Contents

1. Introduction
1.1 POLICY GUIDLINES
1.2 GLOBAL SITUATION
1.2 SITUATION IN OMAN
1.3 REPRODUCTIVE HEALTH
1.4 GUIDELINES FOR DEALING WITH INFERTILE
COUPLES
1.5 COUNSELLING INFERTILE COUPLES
1.6 REFERRAL

2. UNDERSTANDING INFERTILITY
2.1 DEFINITION OF INFERTILITY
2.2 FACTORES AFFECTING INFERTILITY
2.3 CAUSES OF INFRTILITY – FEMALE
2.4 CAUSES OF INFRTILITY – MALE

3. MANAGEMENT OF FEMALE INFERTILITY

3.1 EVALUATION OF INFERTILE FEMALE
3.2 UNEXPLAINED INFERTILTIY
3.3 ASSISTED REPRODUCTIVE TECHNOLOGIES
(ART)

4. MANAGEMENT OF MALE INFERTILITY

4.1 EVALUATION OF INFERTILE MALE
 4.2 TREATMENR OF INFERTILE MALE
4.3 PREVENTION OF INFERTILITY

5. APPENDIX

INTRODUCTION:

POLICY GUIDELINES
Since children are an important part of the fulfilling family life of a
couple, and because Infertility causes unhappiness, mental stress
and social disadvantage to the couple, the Maternal and Child
Health & Birth Spacing (MCH &BS) Program of Oman, will like
to extend its services to address the needs of the infertile couples.
Hence, services for the diagnosis and management of infertility
will be provided all over the country as an essential and integral
component of (MCH & BS) Services.
The Ministry of Health through it’s net work of all health centers,
extended health centers and hospitals of all regions will provide
range of services for infertile couples.
THE SERVICES WILL TARGET
• Newly married couples over the age of 20 years that desire to
have a child but have failed after one year of regular unprotected
intercourse.
• Married couples with secondary infertility that failed to have a
child after two year of regular unprotected intercourse.
THESE SERVICES WILL INCLUDE
I. Counselling: Counseling will be done at all level of health care
systems by providers trained in counseling skill
II. Clinical services (clinical evaluation, investigation and
management): These services will be provided by trained service
providers. However provision of service will vary as per the
expertise and professional background of the service provider

III. Follow up:

SERVICES AT DIFFERENT LEVELS
• At Primary Health Care Facility
Staff of MCHIBS area will fill in the case history, findings of
clinical evaluation and preliminary investigation carried out, on the
specific proforma designed for the couple.
PHC service provider will inform the client on the results of
investigations, counsel the client and then refer the case to higher
health care facility for further evaluation and management.
• At Secondary Health Care level
Gynaecologists and dermatologists (and
rologists/endocrinologist/urologists if available) of the respective
Regional/other major health facilities will team up to deal with the
referred cases. Team will review the case records and available
investigations and develop a further management plan for the
couple.
Based on the need of the infertile couple a detailed work up will be
carried out by male clinician in dermatology/andrology clinic for
Male partner and similarly by the gynaecologist in gynaecology/
infertility clinic for female partner. If required, consultation may
also be done with endocrinologist/urologistisurgeon. All along
couple will be kept informed of findings of clinical evaluation,
investigations done and their results and management/procedure
planned.
• At Tertiary Health Care level
Referred case will be clincally re-evaluated, investgation previosly
done will be reviewed, and further indicated special tests will be
carried out. Information on the ART(assisted reproductive
techniques) will be given to the clients. Provision of IUI (intra
uterine insemination) with husband sperm will be done on the
clients who are willing to avail it. ART available outside MOH
will be availed by the client on her own expense.
GLOBAL SITUATION
Infertility is a problem that affects men and women everywhere in
the world. Although estimates of prevalence rates of infertility are
not that accurate, and vary among countries and different
populations within countries, world wide about 8% -12% of
couples experience some form of fertility problems during their
reproductive lives. 50 - 80 million of the populations globally have
problem with fertility.
Despite the fact that infertility affects both men and women, yet
women, particularly of developing countries, often bear the sole
blame for the barren marriage.
A WHO study on 9, 000 infertile couples from 33 clinics of 25
developed and developing countries between 1980 and 1986 found
that male were either the sole cause or contributory factor to
infertility in more than 50% of infertile couples.
General categories of infertility in developed & developing
countries
The table 1

Incidence of infertility may be influenced by:

• Inaccessibility to adequate health care for childbirth and
postpartum
• Prevalence of sexually transmitted infections and its management
• Environmental factors, affecting levels of disease transmission
• Occupations of men and women of reproductive age
• Exposure to chemical toxins
• Nutrition and genetically determined factors.
In most developing countries, the major preventable causes of
infertility are sexually transmitted infections and postpartum
infection, while in most developed countries, sexually transmitted
infections leading to pelvic inflammatory disease and consequently
resulting in tubal block and adhesions are the cause. Tubal block
alone contributes to 50% infertility in females. Similarly infection
of accesory gland in males contributes to 8 — 12% infertility.
Over the last few years, rapid strides have been taken in the field of
diagnosis and treatment of infertility. Various methods of Assisted
Reproductive Technologies (ART) like Intra-uterine Insemination
(IUI), Gamete Intra-Fallopian Transfer (GIFT), in Vitro
Fertilization & Embryo Transfer (IVF & ET), Intra-Cytoplasmic
Sperm Injection (IC SI) have greatly enhanced the chances of a
successful conception further, where the sperm count is very low.
In Oman currently these methods are not easily available and with
exception of IUI all others will not be provided by MOH health
facilities.
SITUATION IN OMAN
Accurate estimates of infertility in Oman are not known. Until late
1999, majority of infertility cases were attending infertility clinic
at Royal hospital and andrology clinic at Al Nahda hospital.
Data from Royal hospital infertility clinic indicate that 50% of
infertile couples are treatable, and, 35-50% contribution to
infertility is due to female factors alone.
As per MOH Annual Statistical report of year 2000 the out patient
attendance for male infertility was 7/10, 000 of population and for
females 185/10, 000 (females of 15-49years).
History of Infertility Services in Oman:
Until 1974, only the patient’s history and general and pelvic
examinations were carried out in the hospitals. In 1975 at Khoula
hospital semen analysis, hysterosalpingography for tubal patency
and dilatation & curettage for studying the secretary endometrium
to confirm the ovulation were initiated in gynaecology clinic, this
was followed by laparoscopic examination in 1980. In 1984 a
small infertility clinic was started at Khoula Hospital and a basic
proforma for the infertile couples was introduced.
Male infertility clinic was initiated in the year 1981 as a part of
dermatology and genitourinary medicine clinic at Al Nahda
hospital.
With the starting of the Royal hospital in 1987, a separate
infertility clinic for both female and male clients was established.
Investigations like hormonal profile and vaginal ultrasound
examination for follicular studies for the female clients were also
started on regular basis. IUI (intrauterine insemination) was
initiated in 1996.
Since August 1999 the infertility clinic of Royal hospital has been
shifted to Wattaya extended health centre for the female clients and
to Al Nahda hospital for male clients. Currently infertility services
are provided to infertile females in Gynae. Clinic daily and a
special infertility clinic are run once in a week at Wattaya extended
health centre. Two infertility clinics for the male infertile clients
are conducted at Al Nahda hospital biweekly. These clinics cater
all the cases referred from Muscat as well as referred from other
regions.
Special methods of management like A.R.T. (Assisted
Reproductive Technologies), GIFT (Gamete Intra-Fallopian
Transfer), IVF & ET (In Vitro Fertilization & Embryo Transfer),
ICSI (Intra Cytoplasmic Sperm Injection) are not available in
MOH institutions but can be availed in private sector or abroad on
the client’s own expense. Only IUI (Intra-Uterine Insemination)
will be provided by tertiary care health facility of MOH.
To avoid misuse and duplication of investigations and for the
smooth running of the programme, Ministry of Health wishes to
introduce infertility services as standard practice all over the
country.
This manual deals with the standard operating procedures to be
followed by all the staff either working in the infertility clinic or
otherwise with respect to management and treatment of infertile
couples.
REPRODUCTIVE HEALTH
General Goals:
All married couples have optimal reproductive health and a
satisfying and fulfilling family life.
Objectives of Reproductive health Services in Oman are:
To enable married couples:
• To conceive when desired
• To reduce maternal morbidity
• To have best possible pregnancy outcome
• To remain free of reproductive disease and disability
• To raise healthy children
Services contributing to optimal reproductive health and well being
of Omani population that will be available and accessible in Oman
are:
• Preconception
• Antenatal-perinatal and postnatal
• Birth Spacing
• Child Health Services
Reproductive health strategies in Oman are:
• Promote health and nutrition of pregnant and lactating mother:
• Provide prenatal/preconception-counseling services to all married
couple. Screen women at high risk of having congenitally
anomalous babies and provide selective termination of pregnancy,
wherever indicated (grossly anomalous baby).
• Provide quality services to the pregnant women to go through
the pregnancy, delivery and post partum period safely and have a
healthy baby.
• Provide promotive, preventive and curative service to
children under the age of five years.
• Provide information and access to safe, effective, suitable
and affordable methods of birth spacing as per client’s choices for
regulating fertility.
• Prevent all complications and consequent morbidity that can
result due to reproduction.
• Prevent mortality in women associated with pregnancy and
childbirth.
• Provision of information and services for infertility to
married couples.
• Promote and enhance service utilization of all the services
related to reproductive health by mass awareness.

