infertility

Infertility –inability to conceive a child or sustain a

pregnancy
is said to exist when a pregnancy has not occurred
after at least 1 year of engaging in unprotected
coitus (Johnson, 2003).
Primary infertility – no previous conceptions
Secondary infertility – has been a previous viable
pregnancy but the couple is unable to conceive at
present
Sterility – inability to conceive because of a known
condition, such as the absence of uterus.
Subfertility – is a lessened ability to conceive
 infertility
When engaging in coitus an average of four times
per week, 50% of couples will conceive within 6
months, and 85% within 12 months.
Couples who engage in coitus daily may actually
have more difficulty conceiving than those who
space coitus to every other day.
Chance of infertility increases with age
Women who are using oral, injectable or
implanted hormones for contraception may have
difficulty becoming pregnant for several months
after discontinuing these medications, because it
takes that long for the body to restore normal
functioning.
 infertility
Male Infertility Factors
A number of factors typically lead to male infertility:
Disturbance in spermatogenesis
Obstruction in the seminiferous tubules, ducts, or
vessels preventing movement of spermatozoa
Qualitative or quantitative changes in the seminal fluid
preventing sperm motility
Development of autoimmunity that immobilizes sperm
Problems in ejaculation or deposition preventing
spermatozoa from being place close enough to the
woman’s cervix to allow ready penetration and
fertilization
 infertility
Inadequate Sperm Count
Sperm count – the number of a sperm in a single ejaculation or
in a milliliter of semen.
The minimal sperm count considered normal is 20 million per
milliliter of seminal fluid, or 50 million per ejaculation.
At least 50% should be motile, and 30% should be normal in
shape and form
Spermatozoa must be produced and maintained at
temperature slightly lower than the body temperature to
become normal and fully motile
Congenital abnormalities such as cryptorchidism may lead to
lowered sperm production if surgical repair of this problem
was not completed after puberty or if the spermatic cord
became twisted after the surgery
 infertility
other conditions that might affect
male infertility:
Varicocele (varicosity of the spermatic vein)
Trauma to the testes
Surgery on or near the testicles that
results in impaired testicular circulation
Endocrine imbalances
Drug use
Excessive alcohol use
Exposure to x-rays
 Obstruction or Impaired infertility
Sperm Motility
Obstruction may occur at any point along the pathway that spermatozoa travel
to reach the outside
Diseases such as mumps orchitis, epididymitis, and tubal infections such as
gonorrhea or ascending urethral infection can result in this type of obstruction
because of adhesions and occlusions that interfere with sperm transport
Hypertrophy of the of the prostrate gland occurs in many men beginning about
50 years of age. Pressure from the enlarged gland on the vas deferens can
interfere with the sperm transport
A few men who has vasectomies and scarring after an infection develop an
autoimmune reaction or form antibodies that immobilize their own sperm
Hypospadias or epispadias can cause sperm to be deposited too far from the
sexual partner’s cervix to allow optimal cervical penetration
Extreme obesity may also interfere with effective penetration and deposition
 infertility
Ejaculation Problems
Psychological problems, debilitating diseases such as
cerebrovascular accident or Parkinson’s disease, and some
medications may result in erectile dysfunction (formerly
called impotence)
This condition is considered primary if the man has never
been able to achieve erection and ejaculation and
secondary if the man has been able to achieve ejaculation in
the past but now has difficulty.
Can be a difficult problem to solve if it is associated with
stress, because this is not usually relieved
Premature ejaculation is another factor that may interfere
with the proper deposition of the sperm. It is another
problem often attributed to psychological causes
 infertility
Female Infertility Factors
factors are analogous to those causing
infertility in men:
Anovulation
Problems of ova transport through the
fallopian tubes to the uterus
Uterine factors such as tumors or poor
endometrial development
Cervical and vaginal factors that
immobilize spermatozoa
 infertility
Anovulation
Or absence of ovulation, the most common cause of
infertility among women,
May occur from a genetic abnormality such as Turner’s
syndrome (hypogonadism) in which there are no ovaries
to produce ova
May result from a hormonal imbalance caused by a
condition such as hypothyroidism that intereferes with
hypothalamus pituitary-ovarian interaction.
Ovarian tumors may produce anovulation due to
feedback stimulation on the pituitary
Chronic or excessive exposure to x-rays or radioactive
substances, general ill health, poor diet, and stress may
all contribute
 infertility
Anovulation
Stress affect the ovaries by reducing hypothalamic
secretion of gonadotropin-releasing hormone (GnRH),
which then lowers the production of luteinizing hormone
(LH) and follicle-stimulating hormone (FSH)
Decreased body weight or a body/fat ratio of less than
10% as may occur in female athletes or in women who are
excessively lean or anorexic, can reduce pituitary
hormones such as FSH and LH and halt ovulation (termed
hypogonadotrophic hypogonodism)
The most frequent cause, however, is naturally occurring
variations in ovulatory patterns or polycystic ovary
syndrome, a condition in which the ovaries fail to respond
to FSH. Some women ovulate only a few times a year
because of polycystic ovary syndrome
 infertility
Tubal Transport Problems

