INFERTILITY

RESHMI SIBY
DEFINITION
 Infertility is defined as a failure to conceive within one
or more years of regular unprotected coitus.

 Primary infertility denotes those patients who have never

conceived

 Secondary infertility indicates there has been a previous

viable pregnancy but failure to conceive subsequently.
 Fecundability is defined as a probability of achieving a
pregnancy within one menstrual cycle.

 Fecundity is the probability of achieving a live birth

within a single cycle

 Sterility is the inability to conceive because of a known

condition such as absence of uterus
 INCIDENCE

 FACTORS RESPONSIBLE FOR FERTILITY

I. Male factor
II. cervical factor

III. ovarian factor

IV. tubal factor

V. fertilization at the right site

VI. endometrium
CAUSES OF INFERTILITY
 Male 30-40%
 Female 40-55%
 Both 10%
 Unexplained 10%
CAUSES OF INFERILITY IN MALES
 Disturbances in spermatogenesis

 Obstruction in the seminiferous tubules, ducts or vessels

preventing movement of spermatozoa

 Qualitative or quantitative changes in the seminal fluid

preventing movement of sperm

 Development of auto immunity that immobilizes sperm

 Problems in ejaculation or deposition preventing

spermatozoa from being close enough to a woman’s
cervix to allow ready penetration and fertilization
DISTURBANCES IN SPERMATOGENESIS

 Congenital
 Thermal factors

 Infections

 General

 Endocrine

 Genetic

 Iatrogenic

 Immunologic
OBSTRUCTION
 Trauma
 Young’s syndrome

 Surgery

 BPH

 Autoimmune reaction

 Obesity

 Anomalies of penis
QUALITATIVE OR QUANTITATIVE
CHANGES
 Sperm abnormality

 Errors in seminal fluid

EJACULATORY PROBLEMS
 Erectile dysfunction

 Ejaculatory defect
FEMALE SUBFERTILITY FACTORS
 Tubal and peritoneal factors 25-35%
 Ovulatory factors 30-40%
 Endometriosis 1-10%

OR
 Anovulation

 Tubal transport problems

 Uterine problems

 Cervical problems

 Vaginal problems
OVULATORY FACTORS
 Anovulation
 Oligo ovulation

 Luteal phase defect

 Leuitinised unruptured follicular ovum (trapped ovum)

TUBAL FACTORS
 PID
1. Peritubal adhesions

2. Endosalphingeal damage

3. Stricture and scarring of fallopian tube

 Salphingitis isthmica nodasa

 Tubal endometriosis

 Polyps

 Mucus debris
UTERINE PROBLEMS

 Tumors
 Fibroids

 Uterine hypoplasia

 Endometriosis

 Uterine synechiae

 Congenital malformations of uterus

CERVICAL PROBLEMS
 Anatomic defects
 Congenital elongation of cervix

 Second degree uterine prolapse

 Acute retroverted uterus

 Pinhole os

 Polyps

 Physiologic defects
VAGINAL PROBLEMS
 Atresia vagina
 Transverse vaginal septum

 Septate vagina

 Narrow introitus

 vaginitis
COMBINED CAUSES
 General
 Infrequent coitus, lack of knowledge, timing

 Apareunia and dyspareunia

 Anxiety and apprehension

 Lubricants

 Immunologic factors
INVESTIGATIONS
HEALTH HISTORY FOR MALES
 General health
 Nutrition

 Illness

 Radiation exposure

 Surgeries

 Occupation and work habits

 Sexual practices

 Contraceptive devices

 Alternative therapy
FOR FEMALES
 Reproductive tract infections
 Overall health

 Endocrine problems

 Surgeries

 Douches or intra vaginal medications

 Occupational hazards

 Nutrition

 Ovulation
MENSTRUAL HISTORY
 Age of menarche
 Length, regularity and frequency

 Amount of flow

 Dysmenorrhea

 Contraceptive use

 Previous pregnancies or abortions

PHYSICAL ASSESSMENT FOR MALES
 General examination
 Inspection and palpation of the genitalia

 Secondary sexual characteristics

 Genital abnormalities
PHYSICAL ASSESSMENT IN FEMALES
 General
 Systemic

 Gynecologic examination

^ adequacy of hymen opening

^ vaginal infections
^length of cervix
^uterine size, position, mobility
^ presence of nodules in the pouch of Douglas
 Speculum examination
FERTILITY TESTS
 Basic fertility tests involves 3 tests:
semen analysis in males and
ovulation monitoring, tubal patency in females
INVESTIGATIONS DONE IN MALES
 Routine investigations
 Semen analysis