Specific goal of Infertility Services in Oman:

• Through provision of infertility service MOH clinics of
Sultanate of Oman will make an effort to improve the fertility
status of married infertile couples.
• Provide infertility services as an integral part of Maternal and
Child and Birth Spacing
Program free of cost in MOH Clinics within the available resource.

GUIDELINES FOR DEALING WITH INFERTILE

COUPLES
• Before initiating a detailed evaluation of infertile couple, all
available records of previous investigation and management will
be reviewed.
• The parent institute will first book any case of infertility.
• Trained service providers will do clinical assessment, preliminary
investigation and counseling before referring the case to higher
health care facility.
• On first visit, at Primary health care facility, a female client
with primary/secondary infertility will be evaluated when the
husband semen analysis is first found normal and or acceptable.
• In situation where male partner has children from previous or
current other wife/s
• All cases will be referred to a secondary health care level for
further Specialized investigations
• At the secondary health care level a special clinics for
infertility will run in both Gy & Ob dept for females and
dermatology dept. for males. As per the indication, the case may
further be referred for management by other expertise like
endocrinologist, surgeons, urologist... etc.
• Specific day/s will be fixed in all health institutions to
provide infertility services.
• At secondary health care facility, a combined male/female
infertility clinic is advised to run at the same time and place when
possible.
• Couple will be kept well informed on the investigation and
management plans and the results.
• Referral to tertiary health care facility is allowed when
investigation/management are not available at secondary health
care facilities.
• Tertiary level, Infertility clinic for the female clients is at
Wattaya extended health centre And for male clients is at
dermatology/andrology clinic at Al-Nahdha Hospital.
• Infertility clinics at Wattaya extended health centre and
dermatology/andrology clinic at AI-Nahdha hospital will treat the
referred cases of Muscat as well as referrals from other regions.
• If despite all investigations no cause of infertility has been
found or if the cause is not treatable, the couple will be briefed on
the outcome of fertility assessment, reassured and counseled, given
information on the availability of IUI in MOH and other ART
method that can be availed in private clinic/abroad on clients own
expense.
WHO WILL RECEIVE INFERTILITY SERVICES
All couples desirous of having children who either have:
• Primary infertility, i.e. who have never conceived despite regular
unprotected intercourse for one year, will be registered in infertility
clinic and will be evaluated and treated.
• Secondary infertility i.e. who have previously conceived but are
subsequently unable to conceive within 2 years, despite exposure
to regular unprotected intercourse following abortion or full term
normal delivery, will be registered, evaluated and treated in
infertility clinic.
Couples in the age group 15-20 years will be physically examined,
reassured and explained on
The fertile period of menstrual cycle and at the most, non invasive
tests like semen analysis and
Hormonal profile may be carried out.
Despite all investigations and treatment some women may fail to
conceive, such women will be dealt with compassionately and
explained that no further work up is required.

