INFERTILITY

INTRODUCTION
Def: Involuntary failure to conceive within 12 months of
commencing regular unprotected intercourse. (Old definition within
24 months)
Primary Infertility: No previous pregnancy
Secondary Infertility: With previous pregnancy ( whatever the
outcome)

PHYSIOLOGY
Conception requires :
Oocyte, sperm, at optimal stage
Needs transportation
A receptive place for implantation
Intact Male and Female reproductive systems

Incidence:
10-15% of married couples
About 75% of couples conceive by 12 months,

About 85% of couples conceive by 24 months.

POSSIBLE CAUSES OF INFERTILITY

FEMALE
MALE
Ovulatory failure factor: (anovulation)
Coital factor: (psychological or
High centres - hypothalamic-pituitary axis
organic)
Thyroid
Spermatogenesis problem:
Adrenal
Azospermia, oligospermia
Ovarian - PCO(20%), premature failure( >30IU/L)
Ductus problem: Azospermia due
Genetic & Chromosomal
to obstruction (infection)
Tubal factor: PID,T.B
Uterine factor: Ashermans, congenital anomaly.
Cervical factor: infection, immunological
Endometriosis:
Coital factor: aparunia, dysparunia, vaginismus
Psychosomatic: ? Neurohormones

IDIOPATHIC
About 15-30% of Infertility. It
is a definition by exclusion,
and that depends on the
standard investigations
used.
(Ovulatory, Tubal, Male)

INFERTILITY WORK UP
HISTORY
EXAM
Male: Age, history of mumps, occupation, drugs, chemical,
Male: exam.vas deference -size of testicles ,
irradiation, hernia operations, varicocele
varicocele, endocrine stigmata
Female: Age, menstrual cycle (regularity) - previous pregnancies,
Female: B.P - Thyroid - galactorrhoea
Abortions and TOP, galactorrhoea - 1/2 - contraceptions ,
hirsutism. Abdominal and pelvic exam
Hirsutism.
genitalia (External & Internal)
Both: Coital history:- S.T.D - past med & surgical hx, smoking and
taking drugs
SPECIAL INVESTIGATIONS
OVULATION
CERVICAL FACTOR
TUBAL & UTERINE
MALE FACTOR
OTHERS
FACTORS
1. B.B.T.chart:
- Cx score (amount,
(CILIA, FERTILIZATION,
Semen analysis: by
CBC
Biphasic an increase
spinnbarkeit, ferning, os)
TRANSPORT)
coitus interruptus or
Urine analysis
of 0.5C, progesterone
- Cervical mucus alteration: - Tubal insufflation
masturbation after
S.T.D
effect
thin-clear-wateryelastic
(Rubins test) obsolete
abstinence of 3-5 days Chlamydia
2. Cx mucus
(subjective)
nowadays
delivered within 2 hours
Rubella titer
alteration:
- Elasticity (spinnbarkeit)
- Hysterosalpingogram:
to lab.
TFT
Mittelschmerz pain
- Fernning (arborization or
using radioopaque water
Skull x ray
3. Hormonal assay:
crystallization) of NaCl due
soluble, no G.A
Normal values: by WHO
CT Scan
S. progesterone d21
to unopposed action of
- Laparascopy +
criteria
X ray chest.
(20-30nmol/L),
estrogen
Methylene blue dye test: Volume: >2ml S. prolactin
- P.C.T:(post coital test):
under G.A, checks for
liquification in 20- 30
<20ng/ml
positive if: more than 5-10
endometriosis and D&C
minutes
S. FSH and LH first
sperm in (H.P.F) alive
in the same sitting
Density: >20-250 Mil/ml
days of period
forward progressive motility (when done in luteal
Motility: > 50% forward
4. Endometrial biopsy after 6-12 hours of sexual
phase)
motility within 2 h.
-d 21- secretory
intercourse at time of
- Hysteroscopy - in
Morpho: > 30% normal
endometrium. i.e.T.B
ovulation. Repeat 3 times if Ashemanns synd.
forms
5. U.S.S - monitoring
Negative (wrong timing,
congenital anomaly to
of follicles 18-22 mm,
cervical hostility due ?
visualize the uterine
Seminal fluid 90% of
d12=12mm
antibodies, severe oligo or
cavity (using CO2 or
ejaculate: 2\3 from
6. Laparascopy azospermia)
glyceine solution)
seminal vesicles
laparatomy - Cross hostility test
- Hy-co-sy
(fructose), 1\3 from

incidental findings
7. LH peak (LH home
kits): 26h later
ovulation occur
8. Pregnancy

