Infertility

Chapter 31
 Definition
• Strictly defined as the inability to
conceive after one year of unprotected
regular sexual intercourse
• More workable definition: is any
involuntary inability to conceive at
the time desired
• The definition expanded to
include couples who
conceive but repeatedly lose
a pregnancy before the fetus
is old enough to survive
 Definitions
• Primary infertility
• Couples have never conceived
• Secondary infertility
• Couple may have conceived before
but are unable to conceive again
 Factors contributing to
Infertility
• Factors in man
• 1. Abnormalities of the sperm;
• Twenty million sperm /milliliter of
semen is considered minimum number
adequate for fertilization
• Abnormal structure or motility may
reduce motility regardless of number
• Some sperm look normal but unable to
penetrate ovum
Factors impair function and # of
sperm include

• Abnormal hormonal stimulation of sperm

production
• Acute or chronic illness such as mumps,RF
• Infection of genital tract
• Anatomic abnormalities e.g. Varicocele or
obstruction of ducts that carry sperm to
penis
• Exposure to toxins(lead, pesticides)
• Therapeutic treatment
(radiation ,antineoplastic)
• Excessive alcohol intake
• Use of illicit drug such as cocaine
• Elevated scrotal temperature that may
result for example from febrile illness,
sauna , hot tub or prolonged sitting
• Immunologic Factors by man or
woman against sperm (autoantibodies)
 Abnormal Erections .2
• Reduce man ability to deposit
sperm,bearing seminal fluid in
woman’s upper vagina near her cervix
• Can be caused by physical and
psychologic factors for example: CNS
dysfunction caused by drugs,
psychiatric disturbance or chronic
illness.spinal cord disorders, peripheral
vascular disease and drugs such as
antihypertensive also reduce erections
 Abnormal Ejaculation .3
• Prevent deposition of sperm in the
ideal place to achieve pregnancy
• Retrograde ejaculation such as
with DM or nuerologic disorders
Anatomic abnormalities such as
hypospadias,
Excessive alcohol
• Premature ejaculation related to
biological or psychologic disorders
(Anxiety)
 Abnormalities of Seminal .4
Fluids
• Seminal fluid that is abnormal in amount (With each
ejaculation during intercourse about 35-200 million sperm are deposited in
upper vagina and over cervix), consistency or chemical
composition suggest obstruction, inflammation or
infection
• The PH of seminal fluids is slightly alkaline to protect
sperm from acidic secretion of vagina
• Adequate frouctose,citric acid and other nutrients
must be present to provide energy for the sperm to
move
• Seminal fluid that remain thick impede sperm motility
into cervix
 Factors in the woman
• 1. Disorders of ovulation
• Ovulation can be disrupted by
1. Dysfunction of hypothalamus or pituitary
gland that alter secretion of GNRH,FSH,LH
2. Failure of ovaries to respond to FSH and
LH stimulation
• These two factors can be caused by many
factors such as cranial tumors ,stress ,
obesity..etc
• A few woman has a premature ovarian
failure (early menopause)
• Polycystic ovary Syndrome also
affect fertility
• Other factors include: Cancer
chemptherapeutic agents,
Excessive alcohol intake and
cigarette smoking
Abnormalities of fallopian tube.2
1. Tubal obstruction: scaring, adhesions,
result from infection such as STD
2. Endometriosis
3. Congenital anomalies of the tube
4. Poor movement (motility of the distal end of
the tube prevent ovum pickup and abnormal
cilia actions prevent ovum transport)
 Abnormalities of Cervix .3
• Low estrogen level prevent
development of appropriate
cervical mucus
• Polyps or scaring from previous
surgery may obstruct cervix
• Surgical destruction of the mucus
secreting gland and infection
 Repeated pregnancy loss