WHO WILL PROVIDE INFERTILITY SERVICES

All trained health personnel having knowledge about the causes,
investigations and management of infertility will provide infertility
services, they all should acquire training on inter personal
communication.
WHAT DO INFERTILITY SERVICES WILL INVOLVE:
History taking and Counseling
Trained nurses/midwifes, doctors working in MCH/BS
clinic/Infertility clinic at all level of health care system will be
involved in obtaining case history and doing counseling.
Physical Examination
Trained female doctors at all level of health care system, working
in gynae/birth spacing/infertility clinic will do physical
examination of female client. Trained male doctors in dermatology!
anthology! infertility clinic will do physical examination of male
client.
Routine investigation
Female staff nurse/doctors at PHC facility will get semen analysis
done for male and haemogram, random blood sugar, VDRL Test,
urine routine test for female client.
Special investigation
For female client:
Gynaecological infertility team will do/order hormonal profile, mid
luteal serum progesterone, ultra-sonography &
hysterosalpingography and do post coital test for the couple if
indicated.
For male clients:
Dermatologist/andrologistlurologist/infertility team wills do/order
hormonal profile, ultra sonography
Highly specialized investigations
Laparoscopy, androgen studies and other special investigations
indicated will be carried out by
gynaecologistldermatologist/andrologistlurologistlendocrinologistli
nfertility team at tertiary care level.
Note: Tests like endometrial biopsy, testicular biopsy, antisperm
antibodies, scrotal thermo-graphy, Doppler echography and
imaging of pituitary region are not done routinely. The respective
experts when indicated will only do them at tertiary health care
facility as per feasibility and availability.
WHERE AND WHAT SERVICES WILL BE PROVIDED
All MOH institutions with trained female/male service providers
will provide infertility services as per the availability of expertise
and laboratory back up.
AT PRIMARY HEALTH CARE LEVEL
In MCH/IBS Clinics:
• History taking of couple and confirming that the attending
couple fits in the criteria of
infertility as per the protocol of MOH.
• Physical examination of female client
• Semen analysis
• First line investigation of female client
• Counseling on fertile period
• Review of investigations and referral of couple to higher
level for further management
AT SECONDARY HEALTH CARE LEVEL
In Infertility Clinic: (Team of doctors: gynaecologist and
dermatologist/anthologist)
• Review of case records. .
• History taking of couple
• Physical examination of female client by gynaecologist.
• Physical examination of male client by
dermatologist/andrologist.
• Discussion on the investigation and management plan.
• Based on the treatable cause of infertility in either or both the
partners, female clients will be
• Treated by gynaecologist and male clients by male
dermatologist /andrologist
• Counseling the couple.
• Reference to tertiary care level if cause couldn’t be treated at
secondary health care level.
• Antenatal care for those that conceive after infertility
management.
AT TERTIARY CARE LEVEL
In Infertility Clinic: (Team of doctors: gynaecology/ dennatologist
/andrologist/endocrinologist/Urologist)
• Review of history and investigation
• Repeat clinical evaluation if needed
• Do special Investigations and treat as per the cause.
• Counsel
• Provision of Intra-uterine Insemination (IUI) where ever
indicated
• Give informationladvise on other assisted reproductive
techniques (ART) where ever indicated as per infertility work up
out come that could be availed by the couple on their own expense
in Private hospitals in the country or abroad
COUNSELING INFERTILE COUPLES
The counselors who have been trained in interpersonal
communication (IPC) skills and have interest and knowledge about
causes, investigations and management of infertility will do
counseling.
Before evaluating any infertile couple, it is important to explain to
them that full work up may require few months and several visits
by them. During the course of investigations they might have to go
to higher health care facilities that has specialists and laboratory
back up, hence, their cooperation and patience will be needed all
through out, and appreciated.
All couples should be explained:
• That Infertility is a shared concern, evaluating both partners is
mandatory and problem Could lie with any of the partner.
• On how to recognize the fertile period of menstrual cycle. How to
track the number of days in the menstrual cycle, monitor the
appearance and texture of her mucus, which becomes clear, watery
and copious at the time of ovulation.
• How often to have intercourse and the timing of intercourse i.e.,
intercourse should take place three days preceding ovulation and
one day after it (between day 11-17 of a 28 days menstrual cycle).
• On the kind of investigations/procedures planned/carried out and
their outcomes.
• Due to social taboo a woman may feel guilty and responsible for
not being able to bear children. Explain to her and her husband that
infertility can be contributed by either of them, or by both of them.
Reassure them that as a physician you will do your best to help
them.
• Where cause of infertility is not amenable, or if all available
methods of infertility treatment have failed, counselors should help
the clients to cope with the bad news. Explain to the couple that no
further investigations or treatment are required and further visits to
any of the clinics should be discouraged.
• Ensure that the client knows that birth spacing methods used, do
not cause infertility.
• Some hormonal oral, injectable contraceptives and implants can
delay fertility by a few months but fertility eventually will return.
• Barrier methods protect against STIs, therefore can protect
against tubal infertility.
• IUCDs are also safe and effective method of birth spacing and do
not cause any pelvic infection by themselves or contribute to
infertility but may accelerate ascending infections in those women
that are at high risk of STIs and increase the risk of tubal infertility.
Such women should use barrier methods and should receive
adequate treatment for the STIs and pelvic infections.
REFERRAL
Proper communication between the primary, secondary and tertiary
centres is of utmost importance To ensure the best and optimum
utilization of time, efforts and resources.
REFERRAL FROM PRIMARY TO SECONDARY HEALTH
CARE LEVEL:
Couple will be referred to secondary health care facility after
having:
• Taken the detailed male and female clienf s history. Completing
clinical examination of the female client (if female doctor is
available).
• Getting semen analysis done.
• Carrying out routine blood and urine tests.
REFERRAL FROM SECONDARY TO TERTIARY HEALTH
CARE LEVEL:
Couples will be referred to tertiary health care facility after having:
FOR FEMALE CLIENT:
• Done clinical re-evaluation to confirm the findings and review of
investigations.
• Pelvic ultra-sonography.
• Assessing hormonal profile: serum follicular stimulating
hormone, leutinizing hormone,
prolactin, mid luteal progesterone and thyroid function tests (T3,
T4 & TSH if indicated)
• Evaluating tubal patency by laparoscopylhysterosalpingogram (if
facility available).
• Given a trial of 6 months of induction of ovulation with
clomiphene citrate and failed.
• Doing endometrial biopsy if indicated (Suspected case of genital
tuberculosis).
FOR MALE CLIENT:
• Doing semen analysis, if needs repetition.
• Assessing hormonal profile serum follicular stimulating hormone,
leutinizing hormone, prolactin (If gynaecomastia is present), and
thyroid function tests (T3, T4 & TSH).
• Doing ultra-sonography.
Carrying out following tests if indicated and if facility & expertise
are available
• Anti sperm antibodies (Immunobead test).
• Serum estradiol and serum testosterone.
• Doppler test.
• Scrotal thermography.
• Testicular biopsy.
INDICATIONS FOR REFERRAL TO THE TERTIARY LEVEL:
FEMALE:
• Repeated abnormal post coital test (minimum twice).
• Endocrine disorders, Hyperandrogenemia, Hypogonadotropic
hypogonadism.
• High prolactin levels with/without adenoma.
• Previous ectopic pregnancy.
• Amenorrhoea.
• Primary ovarian failure.
• Tubal block.
. Failure of clomiphene citrate therapy x 6 cycles.
• History of prior urogenital surgery.
• Genital malformations.
• Unexplained infertility (> 18 months).
MALE:
• History of testicular mal-descent.
• Previous history of genital pathology including orchitis,
varicocele, STI.
• Any urogenital surgery.
• Any abnormality on physical examination.
• Any endocrine disorder.
• Severe oligozoospermia /asthenozoospermia/azoospermia.
UNDERSTANDING INFERTILITY

DEFINITION OF INFERTILITY
Infertility is defined as ‘ inability of a couple to achieve conception
after a year of regular unprotected intercourse”.
This means either a woman’s inability to conceive and bear child
or a man’s inability to impregnate a woman.
Most couples that are evaluated are sub-fertile rathei than sterile.
Data from some countries
Have shown that as high as 38 % couple conceive before the
treatment was begun and another
27% before the treatment was completed.
PRIMARY INFERTILITY:
A couple that has never conceived despite unprotected regular
intercourse for at least 12 months.
S1 INFERTILITY:
The couple has previously conceived but is subsequently unable to
conceive within 12 months after delivery or abortion despite
exposure to regular unprotected intercourse
PRIMARY MALE INFERTILITY: when man has never
impregnated a woman.
SECONDARY MALE INFERTILITY: when man has
impregnated a woman, irrespective of whether she is his present
partner are not, and irrespective of the outcome of the pregnancy.
PRIMARY FEMALE INFERTILITY: when woman has never
been pregnant.
SECONDARY FEMALE INFERTILITY: a woman has been
previously pregnant but not necessarily by the same partner,
irrespective of pregnancy outcome.
PREGNANCY WASTAGE:
The woman is able to conceive but unable to produce a live birth
(unable to carry the fetus to a viable age).
SUB FERTILITY:
The couple has difficulty in conceiving jointly because both
partners may have reduced fecundity.
PROBABILITY OF PREGNANCY:
In normal fertile population there are 20% chances of pregnancy
happening in each cycle. 95% of couples will get pregnant by 13
cycle.
DURATION OF INVOLUNTARY INFERTILITY:
Longer the duration of infertility less is the chance of pregnancy.
Couples with duration of less than 3 years of infertility stand a
better chance of pregnancy