An average ejaculation should produce 2.5 ml to 5 ml of

semen and should contain a minimum of 20 million
spermatozoa per ml of fluid (average normal sperm count
is 50 to 200 million per ml)
In selected cases, biochemical teats of creatinine
phosphokinase and reactive oxygen species are done as
sperm function test.
NOMENCLATURE
 Aspermia- failure of emission of sperm
 Oligospermia- sperm count < 20 million/ml

 Polyzoospermia- count is more than 350 million/ml

 Azoospermia- no spermatozoan in the semen

 Asthenozoospermia- reduced sperm motility

 Leucocytospermia – increased white cells in semen

 Necrozoospermia- sperms are dead or motionless

 Teratozoospermia- >70% spermatozoa with abnormal

morphology
 Oligoasthenoteratozoospermia- disturbance of all 3
variables
IN DEPTH EVALUATION
 Serum FSH, LH, testosterone, prolactin and TSH
 Fructose content in seminal fluid

 Testicular biopsy

 Trans rectal ultrasound

 Vasogram

 Karyotype analysis

 Immunologic tests

 Sperm penetration assay and anti sperm antibody testing

INVESTIGATIONS DONE IN FEMALES
 Ovulation monitoring
 Tubal patency assessments

 Additional tests include a rubella titre, serological test

for syphilis, HIV evaluation, TFT,TSH, FSH, Estrogen,
LH, progesterone levels, sr prolactin
 Pelvic USG
DIAGNOSIS OF OVULATION – INDIRECT
METHODS
 Menstrual history
 Evaluation of peripheral or end organ changes

1. basal body temperature

Cervical mucus study

Vaginal cytology
Hormone estimation

Endometrial biopsy
 Sonography
DIRECT METHOD
 Laparoscopy

 Conclusive - pregnancy
TUBAL PATENCY TESTS
 Dilatation and insufflation test(Rubin’s test)
HYSTEROSALPHINGOGRAPHY
 Laparoscopy and chemopertubation
SONOHYSTEROSALPHINGOGRAPHY
HYSTEROSCOPY
 Falloposcopy

 Salpingoscopy
OTHER TESTS IN FEMALES
 Cervical factor

1. Post coital test

2. Sperm cervical mucus contact test

 Immunological studies
TREATMENT FOR INFERTILITY
COUPLE INSTRUCTIONS
 Assurance

 Body weight

 Smoking and alcoholism to be avoided

 Coital problems
MALE INFERTILITY
INDICATIONS FOR TREATMENT
 Extreme oligospermia
 Azoospermia

 Low volume ejaculate

 Impotency
TREATMENT- MEDICAL
 General care
 Vitamins E, C, D, B12 and folic acid

 hCg

 hMg+ hCg

 Dopamine agonist

 Pulsatile GnRH therapy

 Clomiphene citrate

 Antisperm antibodies

 Antibiotics
 TREATMENT- SURGICAL
 Microsurgery
1. Vasoepididymostomy

2. Vasovasostomy
 Surgery for varicocele, hydrocele

 orchidopexy
IMPOTENCY

 psychosexual treatment

 Sildenafil
 Tadalafil
FEMALE INFERTILITY MANAGEMENT
OVULATORY DYSFUNCTION
 General
1. Psychotherapy

2. Reduction of weight
 Drugs

1. Clomipehene citrate

2. hMG

3. FSH

4. hCg

5. GnRH

6. GnRH analogues
 Hyperinsulinemia- metformin
 Androgen excess- dexamethasone

 Prolactin raised- bromocriptine

SURGERY
 Laparoscopic ovarian drilling or laser vaporisation-
multiple puncture of cysts in PCOD by diathermy or
laser

 Wedge resection of ovaries

 Surgery for pituitary prolactinomas

 Surgical removal of virilising or other functioning

ovarian or adrenal tumor
TUBAL FACTORS
 Peritubal adhesions by salphingo ovariolysis by
laparoscopy or laparotomy

 Proximal tubal block by

1. salphingography under fluroscopy
2. Cannulation and balloon tuboplasty
 Distal tubal block by
1. Fimbrioplasty- release of fimbrial adhesions and
dilatation of fimbrial phimosis

2. Neosalphingostomy- to create a new tubal opening in

an occluded tube
 Mid tubal block – reversal of tubal ligation
Neosalphingostomy reversal of tubal ligation
Cervical factor
 Conjugated estrogen 1.25 mg orally daily

Immunological factor
 Dexamethasone 0.5 mg HS
UTEROVAGINAL SURGERY
 Myomectomy
 Metroplasty

