FEMALE AND MALE

INFERTILITY
Professor Adeyemi O. Adekunle
Department of Obstetrics and Gynaecology
College of Medicine, University of Ibadan
University College Hospital,
Ibadan, Nigeria.
Adekunle A.O.

FEMALE AND MALE INFERTILITY

ENABLING OBJECTIVES

Define the various terms associated with

infertility;

List the causes of infertility;

Discuss the diagnosis and routine clinical

examination of the infertile couple;

Discuss the investigations and treatment for

the infertile couple;

List the various forms of Assisted Reproductive

Techniques
Adekunle A.O.

Introduction

Infertility is the involuntary failure of a couple

to conceive after 12 months of unprotected
regular coital exposure.

It constitutes 50% of gynaecological

consultations in developing world.

Infertility is associated with emotional and

social distress.

Sterility is a synonymous term.

Fecundity denotes the probability of

conception.
Adekunle A.O.

TYPES AND PREVALENCE

TYPES
Primary Infertility no previous conception;

Secondary Infertility previous conception

(whatever the outcome).

PREVALENCE
10 15% of married couples of reproductive
age.

Infertility is a disorder of couples and both

partners must be evaluated.
Adekunle A.O.

Contributions of Partners to Infertility

and Probability of Conception

SOURCE OF THE PROBLEM

Sole cause in the male
Sole cause in the female
Combined cause
No recognizable cause

- 30% - 40%
- 30% - 40%
- 15% - 30%
- 5% - 10%

CHANCES OF PREGNANCY (Normal Couples)

60% of couples conceive in 6 months
80% - 85% in 1 year
90% in 18 months, and
10% - 15% -- infertile.
Adekunle A.O.

ISSUES ASSOCIATED WITH

INFERTILITY IN NIGERIA

Regarded as a social stigma;

Causes marital instability and social neglect;

Results in exploitation and economic

deprivation of female partners;

Causes emotional stress and unhappiness/

psychological consequences;

Male ego.
The longer the couple has been trying to
conceive without success, the greater the
decline in conception rate.
Adekunle A.O.

CAUSES OF INFERTILITY - Female

GENERAL
Dietary disturbances
Severe anaemias
Anxiety, fear, etc
(hypothalamus)
ENDOCRINE
Pituitary failure
Adrenal hypoplasia
Polycystic disease
Thyroid disturbances
Ovarian failure

DEVELOPMENTAL
Uterine absence
Uterine anomalies
Hypoplasia
Gonadal dysgenesis
GENITAL DISEASE
Pelvic inflammation
STIs
Tubal obstructions
Myomas and polyps
Vaginitis, Cervicitis
Endometriosis,
Tuberculosis
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Adekunle A.O.

CAUSES OF INFERTILITY - Male

GENERAL
Fatigue
Alcohol
Excessive smoking
Fear
Excessive coitus
Impotence
ENDOCRINE
Pituitary failure
Adrenal hyperplasia
Thyroid deficiency

DEVELOPMENTAL
Undescended testis
Testicular germinal
aplasia
Klinefelters syndrome
Thyroid deficiency
GENITAL DISEASE
Mumps orchitis
Sexually Transmitted
Infections (STIs)
Prostatitis
Adekunle A.O.

CAUSES OF INFERTILITY
Female and Male

Marital maladjustments

Sex problems

Ignorance (timing, douching)

Low fertility index

Immunological incompatibility

Adekunle A.O.

FUNCTIONAL CLASSIFICATION OF
INFERTILITY

TIME
Time of intercourse
Frequency of intercourse
SEMEN
Semen profile
Other components of
ejaculate
OVA
Ovulation
Implantation
Adequacy of corpus luteum

INCUBATOR
Endometrial dysfunction

TRANSPORT
Male coital
Female Transport
Failure
Cervical, Uterine
and Tubal
OTHER PROBLEMS
Generalised
endocrine
disorders
Systemic diseases
(e.g. Diabetes
Mellitus)

Adekunle A.O.

10

MANAGEMENT

History
Clinical Examination
Investigations
Treatment
PRINCIPLES OF MANAGEMENT

Deal with the infertile couple together

No one is at fault or to blame
Carry out investigations and treatment
consistently in proper sequence.
Adekunle A.O.

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RATIONALE FOR SEEING COUPLE AS

A UNIT

To determine presence of single or multiple

defects;

Engender cooperation between couples on

one hand or couple and gynaecologist on the
other;

Assess level of motivation and emotional

stress of partners;

Improve liaison with other specialists to be

involved e.g., urologist.
Adekunle A.O.

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History Taking Female Factors

Age, Current problems.