FACTORS AFFECTING FERTILITY

AGE OF WOMAN:
After late 30’s there is slight decline in fertility and some women
may take longer to conceive.
AGE OF MAN:
Although age does not affect sperm capabilities but it does affect
the sexual functions and coital frequency thus indirectly affecting
the reproductive performances.
COITAL FREQUENCY:
Frequency of coitus is positively related with the frequency of
pregnancy.
TIMING OF INTERCOURSE:
Sperm survives for 48 - 72 hours in genital tract, where as ovum
survives only for 12 - 24 hours and the window time for
fertilization is only few hours, so for fertilization to occur sperm
should be available in genital tract shortly after ovulation.
DOUCHING:
Douching of vagina soon after intercourse can destroy sperms.
PREVIOUS OR CURRENT DRUG USE:
Many a drugs can like narcotics, anticancer, phenothiazines,
monoamine oxidase inhibitors, methyldopa, cimetidine,
salfasalzine and toxins like arsenic and lead can interfere with
ovulation, change semen quality and reduce sperm count.
Contraceptives like depot medroxy progesterone acetate or
norplant can temporarily delay the return of fertility in female
clients for few months.
Some drugs, alcohol, tobacco and exposure to radiation can cause
pregnancy wastage. Drugs like guanethidine, methyldopa may
affect ejaculation.
CAUSES OF INFERTILITY
Only 5% of couples will suffer from infertility due to anatomical,
genetic, endocrinological and immunological causes. All
remainder are largely because of preventable conditions that
include:
• Genital tract infections due to STI’s, non STI’s & parasitic
diseases.
• Health care practices — Unhygienic practices
• Exposure to toxins in the diet and in the environment,
• Cultural and social factors like age at marriage, female genital
mutilation, consanguineous marriage;
• Use of alcohol, tobacco & caffeine etc.
In 5 — 15% infertile couples even thorough evaluation will not
find any cause for their infertility.
MANAGEMENT OF FEMALE INFERTILITY

EVALUATION OF INFERTILE FEMALE

I HISTORY
Evaluation should begin with asking full medical history, doing
physical examination and investigations as per the availability of
health personnel expertise and laboratory back up at health care
facilities.
It is very important to take proper obstetrical, fertility history and
history of any previous investigations done, to avoid unnecessary
repetition.
PERSONAL HISTORY
Age: If exact age of the partners is not known, approximate age
should be determined. Address and Telephone No: To be able to
contact and recall whenever required.
INFERTILITY HISTORY:
Whether infertility is primary or secondary duration of infertility
(number of months
with unprotected intercourse, excluding separation abstinence &
use of contraception).
MARITAL HISTORY:
Number of marriages.
PERSONAL HISTORY:
Excessive smoking, alcohol intake or addition of drugs likes heroin.
COITAL HISTORY:
Frequency of coitus (coital frequency 2-3 times a week is
considered to be within normal range), coital difficulties. If
husband is away and comes homes only on weekends missing the
fertile periods.
ENVIRONMENTAL AND OCCUPATIONAL HISTORY:
Intense physical activity, exposure to petroleum, chlorinated
hydrocarbons, organic,
dyes, inorganic mercury etc.
MENSTRUAL HISTORY:
• Age of menarche, late menarche is associated with ovulatory
disorders.
• Even with regular periods a patient may have luteinising
hormone: follicular stimulating hormone ratio > 3:1 indicating
polycystic ovarian disease.
• Oligomenorrhoea (cycle > 42 days) with scanty menses may
indicate high prolactin levels.
• Polyn and menorrhagia may indicate anovulation.
• Secondary dysmenorrhoea may indicate endometriosis, PID or
fibroid uterus.
OBSTETRICAL HISTORY:
Outcomes of previous pregnancies - abortions, miscarriages, live
born, ectopic pregnancy, and molar pregnancy, and history of post
abortion sepsis or puerperal sepsis and severe post partum
haemorrhage leading to amenorrhoea (Sheehan’ s. syndrome).
MEDICAL HISTORY:
Present or past history of: Systemic diseases like tuberculosis,
diabetes mellitus, thyroid disease, pelvic inflammatory diseases
and STIs.
Galactorrhoea: history should be elicited and searched for, as it
may indicate high prolactin levels with or without pituitary
adenoma.
DRUG HISTORY:
Present or past use of drugs, their dosage and duration - cytotoxic
agents, phenothiazines, haloperidol, tricyclic arni depressants -
monoamine oxidase inhibitors, hypotensive drugs — methyldopa,
metaclopromide Cimetidine, steroids, ovulation induction drugs.
CONTRACEPTION HISTORY:
History of use of contraceptives in immediate past: oral, injectable
depot medroxv progesterone and IUCD insertion
SURGICAL HISTORY:
Appendicectomy, laparotomy, laparoscopy and related procedures
or any major gynae surgery.
FAMILY HISTORY:
Endocrine disease e.g. polycvstic ovarian disease is often familial
• PHYSICAL EXAMINATION
GENERAL EXAMINATION:
Weight:
Over weight or under weight women may have ovulatory disorders.
Sudden gain or decrease of 10% in weight within past one year
may be associated with oligomenorrhoea or amenorrhoea and
anovulation.
Height:
Short stature with primary amenorrhoea with webbed neck
suggests Turner’s syndrome.
Build:
Very thin patients may often give a clue- anorexia nervosa - WHO
Group I. Obese and short patients- Polycystic ovarian disease -
WHO Group II.
Development of secondary sexual characteristics:
Examine breast to check developmental deficiencies such as
hypogonadism and hyper- prolactinemia. Confirm galactorrhoea
by gentle pressure on areola.
Visualize hair distribution:
Presence of abnormal distribution of hair may suggest
hyperandrogenism, adrenal hyperplasia, hypothyroidism and
ovarian dysfunction.
SYSTEMIC EXAMINATION:
To rule out any cardio-vascular, respiratory, gastrointestinal and
uro-genital diseases that could influence fertility. Do abdominal
examination to look for organomegaly, which could indicate
systemic diseases.
GENITAL TRACT EXAMINATION:
Speculum exam:
Inspect vagina and cervix for any lesions and discharge. Collect
cervical smear and vagina swab for microbiological examination
wherever indicated.
PELVIC EXAMINATION:
Examine external genitalia, clitoris greater than 2cm and gland
more than 1cm indicates virilism. Palpate uterus to rule out uterine
hypoplasia and congenital anomalies, adnexae to reveal any
adenexal tumours. pelvic inflammatory diseases or endometriosis,
and cervix to feel cervical lesions.
• INVESTIGATIONS
ROUTINE INVSTIGATIONS (at PHC facility)
On first visit: Do/order semen analysis for the male partner.
Investigations for female client can be initiated on first visit where
male partner has children from previous
wife/s or from other wife/s with whom he is currently married
On follow up visit Review semen analysis report if
normal/acceptable proceed with complete blood count, urine
routine and microscopic, VDRL, and RBS/OGCT for the female
client. Review the all the test reports and then refer the case to near
by health care facility with gynaecologist If semen analysis is
abnormal/if abnormality is
found in both partners refer the couple to secondary health care
facility with
infertility clinic
EVALUATION
EVALUATION AT SECONDARY CARE LEVEL BY
GYNECOLOGISTS
Reconfirm clienf s history and physical examination findings and
review the investigations carried at PHC level. Do or order semen
analysis if not already done. If semen analysis is normal proceed
with investigations like abdominal and pelvic ultrasound and other
investigations that are indicated and are feasible on the first visit
like high vaginal swab, cervical swab for chlamydia trachamatis,
PAP smear etc.
PLANNED INVESTIGATIONS AT THE SECOND AND
SUBSEQUENT VISITS
The patient is to be called according to her menstrual cycle for
subsequent visits for investigations as detailed below:
“Type of test, timing in relation to menstrual cycle, indications and
interpretation”
Follicular stimulating hormone and leutinizing hormone and serum
prolactin should be done on day 2 to 4 of the menstrual cycle.
• In ovulatory patients with regular cycles follicular
stimulating hormone and leutinizing
hormone are not mandatory. -
• Anovulatory patients with regular cycles, leutinizing
hormone: follicular stimulating
hormone ratio more than 3:1 indicates poly-cystic ovarian disease.
• High levels of follicular stimulating hormone and leutinizing
hormone indicates primary
ovarian failure for which there is no treatment.
• Prolactin levels 1000 miu/litre on two occasions requires
ruling out of pituitary tumours
by imaging of hypothalamic pituitary region by CT Scan or MRI.
Note: Prolactin test should not be done after pelvic or breast
examination or early in the morning as that may give high false
positive results. Repeated test for prolactin are advised.
Mid luteal serum progesterone test (Day 20-24 of 28 days/Day 28
of 35 days cycle): avalue of >25 nmo/litre suggests ovulation
(Progesterone test has replaced endometrial biopsy, as far evidence
of ovulation is concerned).
Thyroid function test: Is indicated if there is oligomenorrhoea,
polymenorrhoea, or hyperprolactinaemia.
Androgen studies: should be done in patients with hirusutism,
virilism and in patients who do not respond to the highest
permitted doses of clomiphene citrate therapy (serum dehydro
epiendestrone acetate levels are> 2.5 ng/ml).
Ultrasound: Abdominal, trans-vaginal and hydrosonography to
detect any abdominal organomegaly, and uterine, ovarian and tubal
pathology.
Laparoscopy: If the initial blood analyses including hormonal
assay and semen analysis are
normal then diagnostic laparoscopy or hysterosalpingography for
tubal patency testing
should be done.
Diagnostic laparoscopy is preferred to hysterosalpingography as it
has advantage of direct visualization of the pelvis, but being an
invasive procedure it can be deferred for couples with infertile
period less than 2 years and whose clinical evaluation, hormonal
and other investigations are normal.
Early Investigation for pelvic pathology by laparoscopy is
indicated in female client with
history suggestive of PID, history of long standing infertility and if
client’s age is above 30
years and she is just beginning her fertility evaluation work up.
Hysteroscopy: if indicated can be combined with laparoscopy.
If laparoscopy facilities are not available. Hvsterosalpingography
can be done as a preliminary procedure for tubal testing. But if.
when laparoscopy is done and it reveals a tubal block, it is
advisable then that the hysterosalpingography is done to localize
the site of the block.
{Note: HSG is typically performed early in the menstrual cycle
after bleeding on the day 7 - 10 of 28 days cycle}
Post coital test: should be carried out in pre-ovulate phase (on 12
day of a 28 days regular
menstrual cycle) This test is done to confirm that ejaculation has
taken place in vagina and to
rule out any impaired semen cervical mucus interaction in patients
who are ovulating
normally and whose other infertility investigations are normal.
Instruction to the female client/couple prior to Post coital test
(PCT):
• To abstain from intercourse at least 48 hours prior to test (as
per appointment date)
• To have intercourse early in the morning on the PCT date.
• Not to take a vaginal douche after the intercourse.
Explain to the client procedure before taking the sample that
you/doctor will gently insert a
speculum and take samples for examination and she will not
experience any pain except for
some discomfort while doing pelvic examination.
Pre-menstrual endometrial biopsy: indicated if there is a past
history suggestive of endometrial tuberculosis.
Immunobead test (MAR Test): for detection of antisperm
antibodies.
Once the above work up is complete, couple’s cause of infertility
will be categorized as:
S Infertility due to female factors:
• Anovulatory cycles
S Cervical factors (assessed by PCT)
• Uterine factors (assessed by clinical assssment)
• Tubal disease
• Infertility due to Male factor.

