InfertilityInfertility

By as. Stelmakh O.

ObjectivesObjectives

• Define primary and secondary infertility

• Describe the causes of infertility

• Diagnosis and management of infertility

Infertility - StatisticsInfertility - Statistics

• causes are identified in 90 % of patients• pregnancy results in 40 % of those• 30 % of couples have male AND female factors• Of 100 subfertile couples the break down is as

follows:• 40 % male factor etiology• 20 % female hormonal imbalance• 30 % female peritoneal factor• 5 % ‘hostile’ cervical environment• 5 % unexplained• psychological impact can be significant

InfertilityInfertility• Primary infertility

– a couple that has never conceived

• Secondary infertility– infertility that occurs after previous pregnancy regardless of

outcome

Causes for infertilityCauses for infertility• Male

– Drugs

– Tobacco

– Health problems

– Radiation/Chemotherapy

– Age

– Enviromental factors

• Pesticides

• Lead

• Female– Age – Stress– Poor diet– Athletic training– Over/underweight– Tobacco

– STD’s– Health problems

Causes of InfertilityCauses of Infertility• Anovulation (10-20%)• Anatomic defects of the

female genital tract (30%)• Abnormal spermatogenesis

(40%)• Unexplained (10%-20%)

Evaluation of the Infertile Evaluation of the Infertile couplecouple

• History and Physical exam• Semen analysis• Thyroid and prolactin evaluation• Determination of ovulation

– Basal body temperature record– Serum progesterone– Ovarian reserve testing

• Hysterosalpingogram

Abnormalities of Abnormalities of SpermatogenesisSpermatogenesis

NormalNormal

• Sperm made in seminiferous

tubules• Travel to

epididymis to

mature

• Sperm exit through vas deferens

• Semen produced in prostate gland, seminal glands, cowpers glands

• Sperm only 5% of ejaculation

• Sperm can live 5-7 days

NormalNormal

Semen Analysis (SA)Semen Analysis (SA)

• Obtained by masturbation• Provides immediate information

– Quantity– Quality– Density of the sperm– Morphology– Motility

• Abstain from coitus 2 to 3 days • Collect all the ejaculate• Analyze within 1 hour• A normal semen analysis excludes male factor

90% of the time

Normal Values for SANormal Values for SA

Volume

Sperm Concentration

Motility

Viscosity

Morphology

pH

WBC

– 2.0 ml or more– 20 million/ml or more– 50% forward progression

25% rapid progression– Liquification in 30-60 min– 30% or more normal forms– 7.2-7.8– Fewer than 1 million/ml

Causes for male infertilityCauses for male infertility

• 42% varicocele– repair if there is a low count or decreased

motility

• 22% idiopathic

• 14% obstruction

• 20% other (genetic

abnormalities)

Abnormal Semen AnalysisAbnormal Semen Analysis

• Azoospermia– Klinefelter’s (1 in 500)– Hypogonadotropic-

hypogonadism– Ductal obstruction

(absence of the Vas deferens)

• Oligospermia– Anatomic defects– Endocrinopathies– Genetic factors– Exogenous (e.g. heat)

• Abnormal volume– Retrograde ejaculation– Infection– Ejaculatory failure

Evaluation of OvulationEvaluation of Ovulation

Female Reproductive SystemFemale Reproductive System

• Ovaries– Two organs that

produce eggs– Size of almond– 30,000-40,000 eggs– Eggs can live for

12-24 hours

MenstruationMenstruation• Ovulation occurs 13-14 times per year• Menstrual cycles on average are Q 28 days with

ovulation around day 14• Luteal phase

– dominated by the secretion of progesterone– released by the corpus luteum

• Progesterone causes– Thickening of the endocervical mucus– Increases the basal body temperature (0.6° F)

• Involution of the corpus luteum causes a fall in progesterone and the onset of menses

