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Fawaz EdrisMD, FRCSC, FACOG, RDMS, AAACS
Maternal Fetal Medicine
Reproductive Endocrinology & Infertility
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Background
Definition:y 1 yr unprotected coitus without conception
10-15% couples affected
Etiologyy Couples:
35% Tubal and pelvic pathology
35 % Male problems
15% Ovulatory dysfunction 10% Unexplained
5% unusual causes
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Background
Etiology
y Women:
40% Tubal and pelvic pathology
40% Ovulatory dysfunction 10% Unexplained Infertility
10% Unusual causes
Normal couple:
y 25-30% chance of pregnancy per ovulatory
cycle
Fertility decreases with age
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Infertility
Time of Exposure % Pregnant
3 months 60%6 months 70%
1 year 85%
18 months 90%
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Approach to Infertility
DDX
Hx
Px Tests/Inv
Dx
Rx
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Approach to Infertility
Production
Storage
Delivery
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Male Infertility
1. Production:
y Hypothalamus
yAnterior Pituitary
y Testes
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Hypothalamic-Pituitary-Gonadal Axis
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Male Infertility
1. Production
y Hypothalamus
Congenital abnormalities of hypothalamus
y e.g. Kallmans syndrome
Starvation, stress or severe illness
Tumors (craniopharyngioma, metastatic tumor)
Head injury
Inflammation (sarcoidosis) Infection (tuberculosis)
XRT
Drugs: marijuana
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Male Infertility
1. Production:y Pituitary
Endocrine: thyroid, prolactin
Tumors
Inflammation: sarcoidosis, meningitis
Infiltration
Infarction
Trauma/XRT
Drugs: anabolic steroids
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Male Infertility Production:y Testes:
Congenital: Klinefelters (XYY), developmental
disorders
Disorders of gonadal steroidgenesis
Infection: chlamydia, prostatitis, mumps orchitis
Autoimmune
Cryptorchidism
Tumors; chemo/XRT
Drugs / alcohol
Vascular: testicular torsion
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Male Infertility
2. Storage:
y Temperature
Rise in scrotal temperature
Occupation
Varicocoele
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Male Infertility
3. Delivery:y Impotence/Ejaculation
Neurogenic: medications (-blockers,methyldopa)
Endocrine: diabetes Congenital: absence vas deferens (CF)
Genetic: cystic fibrosis
Primary ciliary dyskinesia: Kartagener syndrome
Hypospadia Vasectomy
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Male Infertility
History:y Previous children
y Infections: prostatitis, STD, mumps orchitis
y Trauma to head or testiclesy Surgery to testicles or hernia
y Occupation (sitting, bio hazards, XRT)
y Chemo or Radio therapy
yEthanol or Smoking
y Medication
y Medical history (DM, HTN)
y Previous investigations
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Male Infertility
Physical
yAnatomy (meatus)
y Testicular size
y Varicocele (valsalva)
y Rectal exam (protatitis, discharge)
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Male Infertility
Investigations:
y semen analysis
Abstain 2-4 days prior
At least 2 samples over different period of
time
y If abnormal:
Blood work: FSH, LH, TSH, testosterone, PRL
Testicular U/S
Chromosomal analysis
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Male Infertility
Semen analysis:
y WHO (1992)
Volume > 2.0 mL
Sperm > 20 million/mL
Motility > 50% forward progression or
> 25% rapid progression within
60 min
Morphology > 30% normal forms
WBC < 1 million/mL
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Female Infertility
Fecundability: probability of achieving apregnancy within 1 menstrual cycle (25%)
Fecundity: ability to achieve a live birth within 1menstrual cycle (6%)
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Female Infertility
Production
Storage
Delivery
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Female Fertility
Production:
y Hypothalamus
y Pituitary
y Ovary
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Hypothalamic-Pituitary-Gonadal Axis
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Female Infertility
Hypothalamus:y Stress
y Exercise
y Eating disorders
y Psychogenic
y Congenital/genetic: Kallmans syndrome (hyposmia &
hypoplasia olfactory lobes of brain)
y Starvation/stress or severe illness
y Tumors (craniopharyngioma, metastatic tumor)
y Head injury
y Inflammation (sarcoidosis)
y Infection (tuberculosis)
y XRT
y Drugs
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Female Infertility
Pituitary:y Sheehan syndrome
y Tumors: Pituitary adenoma, metastatic
y Empty sella syndromey Inappropriate gonadal steroid feedback:
estrogen excess: obesity/ tumors
estrogen deficiency: aromatase deficiency/ ER genemutation
androgen excess: adrenal or ovarian PCOS
y Testicular feminization (46 XY) - absenceandrogen receptors
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Female Infertility
Ovary
y Gonadal dysgenesis - Turners Syndrome
45XO or mosaics 46 XX/45 XO
y Testicular feminization
y XRT / Chemo for childhood malignancies
y Premature ovarian failure
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Female Infertility
Storage (R.P.L. unless severe)
y Uterine abnormalities
y Mullerian Agenesis: Mayer-Rokitansky-
Kuster-Hauser syndrome
yAshermans syndrome
y Leiomyoma
yLuteal phase deficiency
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Female Infertility
Delivery:
y Uterine abnormalities
y Vaginal septum
y Tubal Disease
Infections/ STD/PID
Ruptured appendix
Septic abortiony Endometriosis
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Female Infertility
History:yAge
y GTPAL
y Regulatory of periody Prolactin S/S
y Thyroid S/S
y Infections, Surgeries
y Medication, Smoking, Ethanol
y Medical history
y Previous investigations
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Female Infertility
Examination:
y Thyroid
y Breast (milk)
yAbdomen (masses, scars)
y Vaginal (abnormalities)
y Bimanual (Uterus, masses)
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Investigations Blood work:y TSH
y PRL
y D3 FSH
y D3 LH
y Luteal phase Progesterone
Imaging:y
Pelvic Ultrasoundy HSG
Diagnostic
y Laparoscopy (later)
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Treatment
Treat the underlying cause
Medical
Surgical
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TreatmentAnovulation:y Clomiphene induction s IUI
y Gonadotropin s IUI
IVFy Bilateral tubal disease
y Unexplained infertility after Gonadotropin + IUI
failure.
y Failure of the above
ICSI
y Male factor
y
Unexplained infertility
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Take Home Points
DDx Hx Px Inv - Rx
Age is important factor for female
Hypothalamic-Pituitary-Gonadal axiscentral in working up both male and
female infertility
Investigations:
y Male: Sperms
y Female: Tubes (HSG) + Ovaries (FSH, LH,
PRL, TSH)
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Thank you
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