(Kremer test) if P.C.T is

(hysterosalpingoprostate (zinc & acid ph.)
negative
contrast-sonagraphy)
In azospermia +
- Antisperm antibody titre using Echovist
oligospermia: hormonal
and MAR ( mixed
FSH,LH, prolactin &
agglutination reaction)
karyotyping
INFERTILITY MANAGEMENT
INDUCTION OF OVULATION
TUBAL FACTORS
CERVICAL FACTOR
A] Fertility agents:
Selective
improve cervical score: Treat
Oral agents: 90% induce ovulation, but 60% pregnancy
Hysterosalpingogra
infection, Cryocautery,
-In cases of hyperprolactinaemia :
m
Estrogen
Bromocriptine (ergot alkaloids, dopamine agonist)
Surgery:
immunological - ?
Lisuride 1x1
microsurgery: after
corticosteroids for the male
Cabergoline(Dostinex) 1mg weekly
falloposcopy:
during the luteal phase of
-Clomiphene citrate (clomid): 50mg _ 200mg _ (d2 - d6), for 6 Salpingolysis,
female ,Male use of condom
cycles. It is oral cyclical, synthetic, nonsteroidal, weak
for 6 months
salpingostomy,
estrogen with antiestrogenic activity
excision &
SIUI and SIVF
-Tamoxifen : 10-40mg (d2 - d6) for 6 cycles, in PCO
reanastom. (success
-Cyclofenil : 200mgb.d for 10 days
from 10-40%)
In PCOS :metformin (oral insulin sensitizers)

Uterine anomalies:
Side effects: ovarian cysts, twins 5%, hair loss, GIT, rarely
Myomectomy for
hyperstimulation syndrome (OHSS)
fibroids
Metroplasy in certain
Injectable agents
cases
Gonadotrophin therapy: urinary extracts, now recombinant
I.V.F program
- HMG: (FSH+LH) (Humegon-pergonal) injections 1-3
ENDOMETRIOSIS
MALE FACTOR

ampules daily or every other day till follicular maturation,

about 5-10 injections
- FSH: only (metrodin) in P.C.O
- H.C.G: (pregnyl,profasi) - 5000 - 10000 unit after
follicular maturation to release oocyte
- L.H.R.H-a: - ( Busserlin-Zoladex-superfact-Decapeptyl )
continuous (nasal or s.c. 4-6 times daily or depot IM) to
deplete endogenous FSH,LH
- L.H.R.H-a: - pulsatile infusion every 90 minutes, 15ug
- L.H.R.H.antagonist
Side effects: multiple pregnancy 25% - hyperstimulation
syndrome (if severe) -ascitis, large ovarian cysts,
hydrothorax, thromboembolic disease, multiorgan failure
B- Surgical: Ovarian drilling, wedge resection(obsolete)
Options of treatment: Oral fertility agents Injectables
SIUI,SIVF

Danazol, LHRH a
treatment (medical)
Conservative
surgery:
I.V.F. program

Treatment directed towards

cause.
Advice: stop smoking and
alcohol, avoid tight
underwear, take regular cold
baths, improvements in coital
practice.
Psychological therapy: for
sexual dysfunction
In severe oligospermia and
azoospermia, check for
karyotype (Klinefelters
syndrome, testicular atrophy)
hMG for hypothalamicpituitary failure.
Bromocriptine for
hyperprolactinemia.
Surgical treatment in
vasectomy reversal.
Varicocele ligation in
varicocele.
ART: SIUI,ICSI (by TESE or
MESA)

ARTIFICIAL INSEMINATION

Artificial insemination
(AI)
AIH: intravaginal,
intracervical and
pericervical,
intrauterine,
intraperitoneal
AIH(DI)
IUI and SIUI
The mostly used
nowadays: is SIUI
(stimulated
intrauterine
insemination:
- Proper selection of the
cases
- Controlled ovarian
stimulation
- Preparation of semen
- Timing of insemination

ASSISTED REPRODUCTION TECHNIQUES (ART)

IVF + ET (EMBRYO
VARIANTS OF IVF
TRANSFER)
Up to 35% could
o G.I.F.T: Gamete intra fallopian
transfer (indicated: unexplained
benefit from infertile
infertility, oligospermia,
couples
endometriosis. (C.I.tubal damage)
Candidates: Tubal
factor , endometriosis o Procedure: Laparascopy at ovulation retrieve oocycte mix with prepared
, oligospermia
semen - deposit both in tube
,unexplained infertility
o Z.I.F.T
It is expensive,
requires sophisticated o SUZI subzonal injection
lab. facilities, highly
o ICSI intracytoplasmic sperm injection
skilled medical,
o PESA percutaneous epididymal sperm
nursing, scientific and
aspiration
tech. personnel
o MESA
o TESE
OUTCOMES OF IVF PREGNANCIES
25% risk of miscarriage
2-5% risk of ectopics, heterotropic
pregnancy
25% risk of multiple pregnancy
Increase risk of prematurity, low birth
wt, Cs

RESULTS OF IVF

E.T (1) - 10% chance

of single pregnancy
E.T (3) - 25-30%
chance of single
pregnancy. 5% twins,
1%triplets
Efficiency: 25-35%
for each cycle - Take
home baby 15-20%
According to the
infertility factor and
the centre

RISKS OF IVF
Psychological trauma if
failed
(OHSS) ovarian
hyperstimulation
syndrome
Multiple pregnancy