In utero DES exposurestenosis/cervical
abnormalities
History of pubertal
development (menarche
etc)
Present menstrual cycle
characteristics (length,
duration)
Contraceptive history;
Frequency of
intercourse, timing,
correct acts,
dyspareunia
Galactorrhoea
Hirsutism

Prievious pregnancies,
outcomes
Previous surgeries,
especially pelvic
Previous infectionsSTIs, PID, Abortions
Past treatments/current
treatments
History of abnormal pap
smear, treatment;
Drugs and medication
Hereditary disease.
General health (Diet,
weight stability,
exercise patterns,
review of systems).
13
Adekunle A.O.

History Taking Ovulatory Factors

Excessive weight loss/weight gain (20%

below or above body weight);

Excessive exercise;

Extreme emotional stress:

death of loved ones;

relocation of home;
Holding too many jobs/responsibilities.

History of heat /cold intolerance, change in

mood - Thyroid disease;

Acne /oily skin - suggests androgen excess;

Exclude galactorrhoea
Adekunle A.O.

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History Taking Peritoneal Factors

History of appendicitis /appendix rupture;

Abdominal pelvic operations;

Treatment for P.I.D. (especially chlamydia,

gonoccocal infections);

Previous IUCD insertion;

Premenstrual spotting, dysmenorrhoea,

dyspareunia Endometriosis.
Adekunle A.O.

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History Taking Cervical Factors

Factors that decrease quantity or quality of

cervical mucus may decrease sperm
viability:

Previous operation on the cervix D & C,

conization, previous abortions;
Prenatal exposure to DES (stenosis &
abnormalities)
Chronic cervicitis,
Douching and use of vaginal lubricants.

Cervical incompetence.
Adekunle A.O.

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History Taking Uterine Factors

Previous abortions,

Previous D & C;

Prenatal exposure to DES -- T-shaped

uterus;

Uterine syneachiae;

Fibroids;

Polyps
Adekunle A.O.

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History Taking Male Factors

Occupation excess heat, radiation, toxic

chemicals,? Sedentary jobs;

In utero DES exposure (microphallus,

epidydymal cysts, hypertrophy of the
prostatic utricle);

Congenital abnormalities (History of

undescended testes);
(Presence of unilateral undescended testes
leads to impaired spermatogenesis)

Prior paternity;
Adekunle A.O.

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History Taking Male Factors (Contd.)

Frequency of intercourse
Sexual function (difficulty in achieving or
maintaining erection)
Exposure to toxins (environmental)
Previous surgery (Testicular operations/
Bladder neck/ Prostate operation; Testicular
cancer)
Previous infections, treatment (e.g. STIs,
mumps orchitis)
Drugs and medications (e.g.,sulphasalazine,
cimetidine, nitrofurantoin)
General health (diet, exercise, review of
systems)
Adekunle A.O.

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Examination of the Infertile Couple Female

Look for signs of endocrine or other

systemic diseases;

Examine:
Heart, lungs, check the BP
Breasts abnormal masses, Check for
galactorrhoea
Abdomen
Pelvis

Perform postcoital test (PCT)

Adekunle A.O.

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Examination of the Infertile Couple Male

Look for signs of endocrine or other

pathology, e.g. eunochoid features;

Examine:
heart, lungs (exclude gynaecomastia),
abdomen,
penis, testes, (exclude varicocoeles,
hydrocoele and hernia (supine and
standing).

Perform rectal examination

Adekunle A.O.

21

INVESTIGATIONS
AIMS OF INVESTIGATIONS

To offer an explanation of the infertility;

A prognosis, and
A basis for treatment.
GENERAL LABORATORY INVESTIGATIONS (Both
partners)

Blood group, Hb, W.B.C., E.S.R., test for syphilis,

Chest x-ray if any history or suspicion of respiratory

disease or TB.

Urinalysis glucose, protein, bacteriology.

Adekunle A.O.

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INVESTIGATIONS: Tests of Ovulation

BASAL BODY TEMPERATURE RECORDING
(BBTR)

A temperature rise in mid-cycle sustained for

about 14 days suggests that ovulation may
have taken place, but it is not an accurate
index of progesterone levels.

The following features may suggest, but are

not diagnostic of abnormal ovulation
patterns:
monophasic (perhaps an inability to take
the temperature)

slow rise in temperature, or short elevation

of temperature
Adekunle A.O.

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INVESTIGATIONS: Tests of Ovulation

Serum progesterone
Mid-luteal phase (day 21- 23 of a 28 day cycle)

Endometrial biopsy
If no hormone assays are available and to
exclude tuberculosis where the disease is
common.
(Premenstrual phase ---Secretory changesevidence of ovulation).

Ovulation patterns vary between cycles and it

may therefore be necessary to repeat tests on
more than one occasion.
Adekunle A.O.