Menstrual cycleMenstrual cycle

Serum ProgesteroneSerum Progesterone

• Progesterone starts rising with the LH surge– drawn between day 21-24

• Mid-luteal phase– >10 ng/ml suggests ovulation

Salivary Estrogen: Salivary Estrogen: Ovulation Tester- 92% Ovulation Tester- 92%

accurateaccurate

Add Saliva SampleAdd Saliva Sample

Non-Ovulatory Saliva Non-Ovulatory Saliva PatternPattern

High Estrogen/ Ovulatory High Estrogen/ Ovulatory Saliva PatternSaliva Pattern

AnovulationAnovulation

Anovulation Symptoms Anovulation Symptoms Evaluation Evaluation**

• Irregular menstrual cycles

• Amenorrhea

• Hirsuitism

• Acne

• Galactorrhea

• Increased vaginal secretions

• Follicle stimulating hormone

• Lutenizing hormone

• Thyroid stimulating hormone

• Prolactin

• Androstenedione

• Total testosterone

*Order the appropriate tests based on the clinical indications

FertilizationFertilization

ImplantationImplantation

Anatomic Disorders of the Anatomic Disorders of the Female Genital TractFemale Genital Tract

Congenital Anatomic AbnormalitiesCongenital Anatomic Abnormalities

HysterosalpingogramHysterosalpingogram

• An X-ray that evaluates the internal female genital tract– architecture and

integrity of the system

• Performed between the 7th and 11th day of the cycle

• Diagnostic accuracy of 70%

HysterosalpingogramHysterosalpingogram

• The endometrial cavity– Smooth– Symmetrical

• Fallopian tubes– Proximal 2/3 slender– Ampulla is dilated

• Dye should spill promptly

HSG: Tubal InfertilityHSG: Tubal Infertility

Some women have trouble getting pregnant because scar tissue prevents Some women have trouble getting pregnant because scar tissue prevents eggs from traveling down the fallopian tubes. This scarring can be caused by eggs from traveling down the fallopian tubes. This scarring can be caused by

endometriosis, the overgrowth of tissue that lines the uterus, a history of endometriosis, the overgrowth of tissue that lines the uterus, a history of

pelvic infections, or previous surgeriespelvic infections, or previous surgeries

Treatment of the Infertile Treatment of the Infertile CoupleCouple

Inadequate Inadequate SpermatogenesisSpermatogenesis

• Laparoscopy surgery• Eliminate alterations of thermoregulation• Clomiphene citrate is occasionally used for

induction of spermatogenesis– 20% success

• In vitro fertilization may facilitate fertilization• Artificial insemination with donor sperm is

often successful

Intrauterine insemination Intrauterine insemination (artificial insemination)(artificial insemination)

Artificial InseminationArtificial Insemination

• Sperm donation or sperm aspiration

In Vitro FertilizationIn Vitro Fertilization

IVF ProtocolIVF Protocol

• GnRH agonist (e.g. Lupron) for 7 days• FSH agonist (follistim, Gonal-F,

Repronex) until follicles measure 17-20 mm in diameter

• hCG given to induce egg maturation• Egg retrieval (transvaginally) 34-35 h

later

IVF Protocol, cont’d.IVF Protocol, cont’d.

• 3 to 5 embryos are injected to increase chances of pregnancy

• woman given progestagen to prevent miscarriage

Surrogate motherSurrogate mother

– Woman unable to have children may have IVF in another woman who has the child

IVF With Donor EggsIVF With Donor EggsWomen who are over 40, have poor egg quality, or have not had Women who are over 40, have poor egg quality, or have not had

success with previous IVF cycles may consider IVF with donor success with previous IVF cycles may consider IVF with donor eggseggs

Primary Diagnosis of Women Undergoing ART- 1998

26%

27%

12% 15%

9%

2%

9%

Tubal factorMale factorOvulation dysfxnEndometriosisUnexplainedUterine factorOther

ConclusionConclusion• Infertility should be evaluated after one

year of unprotected intercourse.

• History and Physical examination usually will help to identify the etiology.

• If patients fail the initial therapies then the proper referral should be made to a reproductive specialist.