• 1. Abnormalities of fetal chromosome

• 2. abnormalities of cervix or uterus
may include
-Congenital malformation and stenosis
-Prenatelly exposure to DES: lead to uterine
malformation or incopmetent cervix)
-
 Cervical or uterine abnormalities
occurs after surgery
-Uterine myomas or fibroid (may
lead preterm birth)
• 3. Endocrine abnormalities
-inadequate progesterone secretion
by corpus luteum
-hypothyroidism and hyperthyroidism
-poorly controlled diabetes
• 4. Immunologic factors
-rejection embryo
-SLE related to thrombosis
• 5. Environmental agent
-Ionizing radiation,alcohol
-suspected toxins such as
smoking ,mercury, lead, anesthetic
gas, pesticides…..etc
• 6. Infections
 Evaluation of Infertility
• Preconception Counseling
• Couples may be offered a
preconception counseling to help them
evaluate their risk of birth defects and
reduce their risk of bearing child with
serious birth defect
• History and Physical Examination
• General health history and extensive
reproductive history which includes
 Reproductive History
• Woman's age at menarche and menstrual
characteristics
• Pattern of intercourse in relation to
woman’s menstrual cycle
• Contraceptive history
• Previous pregnancies and their
outcomes
• Previous surgeries ,infection and serious
illness or injuries
• Previous fertility of the man or the
woman with other partner
 .Reproductive history cont
• Length of time the couples has had
unprotected intercourse
• Exposure to potential toxins
• Family history of multiple pregnancy
losses ,birth defects ,mental retardation
• Any home tests the couples has
used ,such as ovulation predictor kits
or BBT
 Physical Examinations
• Thorough physical examination of each
partner may identify problems such as
endocrine disorders ,infection or other
chronic disease
• Specific examination of reproductive
organs may reveal structural
defects ,infection ,or other conditions
• Chromosomal analysis may be done for
couple experiencing repeated pregnancy
loss
 Diagnostic Tests
• Tests generally proceeds from simple to
complex, and test is individualized
according to each couple condition
• Example of some tests done:
• 1.Basal body temperature
2.Hormoneevaluation(estrogene,progest
rone,LH,Fsh, and thyroid functions)
• 3.Ultra sound,
Hystrosalpingograghy,endometrial
biobsy,semen analysis,testicular biopsy
hysteroscopy
hysterosalpingogram
 Therapies to Facilitate
Pregnancy
• Many Factors must be considered when
identify therapy for treatment include
couple’s history ,medical conditions,
financial resources, age and time
constrains,a and religious and cultural
values
• 1. Medications
• May be used for example to improve semen
quality, reduce endometriosis, induce
ovulation…..etc
 2. Ovulation induction
• Used for woman who does not ovulate or who
ovulate erratically
• Also given to provide multiple ova if a woman
plans to have intrauterine
insemination,IVF,GIFT…
• Clomide (Clomiphene citrate) is drug often
used to stimulate follicles development
• Complications
• -Increase risk of multiple births (triplets or
more)
• -Ovarian hyperstimulating Syndrome
syndrome(marked ovarian enlargement)
 3. Surgical procedures
• Endoscopic procedures may be used to
correct obstructions
• Laparotomy may be needed to relieve pelvic
adhesions and obstructions if not corrected
by laparoscopy
• Laser surgical techniques may be used to
reduce adhesions
• Correction of Varicocele by ligating or
embolizing dilated vein, may improve sperm
quality and quantity
• Other measures may also used
 Therapeutic Insemination .5
• Intrauterine inseminations (IUI),
allows sperm to bypass cervical
mucus and reduce immunologic
incompatibility by injecting
prepared sperm directly into uterus
• Surrogate parenting and Egg
donation( religiously not
acceptable in our countries)
 Advanced Reproductive .5
Techniques
• 1. Invitro Fertilization(IVF)
• 2. GIFT: Gamete Intrafallopian
Tube Transfer
• 3. Zygote Intrafallopian tube
transfer
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 GIFT: Gamete Intrafallopian Tube Transfer

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