Usually occurs because of scarring

Typically caused by chronic salpingitis (chronic
pelvic inflammatory disease). It can result from a
ruptured appendix or from abdominal surgery
involving infection that spread to the fallopian
tubes and left adhesion formation in the tubes
 infertility
Pelvic Inflammatory Disease
is infection of pelvic organs: the uterus, fallopian
tubes, ovaries, and their supporting structures
Can spread even further causing pelvic peritonitis
Chlamydia and gonorrhea are among those most
frequently causing PID
Occurs at a rate of 25 per 100 women – ¼ of all
women will experience this type of infection in a
lifetime
About 20% of those who acquire PID will be left
infertile
There may be higher incidence of PID among
women who are using intrauterine devices (IUDs)
 infertility
Pelvic Inflammatory Disease
Usually begins with a cervical infection that spreads by
surface invasion along the endometrium and then out
to the fallopian tubes and ovaries
Such invasion is most apt to occur at the end of a
menstrual period, because menstrual blood provides
and excellent growth medium
There also is lost of the normal cervical mucus barrier
at this time, which increases the risk for initial invasion
If left unrecognized or untreated, PID enters a chronic
phase, which causes the scarring that can lead to
stricture of the fallopian tubes and resulting fertility
problems
 infertility
Uterine Problems
Tumors such as fibromas (leiomyomas) may be a
rare cause of infertility if they block the entrance of
the fallopian tubes into the uterus or limit the
space available on the uterine wall for effective
implantation
Congenitally deformed uterine cavity may limit
implantation sites – rare
Poor secretion of estrogen or progesterone from
the ovary inadequate endometrium
formation
 infertility
Uterine Problems
Endometriosis
Refers to the implantation of uterine endometrium, or
nodules, that have spread from interior of the uterus
to locations outside the uterus
The most common sites of spread include Douglas’s
cul-de-sac, the ovaries, the uterine ligaments, and the
outer surface of the uterus and bowel
Occurs in as many as 50% of women, most probably
from the regurgitation through the fallopian tubes at
the time of menstruation
Viable particles regurgitated begin to proliferate and
grow
 infertility
Endometriosis
If growth occur in the fallopian tubes, tubal
obstruction may result or adhesions forming from
these growths may displace fallopian tubes away
from the ovaries, preventing the entrance of the ova
into the tubes
Peritoneal macrophages that are drawn to these
distant sites when the abnormal tissue is recognized
can destroy sperm
The occurrence of endometriosis may indicate that
the endometrial tissue has different or more friable
qualities than normal endometrium
 infertility
Cervical Problems
Infection or inflammation of the cervix (erosion) may
cause so much thickening in the cervical mucus that
spermatozoa cannot penetrate it easily or survive in
it
A stenotic cervical os or obstruction of the os by a
polyp may further compromise penetration
This is rarely enough of a problem to be the sole
cause of infertility
A woman who has undergone D&C procedures
several times or cervical conization should be
evaluated in light of the possibility that scar tissue
and tightening of the cervical os has occurred
 infertility
Vaginal Problems
Infection of the vagina can cause the pH of the
vaginal secretions to become acidotic, limitying or
destroying the motility of spermatozoa
Some women appear to have sperm-immobilizing
or sperm-agglutinating antibodies in their blood
plasma that act to destroy the sperm cells in the
vagina or cervix
 infertility
Unexplained Infertility

In a small proportion of couples, no

known cause for infertility can be
discovered
 infertility
Fertility Assessment
Not all couples who desire fertility testing want
to have children immediately but for their peace
of mind that they are fertile
Others want to know if they are infertile so they
can discontinue contraceptive measures
The age of the couple and the degree of
apprehension they feel about possible infertility
make a difference in determining when they
should be referred for fertility evaluation
As a rule of thumb, if the woman is younger
than 35 years of age, she should be referred for
evaluation after 1 year of infertility; if older than
35 years, after 6 months of infertility.
 infertility
Health History
A minimum history for the man should include
the ff:
• General health
• Nutrition
• Alcohol, drug, or tobacco use
• Congenital health problems such as hypospadias or
cryptorchidism
• Illnesses such as mumps orchitis, UTI, or STD
• Operations such as surgical repair of a hernia, which could
have resulted in a blood compromise to the testes
• Current ilnesses, particularly endocrine illnesses or low-grade
infection
• Past and current occupation and work habits
 infertility
It is important to document sexual practices such as the
frequency and coitus and masturbation, failure to achieve
ejaculation. Premature ejaculation, coital positions used,
use of lubricants and past contraceptive measures, and
existence of any children produced from a previous
relationships
A woman should be asked about current or past
reproductive tract problems, such as infections; her overall
health, emphasizing endocrine problems such as
galactorrhea (breast nipple secretions) or symptoms of
thyroid dysfunction; and any abdominal or pelvic operations
she has had that could have compromised blood flow to
pelvic organs.
Additional questions focus on the frequency of using
douches or intravaginal medications or sprays; exposure to
occupational hazards such as x-rays or toxic substances; and
nutrition especially folic acid intake
also, obtain information from the woman about
whether she can detect ovulation. Pay particular
attention to the typical symptoms, such as breast
tenderness and midcycle “wetness” that indicate
ovulation.
Menstrual history should also be obtained including:
• Age of menarche
• Length, regularity, and frequency of menstrual
periods
• Amount of flow
• Any difficulties experienced, such as dysmenorrhea
or premenstrual dysphoric order
• History of contraceptive use
• History of any previous pregnancies or abortions
 infertility

