
fertilization.
DIRECT:
 LAPROSCOPY:

Laproscopic visualization of recent corpus

luteum or detection of the ovum from the
aspirated peritoneal fluid from the pouch of
douglas is the only direct evidence of
ovulation.
CONCLUSIVE:
 Pregnancy is the surest evidence of ovulation.

Luteal phase defect(LPD):

Diagnosis is based on the following:
 BBT chart: slow rise of temperature taking 4-

5 days following the fall in the mid cycle, Rise

of temperature sustains less than 10 days.
 Endometrial biosy: Biopsy done on 25-27th
day of the period reveals the endometrium at
least 2 days out of phase. This lag phase
endometrium must be proved in more than
one cycle.
 Serum progesterone estimated on 8th day

following ovulation is less than 10ng/ml.

LUTEINISED UNREPTURED FOLLICLE:
 Luteinised unreptured follicle(LUF) Syndrome

refers to an infertile women with regular

mensus and presumptive evidence of
ovulation without release of the ovum from
the follicle(trapped ovm).The features of
ovulation- formationof corpus and its stigma
are absent. It is often associated with pelvic
endometriosis.
Diagnosis
In the presence of biological effects of
progesterone in the early luteal phase:
 Sonography – Persistence of echofree dominant

follicle beyond 36 hours after LH peak.

 Laproscopy – Failure to observe a stigma of

ovulation
 Ovarian biopsy – Conclusive proof is

determination of ovum amidst the structure of

corpus luteum.
TUBAL FACTORS
The anatomical patency and functional integrity
of the tubes are assessed by the following
tests.
 Dilatation and insufflations test (D I)
 Hysterosalpingography (HSG)
 Laproscopy and Cromopertubation
 Sonohysterosalpingography
 Falloposcopy
 Salpingoscopy
Insufflation test (Rubin’s test)
 Principle: the underlying principle lies with

the fact that the cervical canal is in continuity

with the peritoneal cavity through the tubes.
As such entry of air CO2 into the peritoneal
cavity when pushed transcervically under
preasure , gives evidence of tubal patency.
Observations- the patency of tube is confirmed
by
1. Fall in the pressure when raised beyond 120
mm Hg .
2. Hissing sound heard on auscultation on
either iliac fosse .
3. Shoulder pain experienced by the patient.
Hysterosalpingography (HSG)
 Principle – the principle is same like that of

insufflations test. Instead of air or CO2 , dye

is instilled transcervically.
 Advantages-

It has got distinct advantages over insufflation

test. It can precisely detect the side and site
of the block in the tube.
Disadvantages-
It involves radiation risk.
LAPROSCOPY AND
CHROMOPERTUBATION:
The scope of diagnostic laproscopy in
the investigation of infertility has been
widended.As it is the most invasive
investigation, it should be the final
procedure performed in the basic
infertility work up.
Indications:
 Abnormal HSG findings.
 Failure to conceive after reasonable period(6

months) even with normal HSG.

 Unexplained infertility.
 Age >35 years.
Advantages over HSG.
 It can precisely diagnose peritubal adhesions,

pelvic endometriosis or evidences of

ovulation.Chemopertubation with methylene
blue cannot only reveal patency of the tube
but the nature of tubal motility.
Drawbacks:
 It is more invasive than HSG
 It cannot detect abnormality in the uterine

cavity or tubal lumen.

INDICATIONS OF LAPROSCOPY IN INFERTILITY:
DIAGNOSTIC:
 Age >35 years.
 Abnormal HSG.
 Failure to conceive after reasonable period(6

months) with normal HSG.