ANOVULATION
INCIDENCE: 30 - 40 % infertile females have ovarian dysfunction.
If appropriately diagnosed and managed the success rate is as high
98%
Regular ovulation occurs when the hypothalamic-pituitary ovarian
axis is intact. Any disorder occurring at one or more levels of
hypothalamic-pituitary ovarian axis may lead to anovulation.
Treatment of anovulation depends on the site of involvement,
which is assessed by specific hormonal assays. WHO classification
(based on the hormonal assay results) for ovulatory disturbances is
as follows:
WHO CLASSIFICATION:

CLINICAL PRESENTATION:
• Regular menstrual cycle:
• Menstrual irregularities:
• Amenorrhoea: primary and secondary
• Oligomenorrhoea
• Galactorrhoea
• Obesity
• Abnormal development of secondary sexual characters
• Hyperandrogenic state- hirsutism, virilism
• Anosmia
• Manifestation of other endocrine abnormalities e.g. thyroid
dysfunction
MANAGEMENT OF ANOVULATION/OVULATION
INDUCTION
The commonly used drugs for ovulation induction are:
1. Clomiphene citrate
2. Human menopausal gonadotropins (HMG)
3. Human chorionic gonadotropins (HCG)
CLOMIPHENE CITRATE: (WHO Group 1)
Start with clomiphene citrate 100 mg from Day 2-6 of menstrual
cycle. Give three cycle If no ovarian response is seen increase the
dose by 50 mg every cycle until maximum dose i.e. 250 mg. is
reached and the ovarian response is seen (serum progesterone 30
nmol/litre on Day 21 —23 of menstrual cycle)
The dose at which ovulation occurs, should be continued for a
period of 6-9 months. If there is failure of ovulation with
maximum dose of clomiphene citrate (250 mg), administration of
human chronic gonadotropins (HCG) whenever trans-vaginal
ultrasound expertise is available, can be initiated (see below) or
client should be referred to endoscopic center for laparoscopy plus
ovarian drilling.
GONADOTROPINS (WHO GROUP - I & II)
Gonadotropins are to be administered if patient fails to ovulate
with clomiphene citrate. From Day 2/3 of menstrual cycle start
Human Menopausal Gonadotropin (HMG) 2 ampules intra
muscular daily for 5 days (one ampoule of HMG = 75 IU of
follicular stimulating hormone + 75 IU of leutinizing hormone)
Do follicular study by trans-vaginal ultrasound on Day 7/8 of
menstrual cycle. Continue with same dose of HMG & follicular
study every 2 — 3 days interval until follicles reach to 18 mm size.
Give human chronic gonadotropins (HCG) 10, 000 units (when
follicle is 18mm). Advise intercourse between 24 —36 hours
following HCG administration.
If on Day 8 no follicular response is seen, increase HMG by one
ampoule followed by follicular study every 2 — 3 days for 5 — 6
days.
Abandon the cycle and refer client to tertiary health care centre:
• If no response
• If on day 8 of menstrual cycle multiple follicles of 8 mm and 8 or
more in number are seen, it indicates hyper-stimulation syndrome
secondary to gonadotropins therapy.
Ovarian Hyper Stimulation Syndrome (OHSS)
This is a known life threatening complication of gonadotropins
therapy and needs early recognition and management.
Symptoms and Signs are
Nausea, vomiting, diarrhea, abdominal pain and distension, signs
of ascites and pulmonary embolism.
hydrothorax,
Patients should be referred to tertiary health care center
immediately whenever OHSS
is suspected.