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INVESTIGATIONS: Tests of Ovulation

Serum progesterone levels

Is 2 or 3 times as high as those of the rest of the

cycle (15ng/ml compared with 3 to 6ng/ml) if
ovulation has occurred.
If not, FSH rather than LH levels should be checked
for they are more specific of ovulation.
Prolactin levels should be measured to exclude
microadenomata of the pituitary gland; levels > 1000
mu/L are significant and should lead to a CT scan of
the pituitary fossa).

Vaginal cytology and cervical mucus

Laparoscopy
Serial ultrasound folliculography
Adekunle A.O.

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INVESTIGATIONS: Tests of Tubal

Patency

LAPAROSCOPY
Tubal patency may be tested under direct
vision at laparoscopy.

A solution of methylene blue is injected

through a tightly fitting cannula (Sparksman
or Rubin) in the cervical canal.

The passage of the dye may be observed:

When the tubes are normally patent, the dye

pours out of the fimbriated end of the tube into
the pouch of Douglas.

Tubal obstruction may be recognized as can the

presence of adhesions; hydrosalpinx may be seen
to fill with dye that does not spill.
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Adekunle A.O.

INVESTIGATIONS: Tests of Tubal

Patency
HYSTEROSALPINGOGRAHY (HSG)

May be done to evaluate blockage of the

tubes and to show the site of obstruction;

It can also demonstrate a congenital

malformation of the cavity of the uterus,
which will not be apparent at laparoscopy.

A radio- opaque aqueous solution is injected

through the cervix to access the uterine
cavity and patency of the fallopian tubes.
Adekunle A.O.

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INVESTIGATIONS: Tests of Tubal

Patency
HYSTEROSALPINGOGRAHY (Contd.)

Timing: Within the first 10 days of menstruation (but

at least two days after stoppage of menstrual blood
flow) in order to avoid inadvertent exposure of the
early embryo to ionizing radiation.

Free spillage of dye from both tubes confirms

patency.
Loculated spill may indicate peritubal adhesions and
A club-shaped, dilated appearance on X-rays may
suggest hydrosalpinges.
Filling defects in the uterine cavity are due to
submucous fibroids, polyps or adhesions.

Adekunle A.O.

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INVESTIGATIONS: Other Tests of Tubal

Patency
CARBON DIOXIDE INSUFFLATION

Is rarely done now because of the dangers of

gas embolism.
HYSTEROCONTRASTSONOGRAHY (HyCoSy)

A modern, ultrasound-based investigation

using a negative (normal saline) and positive
(Echovist) contrast medium to outline the
uterine cavity and fallopian tubes.

It is a simple test to asses the uterine cavity

and tubal potency and it avoids exposure to
x-rays.
Adekunle A.O.

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INVESTIGATIONS: Other Tests in the

Female

ULTRASOUND
TAS - Global view of the uterus, adnexa and lower
abdomen.
TVS - More detailed evaluation of the uterus &
adnexa.

Evaluates thickness of the endometrium

Favorable endometrium (periovulatory) =7-11mm

OTHER RADIOLOGICAL EXAMINATIONS

Skull x-ray (cone view of the sella turcica).

CT scan/MRI
HYSTEROSCOPY
Submucuos uterine leiomyoma
Intrauterine adhesions or Uterine septum.
TUBOSCOPY AND FALLOSCOPY
Adekunle A.O.

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INVESTIGATIONS: Male Fertility Tests

SEMEN ANALYSIS (WHO Reference values)

Volume: 2 - 5ml
Liquefaction time: within 30minutes
Concentration: 20 million/ml (20 - 250 million/ml)
Motility: > 50% Progressive motility
Morphology: > 50% normal forms
White blood cells: < 1 million / ml
pH = 7.2-7.8
Process: - Masturbation after 2-3 days of sexual
abstinence and examined within 2 hours of collection.

(A second specimen is examined if the first shows sub

optimal results).

Adekunle A.O.

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INVESTIGATIONS: Male Fertility Tests

SEMEN VARIABLES (Nomenclature)

Normozoospermia: Normal ejaculates as defined

by the reference values.
Oligozoospermia: Sperm Concentration less than
the reference value.
Asthenozoospermia: Less than the reference
value for motility.
Teratozoospermia: Less than the reference value
for morphology
Oligoasthenoteratozoospermia: Signifies
disturbance of all three variables. (Combination
of only two prefixes may also be used.
)
Azoospermia: No spermatozoa in the ejaculate.
Aspermia: No ejaculate.

Adekunle A.O.

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INVESTIGATIONS: Male Fertility Tests

ADVANCED SEMEN ANALYSIS

Photomicrography,

Video micrography

These tests are:

Objective, accurate, and reproducible .

They measure;

Linear velocity
Curvilinear velocity
Cross beat velocity
Lateral head displacement
Adekunle A.O.