 Adhesiolysis

 Enlargement of vaginal introitus (Fentons operation)

 Amputation of cervix
THERAPEUTIC INSEMINATION/
ARTIFICIAL INSEMINATION
 IUI may be
1. AIH (artificial insemination husband)
2. AID (artificial insemination donor)

 The purpose of IUI is to bypass the endocervical canal

which is abnormal and to place increased concentration
of motile sperm as close to fallopian tube
INDICATIONS
 Hostile cervical mucus
 Cervical stenosis

 Oligospermia or asthenospermia

 Immune factor

 Male factors- impotency or anatomical defects

 Unexplained infertility
TECHNIQUE
 Washing centrifuging and swim up methods are
commonly used
 About 0.3ml of washed and centrifuged concentrated
sperm is injected through a flexible catheter within the
uterine cavity around the time of ovulation

 Timing
 Ovarian hyperstimulation
ARTIFICIAL INSEMINATION DONOR
 Here semen of the donor is used

Indications
 Untreatable azoospermia, asthenospermia

 Genetic disease

 For woman with Rh sensitisation

Requirements
 Donor

 Specimen
ASSISTED REPRODUCTIVE TECHNIQUES
 IVF ET – In vitro fetilization and embryo transfer
 GIFT - gamate intrafallopian transfer

 ZIFT - zygote intrafallopian transfer

 POST - peritoneal oocyte and sperm transfer

 ICSI - intracytoplasmic sperm injection

 SUZI - subzonal insemination
METHODS OF SPERM RECOVERY
 TESE- testicular sperm extraction
 MESA-microsurgical epididymal sperm aspiration

 PESA-percutaneous epididymal sperm aspiration

PRINCIPLE STEPS IN ART CYCLE
 Down regualtion using GnRH agonist
 Controlled ovarian hyperstimulation (COH)

 Monitoring of follicular growth

 Oocyte retrieval

 Fertilisation in vitro(IVF, ICSI,GIFT)

 Transfer of gamates or embryos

 Luteal support with progesterone

IN VITRO FERTILIZATION
 One or mature oocytes are removed from woman’s ovary
by laparoscopy and fertilized by exposure to sperm
under laboratory conditions outside a woman’s body.

 About 40 hrs after fertilization the laboratory grown

fertilized ova are inserted into a woman’s uterus, where
ideally one or more of them will implant and grow
INDICATIONS
 Tubal disease
 Unexplained infertility

 Endometriosis

 Male factor infertility

 Cervical hostility

 Failed ovulation induction

 Ovarian failure( donor oocyte IVF)

 Women with genetic disease

 Pre procedure
 Procedure

 Post procedure

 Selective termination
GAMATE INTRA FALLOPIAN TRANSFER
 Both the sperm and the unfertilized oocytes are
transferred into the fallopian tubes
 In vivo

 Pre requisites

 Procedure
ZYGOTE INTRAFALLOPIAN TRANSFER
Involves oocyte retrieval by
transvaginal, USG guided aspiration
followed by culture and insemination
of oocytes in the laboratory

 Within 24 hrs the fertilized eggs are transferredinto the

end of waiting fallopian tube
 Difference between GIFT and ZIFT
MICROMANIPUALTION - ICSI
Indications
 Severe oligospermia

 Asthenospermia, teratospermia

 Presence of sperm antibodies

 Obstruction of efferent duct system

 Failure of fertilisation in IVF

 Fertilisation of cryopreserved oocytes( with hardened

zona pellucida
 Unexplained infertility
ICSI
SURROGATE EMBRYO
TRANSFER/OOCYTE DONATION
PRE IMPLANTATION GENETIC
DIAGNOSIS
HEALTH HAZARDS OF ART
 Increased risk of fetal congenital malformations or birth
defects
 Increased pregnancy loss, multiple pregnancy, ectopic
pregnancy, ectopic pregnancy
 Perinatal mortality and morbidity

 Ovarian hyperstimulation syndrome

 Psychological stress and anxiety of the couple

ALTERNATIVES TO CHILD BIRTH
 Surrogate mother
 Adoption

 Child birth living

ROLE OF NURSE
 Fear related to possible outcome of subfertility studies
 Situational low self esteem related to apparent inability to
conceive
 Anxiety related to what the process of fertility testing will
entail
 Deficient knowledge related to measures to promote fertility

 Anticipatory grieving related to failure to conceive or

sustain pregnancy
 Powerlessness related to repeated unsuccessful attempts at
achieving conception
 Hopelessness related to perception of no viable alternatives
to usual conception