BROMOCRYPTINE (dopamine receptor a2onist) : (WHO

GROUP V & VI)
• It is indicated in anovulatory cycle associated with
hyperprolactinaemia.
• It is given in progressively increase dose orally with meals
• Start with dose 1.25mg twice aday for 7 days then increase
gradually to 5 mg twice a day over next 2-3 weeks,
• Followed by doubling of dose every 4 weeks until maximum
daily dose of 30mg is reached i.e. 10 mg three times a day and
beyond which the dose should, not exceed.
• Monitor Serum.Prolactin level on monthly basis and adjust
bromocryptine dose accordingly as per the response (i.e. decrease
in serum prolactin level and reduction in Ga
• Once prolactin levels are normal maintain same dose for 4 — 6
months.
• Confirm ovulation by mid-luteal serum.progesterone (Day 21-24
of 28 days menstrual cycle)
• If still not ovulatory inspite of normal prolactin levels add
clomiphene citrate as per above guidelines
• If prolactin levels are still high inspite of maximum dose of
bromocryptine refer patient to endocrinologist.
NOTE: If the female is < 25 years, has history of infertility less
than 3 years, has anovulatory cycles, and has no history suggestive
of previous inflammatory disease or pelvic surgery, then the trial
with clomiphene citrate for induction of ovulation without
evaluating her tubal factors is justified.
TUBAL FACTORS
TUBAL FACTORS SHOULD BE ASSESSED AFTER INITIAL
WORK UP OF OVULATION AND SEMEN ANALYSIS ARE
COMPLETED.
EVALUATION FOR TUBAL FACTORS
HYSTEROSALPINGOGRAM (HSG):
• HSG gets priority when the couple is very young with past
history of P.I.D.
• HSG should be performed during proliferative phase (day 7 to
day 10) of the cycle.
• Inform the patient regarding the procedure.
• Carry out a detailed physical examination and if indicated high
vaginal swab (HVS) to rule out acute infection.
• Give non steroidal anti inflammatory drug/antispasmodic 30-60
mm before procedure to lessen the pain and tubal spasm.
• In clients with history of PID give antibiotic cover with
Doxycycline 100 mg twice for a week to both partners.
• Carry out the procedure under aseptic precautions.
• Inject 20 ml of water soluble dye slowly through the cervical
canal into the uterine cavity.
• Avoid leakage by steady traction on the volsellum accompanied
by gentle push on the cannula. Partial or complete withdrawal of
the bivalve speculum will allow an adequate view of the cervix.
• A late film would help in visualizing peritubal adhesions and
delayed spill.
LAPAROSCOPY:
• Laparoscopy should be the primary investigation for tube testing.
• It should be done during the proliferate phase on day 7 to day 10.
• Visualization of the pelvic organs should be systematic and
thorough describing each organ in detail including its dimensions,
thickness, appearance, relation to adjacent structures, mobility etc.
LAPAROSCOPY ENABLES CLASSIFICATION OF TUBAL
DISEASES INTO TWO CATEGORIES:
1. Advanced disease -poor surgical outcome- patients benefit with
in vitro fertilization
(IVF).
2. Mild to moderate disease- microsurgery is indicated and may be
beneficial.
MANAGEMENT
• Early and meticulous treatment of patients with pelvic
inflammatory disease (PID).
• Advise oral contraceptives in patients with chronic PID.
• incidental surgery should be avoided e.g. shortening of round
ligaments, wedge resection of ovary, excision of small ovarian cyst
with out proper evaluation etc.
• During laparotomy for ectopic pregnancy, tuboplasty of the
contra lateral tube should not be attempted.
• IUCD insertion should be avoided in patients with past history of
ectopic pregnancy and chronic PID, or those at risk of sexually
transmitted infections (STIs).
TUBOPLASTY
PRINCIPLES:
• Ensure meticulous haemostatsis.
• Do minimum handling during surgery and usage of Teflon/glass
probes.
• Irrigate continuously with an isotonic solution to prevent dryness
of tissues.
• Use fine suture material e.g. 8/0 prolene.
• In procedures like tubocornual implantation, end-to-end
anastomosis, and salpingostomy, magnify to delineate the correct
plane for tissue dissection enabling proper apposition and better
results.
ONLY SKILLED PERSONNEL SHOULD CARRY OUT THESE
PROCEDURES.
Postoperative evaluation
Repeat HSG/Laparoscopy- 12 weeks later to evaluate tubal
patency.
After surgery, a period of 18-24 months should be allowed for
client to conceive, failing
which; she can be told on the alternative methods like IVF that can
be availed outside
MOH.
IVF is a preferred alternative method to tuboplasty

ENDOMETRIOSIS:

INCIDENCE OF ENDOMETRIOSIS:
1% of women in reproductive age.
15 — 25% infertile women.
70 — 80% unexplained infertile women
CLINICAL PRESENTATION:
• Severe dysmenorrhoea (pre, during and post menstrual)
• Dyspareunia.
• Pelvic pain.
• Infertility.
• Menstrual irregularity.
• Haematurialdysuria.
• Abdominal cramps (cyclic).
Clinical signs depend on the site of involvement:
• In mild cases no abnormality may be found clinically despite
severe symptoms.
• In pelvic endometriosis discomfort and tenderness on bimanual
examination along with! without palpable adenexal masses and
indurations of utero-sacral ligaments may be found.
DIAGNOSIS:
• Ultra sonography: Probable diagnosis may be possible
• Laparoscopy: Facilitates a definitive diagnosis and staging as per
the American Fertility society (A.F.S) revised classification.
Further confirmation of the diagnosis can be done by biopsy. (Ref
to appendix 5 & 6)
The staging should be followed judiciously to ensure uniformity in
classification of severity of the disease and further management.
TYPES OF MANAGEMENT:
• Medical:
1. Danazol
2. Leutinizing hormone release hormone Analogues
3. Progestogens
(Ref to page 33 for Medical Management of Endometriosis)
• Surgical (Mainly by Laparoscopic surgery):
Laparoscopy procedure:
1. Cystectomy for endometriomas
2. Adhesiolyses/excision using sharp/blunt dissection for pelvic
adhesions.
3. Cauterization for endometriotic lesions: avoid cautery around
the bladder, ureter, bowels and other vital organs
Laser surgery- precise vaporization of endometnotic nodules of 1-2
mm without severe damage to the surrounding tissue.
Clients needing laparoscopic procedures should be referred to
Endoscopic units
UNEXPLAINED INFERTILITY
INCIDENCE:
5 -15% of infertile couples will have unexplained fertility for
which no cause will be found.
POSSIBLE REASONS ATTRIBUTED ARE:
• Poorly developed follicle
• Abnormal oocyte- genetically or functionally
• Poor quality luteal phase that may not provide the optimal
endocrine environment for tubal transport or endometrial
maturation.
• Aberrant or asynchronous endometrial gland secretion.
• Abnormal acrosomal reaction of sperm
• Improper transport of fertilized egg to the site of implantation due
to defective function of cilia.
• Influence of ovarian steroids directly or indirectly by
prostaglandin and the sympathetic nervous system of the process
of oocyte pick up by the fallopian tube, fertilization, zygote
maturation and transport due to effect on muscular co ordination,
cilial activity and tubal secretion.
TREATMENT:
Three attempts with super ovulation with clomiphene
citrate/gonadotropins followed by intra uterine insemination should
be carried out. Failing which client can be counseled on alternative
methods of Assisted Reproductive Technologies (ART) that are
available out-side MOH institutions, IVF I GIFT is one of them.