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INVESTIGATIONS: Male Fertility Tests

POSTCOITAL TEST (SIMS-HUNNER TEST)
Performed in the mid-cycle and within 6-10 hours after
intercourse. The couple should abstain from
intercourse for 3 days. It is possible to assess the
cervical mucus, sperm motility and morphology.

Normal (positive): more than 5 sperms with progressive motion

per HPF
Inconclusive: 1-5 sperms with good motility.
Abnormal (negative): no sperm or all immobile/ non-progressive
or sperm agglutination

OTHER MALE TESTS

HORMONAL ASSAY----LH, FSH, TSH, Prolactin,
Testosterone
TESTICULAR BIOPSY is unnecessary as it may
compromise future therapy like ICSI except if testicular
CIS is suspected.
VASOGRAPHY

Adekunle A.O.

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TREATMENT Female Infertility

ANOVULATION

Clomiphene citrate.

Tamoxifen

Cyclofenil

Gonadotrophins

Pergonal ( hMG)
Adekunle A.O.

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TREATMENT Female Infertility

TUBAL SURGERY
Microsurgery (Microscopy)
Macro /open surgery (Laparotomy)

Aim: To restore normal anatomy (restore

patency and function) in cases where the
tubes have been damaged by infection.

Salpingolysis: Peritubal adhesions are

divided.
Salpingo-ovariolysis: Removal of
peritubal and periovarian adhesions.
Salpingostomy: Where the fimbrial end is
opened and held open by turning out a
cuff. (Conception rate < 20%).
Adekunle A.O.

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TREATMENT Female Infertility

TUBAL SURGERY (Contd.)

Fimbrioplasty: Division of fimbrial adhesions

or repair of fimbrial disease (Conception=
30% - 50%)
Salpingoneostomy: Creation of a new uterine
tubal orifice
Tubal reimplantation: Where the isthmus is
blocked. The medial tubal end is freed and is
re-implanted into the uterine cavity
Re-anastomosis: If the tube is blocked in the
mid segment, the obstructed area is resected
and the open ends re-anastomosed oftenusing microsurgery. (Conception rate 10
-15%).
Adekunle A.O.

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TREATMENT Male Infertility

Male fertility depends on sperm quality rather

than numbers.
Hypogonadotropic hypogonadium: Hormonal
treatment (Exogenous hCG +/-GnRH for 12 mths)
Poor sperm motility: Intrauterine insemination +
ovarian stimulation. (AID, AIH)
Infection: Antioxidant therapy (Vitamin E +
Vitamin C) + Antibiotics
Antisperm antibodies: Systemic steroids.
Varicocele: Varicocelectomy
Assisted conception: ICSI
Azoospermia: Sperm aspiration + ICSI
(Chromosomal testing for cystic fibrosis,
karyotyping and Y micro deletions prior to
treatment).
Adekunle A.O.

38

ASSISTED CONCEPTION
TECHNIQUES

First IVF success: Louise Brown on 25/7/78.

Since then, many centres have sprung up all over

the world.

Techniques
IVF
DI
GIFT
ZIFT
SUZI
ICSI
TESA
PESA
MESA

--- In vitro fertilization

--- Donor insemination
--- Gamete intrafallopian transfer
--- Zygote intrafallopian transfer
--- Subzonal insemination
--- Intracytoplamic sperm injection
--- Testicular sperm aspiration
--- Percutanous sperm aspiration
--- Micro-epididymal sperm aspiration.
Adekunle A.O.

39

ASSISTED CONCEPTION
TECHNIQUES
SUCCESS OF IVF/ GIFT

PREGNANCY
1 Embryo 3 embryos -

< 10%
25-30% (single)
5% (twins
1-2% (triplets)

TAKE- HOME BABY RATE: 15-20% for each

Adekunle A.O.

40

ASSISTED CONCEPTION
TECHNIQUES
INDICATIONS FOR IVF

Severe tubal disease

Failed tubal surgery

Endometriosis

Hostile cervix

Unexplained infertility
Adekunle A.O.

41

ASSISTED CONCEPTION
TECHNIQUES
COMPLICATIONS OF IVF

Hyperstimulation syndrome

Pelvic abscess following egg retrieval

Ectopic pregnancy

Anembryonic pregnancy

Spontaneous abortion

Premature delivery

IUGR
Adekunle A.O.

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OTHER MODES OF TREATMENT

Adoption

Surrogacy

Cloning

Adekunle A.O.

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FACTORS CONTRIBUTING TO THE

INCREASED DEMAND OF TREATMENT

Increased numbers of women in the

reproductive age group.

A trend towards a later age of child bearing,

with more years of exposure to infections or
toxins as well as age- specific reduction in
fertility.

Availability of new technology and drugs for

treatment of previously hopeless cases.

Greater public awareness of the availability

and scope of such services.
Adekunle A.O.

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