 Unexplained infertility.
OPERATIVE:
 GIFT and ZIFT procedures.
 Ovarian diathermy.
 Reconstructive tubal surgery.
 Fulguration of endometriotic implants.
 SONOHYSTEROSALPINGOGRAPHY:
Normal saline is pushed within the uterine
cavity with a pediatric foley catheter.The
catheter balloon is inflated at the level of the
cervix to prevent fluid leak.Ultrasonography
of the uterus and fallopian tubes are
done.Ultrasound can follow the fluid through
the tubes up to the peritoneal cavity and in
the pouch of Douglas.
ADVANTAGES:
 It is a non invasive procedure.
 It can detect uterine malformations,

synechiae or polyps
 Tubal pathology could be detected as that of

HSG.
 There is no radiation exposure.
 FALLOPOSCOPY:
 Is to study the entire length of tubal lumen

with the help of a fine and flexible fibreoptic

device. It is performed through the uterine
cavity, using a hysteroscope.
 SALPINGOSCOPY:
 Tubal lumen is studied introducing a rigid

endoscope through the fimbrial end of the

tube. It is performed through the operating
channel of a laparoscope.
 UTRINE FACTOR:
 Uterine factors commonly associated with

subfertility are submucous fibroids,

congenital malformations and intrauterine
adhesions(Asherman’s syndrome).They are
more likely to cause recurrent pregnancy loss
rather than primary infertility.
 Ultrasonography, HSG, hysteroscopy and

laproscopy are needed in the evaluation of

uterine factor for sub fertility.
CERVICAL FACTOR:
 The cervix functions as a biological valve.

This is in the sense that, in the proliferative

phase, it permits the entry of sperm and in
the secretary phase, hinders their
penetration. As such dysfunction in this level
should be carefully evaluated.
POST COITAL TEST-Marion Sims(1866) and Max
Huhner(1913):
PRINCIPLE: PCT is to assess the quality of cervical
mucus and the ability of sperm to survive in it.
Prerequisites:
 To avoid intercourse for 2 days.
 To avoid intra vaginal medication or douching

on the day preceding the test.

 The material should preferably be examined

within 8 to 12 hours of intercourse.

COLLECTION OF MATERIAL
 The patient should report to the clinic

preferably with in 8 to 12 hours following

intercourse.
 The cervix is exposed with a cusco’s

speculum. using a polyethylene catheter

attached to syringe , the endocervical mucus
is collected and placed over a warm glass
slide. A cover slip is placed over it and is
examined microscopically under high power.
INFERENCES:
 Presence of at least tem motile sperm per high

power field signifies the test to be normal.

 Absence of any sperm signifies either aspermia

or imperfect coital techniques and the test

should be repeated and examined with in 2 to 4
hours of intercourse (early PCT).
 presence of immotile sperms with a normal

sperm count in agood quality of cervical mucus

signifies presence of immunological
factors(sperm antibodies) .
SPERM CERVICAL MUCUS CONTACT
TEST(SCMCT)
A drop of cervical mucus and a drop of
husband’s semen are placed side by side over
a slide. A cover slip is placed over the drops-
so that the edges are made to touch each
other . after half an hour the slide is
examined under microscope. The penetration
of the sperm and its fate on entering the
mucus are observed.
 If more than 25% of the sperm are exhibiting
jerky or shaky moments, the presence of
antibodies is presumed. Cross testing is
necessary by using husband’s semen with
mucus from another fertile woman and fertile
donor’s sperm with wife’s mid cycle mucus to
assess the presence of antibodies in the
semen or the mucus.
UNEXPLAINED INFERTILITY
Is defined when no obvious cause for
infertility has been detected following all
standard investigations. These include semen
analysis, ovulation detection, tubal and
peritoneal factors , endocrinopathy and PCT.
Overall incidence is 10 to 15 per cent . with
expectant management about 60% of couples
with unexplained infertility will conceive with
in a period of three years. IVF and ET may be
an option for those who fail to respond.
CONCLUSION
A couple undergoing infertility treatments are
usually under stress due to a variety of
reasons. Proper emotional support and
guidance is required by the couple at this
stage. The nurse as a counselor should
provide anticipatory advice and guidance
about the normal range of expectations and
responses throughout the treatment.