ASSISTED REPRODUCTIVE TECHNOLOGY (ART)

PROCEDURES ARE
I. INTRA-UTERINE INSEMINATION (IUI)
II. IN VITRO FERTILIZATION AND EMBRYO TRANSFER
(IVF-ET)
III. GAMETE INTRA FALLOPIAN TRANSFER (GIFT)
IV. INTRA CYTOPLASMIC SPERM INJECTION (ICSI)
V. PARTIAL ZONA DISSECTION (PZD)
VI. SUB ZONAL INSEMINATION (SUZI)
INDICATIONS FOR ART:
• Tubal disease with tubal block orabsent tubes
• Severe Endometriosis- endometriosis after sufficient treatment
without success.
• Unexplained infertility
• Poly cystic ovarian disease with failed ovulation induction
• Oligoasthenozoospermia
• Hostile cervical mucus.
PRELIMINARY REQUIREMENT:
• Age <40 years preferable
• Psychological evaluation- mentally sound and stable marriage
• Semen analysis- count >5-20 million (for IVF), motility - 30%
• Laparoscopy and if possible Hysteroscopy
• HSG if indicated
• Cervical patency - depth and direction of cervical and uterine
cavity, to ensure atraumatic transfer of embryo.
• Patient to be fully informed about the procedure, the cost
involved and the poor success rate (15-40%).
I. INTRA-UTERINE INSEMINATION (IUI)
Intra-uterine insemination is the only ART procedure provided by
MOH, at Wattaya Polyclinic.
INDICATIONS FOR IUI
i. Poor quality semen
ii. Hostile cervical mucus
iii. Unexplained infertility
PROCEDURE:
• Sperm preparation is carried out to separate the highly motile
sperms from the seminal plasma by centrifugation or Percoll
gradients, or using the sperms natural swimming ability.
• The washed Spermatozoa are injected directly into the uterine
cavity using a fine Teflon Catheter.
II. IVF-ET (In Vitro fertilization and embryo transfer)
• Oocyte is recruited by induction of ovulation with various
drugs.
• Oocyte is retrieved transvaginally or under ultra sonography
guidance
• Fertilization of ova and growth of embryo is done in vitro (2-
3) embryos
replaced back into the uterus at 4-cell stage trans- vaginally.
III GIFT (Gamete intra fallopian transfer)
• Oocyte recruitment and oocyte retrieval is the same as in IVF
• Sperms are prepared
• Oocyte and sperm are placed separately in a catheter and
injected
directly into the patient’s fallopian tubes. It is a one step procedure.
• In patients with patent tubes, IVT-ET and GIFT procedures
can be done
simultaneously thereby improving conception rate further.
IV. INTRA CYTOPLASMIC SPERM INJECTION (ICSI)
• A single human sperm cell is injected through the zona right into
the cytoplasm of the egg.
V. PARTIAL ZONA DISSECTION (PZD)
• A hole is made in the outer layer of a single egg making it easier
for the Sperm cells to penetrate and fertilize.
VI. SUB ZONAL INSEMINATION (SUZI)
• This is one Further stage of PZD. A few individual sperm cells
are placed just beneath the outer zona of the egg, so that they only
have to cross the cytoplasm of the egg to achieve fertilization.

MANAGEMENT OF MALE INFERTILITY

EVALUATION OF INFERTILE MALE

HISTORY:
A good history can contribute to diagnosis of infertility in 25% of
cases. It will also facilitate in decision making about management
of the case. It is best to stan by asking the client about his duration
of infertility. The number of months the couple has been having
the intercourse without the use of contraception. Duration of
involuntary infertility has implications on the prognosis of the case.
MARITAL HISTORY:
• Number of years of marriage.
• Number of wives.
• Number of pregnancies that his wife/s have had.
• Number of live born his wife/s have had.
• Number of living and dead children.
• Consanguineous marriage.
SEXUAL HISTORY:
• Desire
• Frequency of coitus (twice or less/month unless done during
ovulation is considered inadequate).
• Potency — Masturbation.
• Extra marital relationships.
• Use of lubricants during intercourse.
PERSONAL & FAMILY HISTORY:
• History of excess alcohol consumption, tobacco/marijuana
smoking,
• Drug abuse, addicted to opiates.
• Away from wife for long periods.
• Hereditary/familial disorders that can affect fertility.
ENVIRONMENTAL AND OCCUPATIONAL HISTORY:
• Exposure to x-rays, radiation, high temperature or sauna
• Heavy metals like Lead, Cadmium, Mercury. substances like
pesticides, herbicides etc.
MEDICAL HISTORY
General health
Age of onset of pubert weight loss or gain history of scrotal trauma
or swelling
Systemic Disease
Diabetes mellitus hypertension tuberculosis chronic respiratory
diseases cystic fibrosis leprosy and neurological disorders
Infections
STIs (syphilis gonorrhea chlamydia. granuloma venereum
mvcoplasma or
nonspecific urethritis, HIV), urethral discharges. urinary tract
infections.
Viral infections like Mumps (age of onset, unilateral/bilateral).
Medication
History of use of hormonal drugs — Androgens, anticancerous
drugs - alkylating agents, other drugs that can cause temporary
infertility, like cimetidine, suiphasalazine spironolactone
nitrofurantoin niradozole and colchicines Contraception duration
and method used etc
SURGICAL HISTORY
Surgery on urethral valve bladder neck operations repair of
urethral stricture reconstructive surgery for hypospadias epispadias
operation for testicular maldescent varicocele testicular torsion and
hernia Prostatectomy hydrocelectomy vasectomy orchiopexy or
orchiectomy appendicectomy lumber sympathectomy etc
• PHYSICAL EXAMINATION
Weight
Gross over obesity is associated with decreased testicular volume.
Height
Span (long limb length has been associated with Klinfelter’s
syndrome).
Fat and hair distribution
Feminine fat distribution and sparse or absent pubic, axillary and
chest hair, poor beard growth suggests hypogonadism.
Breast examination
For gynaecomastia (examine client with hands placed behind his
head).
Abdominal examination
Liver enlargement and any pelvic mass.
GENITAL EXAMINATION:
Penis:
Size, deformities, phimosis, ulceration or urethral discharge
Surgical or traumatic scar (may indicate urethral stricture).
indurations.
Testes:
Size
Normal Volume (normal 15 - 25 ml).
Consistency:
Normal - rubbery to firm (Klinfelter’s syndrome - hard & small,
hypogonadotropic hypogonadism — soft & small).
Site:
Normally in the scrotum ( abnormal locations - in scrotal neck,
inguinal, ectopic. impalpable, incomplete descent).
Vasdifference:
Normally on palpation it feels like a cord when felt between the
thumb and index finger) Check if it they are normal or if
thickened/not palpable.
Scrotum:
Presence of any swelling, hydrococle, varicocele, Calcified
nodules of VAS or absence of VAS.
Inguinal examination:
Presence of any hernia, scar of healed tuberculosis or
lymphogranuloma venereum, or lymphadenopathy.
Prostate:
Normal prostate is soft regular and non-tender (Palpate by per
rectum examination).
It is tender in infections and hard in malignancy.
SEMEN ANALYSIS
Semen analysis is the principal test for the evaluation of the male.
AS THE QUALITY OF THE SEMEN MAY VARY
SUBSTANTIALLY
BETWEEN SAMPLES, TWO SPECIMENS MUST BE
REQUESTED
BEFORE A FIRM OPINION IS MADE, PARTICULARLY IF
ONE IS
ABNORMAL. THE INTERVAL BETWEEN THE SAMPLES
SHOULD BE
AT LEAST 4 TO 8 DAYS. IF THE SECOND SAMPLE
CONFIRMS AN
ABNORMALITY, A POST TREATMEN I SAMPLE SHOULD
BE
EVALUATED AFTER 90 DAYS OF TREATMENT.

INSTRUCTION TO CLIENT ABOUT COLLECTION OF

SEMEN SAMPLE FOR
EVALUATION:
1 Abstain from intercourse (no ejaculation) for at least 3days.
2 Do not drink alcohol or take a hot shower or hot bath
immediately prior to producing specimen.
3. Produce a semen specimen by masturbation into a small, sterile,
dry, wide mouth glass jar. Be sure, the entire specimen is captured
in the container.
4. Label the jar with the client’s name, hospital number, date and
time of collection.
5. Lubricant jellies or soaps are not to be used for masturbation and
if required glycerin is permitted. Ordinary condoms contain
spermicidal and hence should not be used.
6. Take the specimen to the laborator as soon as possible. The
specimen should arrive in the laboratory within 1 hour of
collection maintaining the temperature between 15-
38 C.
If religious norms prohibit masturbation, then a milex sheath,
which does not damage sperms, may be used.
OTHER INVESTIGATIONS:
1. Complete blood picture
2. Urine test: for sugar, albumin, pus cells, significant bacteruria,
and if indicated Chlamydia trachamatis antigen.
3. Fasting blood Sugar
4. VDRL
5. Serum iron concentration
6. Hepatic & renal function tests
7. Thyroid function test
8. Serum testosterone estimation: indicated where there are clinical
signs of hypoandrogenesim with normal Serum follicular
stimulating hormone, suggesting hypogonadotrophic
hypogonadism either of pituitary or thalamic origin.
9. Serum follicular stimulating hormone, high levels suggest defect
in spermatogenesis or primary testicular failure.
10. Serum leutinizing hormone
11. Serum prolactin: 2 —3 samples are taken at interval of 15
minutes with in dwelling needle and record the lowest value.
Indicated in cases of sexual dysfunction or if there are signs of
hvpoandrogenesim with low serum testosterone and normal Serum
follicular stimulating hormone values. High prolactin values may
be due to drugs like tranquilizers, sulphides, or presence of
hypothyroidism or cranipharangioma.
12. Serum estradiol: to be estimated only if gynaecomastia is there.
13. Testicular biopsy: done in case of severe oligozoospermia or
Azoospermia with normal testicular volume and normal Serum
follicular stimulating hormone values.
14. Anti sperm anti bodies (Immunobead test or mixed antiglobulin
reaction)
15. Immunoglobulins G & M (for Chlamydia Trachamatis)
16. Post coital tests: man should abstain for 48 hours prior to
intercourse.
17. Scrotal thermography: to rule out sub clinical varicocele,
indicated where spermatozoa are abnormal and man has no
obvious physical or urogenital abnormalities. Normal temperature
of scrotum does not exceed 33 degree C. Ensure that the
temperature of çxamination room does not exceed more than 22
degree C and man has stood for 5 minutes naked before applying
the flexible strip on scrotum.
18. Ultra-sonography: to detect sub clinical varicocele or search for
the varicocele on the other side when present on one of the
inguinal regions
19. Doppler ultrasound examination: Patients with varicocele have
reflux down the spermatic cord vein which can be heard by the
Doppler stethoscope.

TREATMENT OF MALE INFERTILITY

SURGICAL TTREATMENT FOR:
• Varicocele — high ligature operation ( H.L.O)
• Obstructive Azoospermia
• Cryptorchidism
• Congenital Deformities i.e. Hypospadias.
HORMONAL/MEDICAL:(Treatment for idiopathic
oligozoospermia or Oligoasthenozoospermia.)
1 And rogens:
a) Testosterone undecanoate capsules for oral use in divided doses
i.e. Andriol 40mg three times in a day for 3 months.
b) Synthetic androgens Mesterolone (Proviron) 25 mg T.I.D for 3
months.
c) Testosterone esters 250mg oily preparation I.M injection twice a
month for life long to improve the potency.
Clinical application of androgens:
I) Hypergonadotropic Hypogonadism i.e. testicular failure or
complete atrophy
2) Idiopathic delayed puberty.
3) Asthenozoospermia
4) Andropause and male aging syndrome.
1 Gonadotroph ins:
i) Leutinizing Hormone L.H. i.e. Human Chorionic gonadotrophins
(H.C.G) (Pregnyl) 1500 lU. Twice /week for three months
ii) Human Menopausal gonadotrophins (H.M.G) i.e. (Pergonal)
Intramuscular Inj. One ampoule twice/week for three months
iii) Clinical application of HMG & HCG
1) Hypogonadotrophic hypogonadism.
2) Idiopathic oligozoospermia
3) Maturation arrest (doubtful)
1. Cortisone:
For long period with small dose in autoimmune infertility
treatment 10mg prednesoline OD for 3 months.
2. Bromocryptine (Parlodel):
In hyperprolactinaemia start with low dose 2.5mg daily and
increase gradually weekly until desired dose is reached. The dose
has to be adjusted according to the rise in the value of prolactin.
3. Clomiphene citrate (Clomid)
It is closely related to estrogens that compete with oestrogen for
steroid receptor in the hypothalamus inhibiting negative feedback
mechanism exerted by oestrogens leading to increase of luteinising
releasing hormone and follicular stimulating hormone. Increase in
FHS & LH improves spermatogenesis. Clomiphene citrate has
cumulative effect, so lower dose is preferable i.e.25mg Once Daily
for 3 months.
4. Tamoxifin (Nolvadex)
Similar to clomiphene citrate but with no cumulative effect.
Dose is 20mg/day for 3 months.
5. Kalli Kerein Therapy
It is given where there is motility problem as in case of
asthenozoospermia. Give padutin depot 40 I.U three times per
week for 3 months.
6. Vit A & E (Retinol)
A combination of Vitamin A 200,000 I.U with Vitamin E 40 I.U is
given once daily for 3 months.
PREVENTION OF INFERTILITY
Frequent genital tract infections can lead to infertility in either of
the partners or both hence should be treated judiciously.
Adequate hygiene should be practiced during delivery and post-
partum to reduce the incidence of postpartum infections.
All cases that develop post abortion or post partum infection
should be treated appropriately, adequately and if need may be,
should be followed up to prevent chronic pelvic inflammatory
diseases.
All type of genital tract infections in both partners should be
treated adequately and effectively as per the sensitivity of
organisms (refer to antibiotic policy guidelines of MOH and SOP
manual on STIs & Birth Spacing)
Couples with STIs should be explained on the long-term risk
associated with STIs. Efforts should be done to change the high-
risk behaviour of both or either of the partners as the situation may
be.
Benefits of use of barrier methods should be explained.

APPENDIX