Take time with each partner individually and as a

couple to encourage questions and to discuss
overall attitudes toward sex relations, pregnancy
and parenting.
A frank discussion centered on resolving couple’s
fears and clearing up any long-standing confusion or
misinformation will help to set a positive tone for
future interactions, establish a feeling of trust with
health care personnel, and increase self-esteem.
 infertility
Physical Assessment

For the man, inspect in particular for secondary

sexual characteristics and genital abnormalities
such as the absence of vas deferens, or the
presence of undescended testes or a varicocele
(enlargement of a testicular vein).
The presence of hydrocele (collection of fluid in
tunica vaginalis of the scrotum) is rarely associated
with infertility but should be documented if
present.
 infertility

For the woman, it includes breast and thyroid

examination is necessary
Maturity of secondary sex characteristics and good
pituitary function
Complete pelvic exam including Pap smear
 infertility
Fertility Testing
Basic fertility testing includes only 3 tests: semen analysis in the male,
and ovulation monitoring and tubal patency assessment in the female
Additional testing for men, if warranted, can include urinalysis; a
complete blood count; blood typing, including Rh factor, a serologic
test for syphilis; a test for the presence of HIV, erythrocyte
sedimentation rate; protein-bound test; cholesterol level, and
gonadotropin, prolactin, and testosterone levels
Advanced testing for the women may include a rubella titer, a
serologic test for the syphilis, and an HIV evaluation.
If a woman has symptoms of thyroid dysfunction, a thyroid uptake
determination and thyroid-stimulating hormone level may be
ordered.
If a woman has history of menstrual irregularities, blood may be
assayed for FSH, estrogen, LH, and progesterone levels
If a woman has a history of galactorrhea, a serum prolactin level will
be obtained.
 infertility
Semen Analysis
For a semen analysis, after 2 to 4 days of sexual
abstinence, the man ejaculates by masturbation into a
clean, dry, specimen jar, and the spermatozoa are
examined under a microscope within 1 hour
The number of specimen are counted, and their
appearance and motility are noted.
An average ejaculation should produce 2.5 to 5.0 mL
of semen and should contain a minimum of 20 million
spermatozoa per mL of fluid (the ave. normal sperm
count is 50 to 200 million per mL
The analysis may need to be repeated after 2 or 3
months, because spermatogeneses is an ongoing
process, and 30 to 90 days is needed for new sperm to
reach maturity
 infertility
Sperm Penetration Assay and
Antisperm Antibody Testing
Although sperm penetration studies are rarely
necessary, they may be carried out to determine
whether a man’s sperm, once they reach an ovum,
can penetrate it effectively.
With the use of an artificial reproductive technique
such as IVF, poorly mobile’s sperm or those with
poor penetration can be injected ito the woman’s
ovum under laboratory conditions
(intracytoplasmic injection), bypassing the need for
sperm to be fully mobile.
 infertility
Ovulation Monitoring
The least costly way to determine a woman’s ovulation pattern is to ask her to
record her basal body temperature (BBT) for at least 1 month.
To determine this, the woman takes her temperature each morning, before
getting out of bed or before engaging in any activity, eating, or drinking, using
a special BBT or tympanic thermometer.
She plots this daily temperature on a monthly graph, noticing conditions that
might affect her temperature (e.g. colds, other infections, and sleeplessness).
At the time of ovulation, the basal temperature can be seen to dip slightly
(about 0.5F); it then rises to a level no higher than normal before the next
menstrual flow.
This increases in BBT marks the time of ovulation, because it occurs
immediately after ovulation (actually at the beginning of the luteal phase of
the menstrual cycle, which can occur only if ovulation occurred).
A temperature rise should last approximately 10 days. If it does not, a luteal
phase defect is suggested
 infertility
Ovulation Determination by Test Strip

This can be used in place if BBt monitoring

The woman dips a test strip into a midmorning urine
specimen and then compares it with the kit
instructions for a color change.
They are not a economical as simple temperature
recording, but they are advantageous for women with
irregular work or daily activity schedules, which can
make BBt measurement inaccurate
 infertility
Tubal Patency
Both ultrasound and x-ray imaging can be used not only
to determine the patency of fallopian tubes but also to
assess the depth and consistency of the endometrial
lining

Sonohysterography
• Is an ultrasound technique designed for inspecting the
uterus. The uterus is filled with sterile saline,
introduced trough a narrow catheter inserted into the
uterine cervix. A transvaginal ultrasound transducer is
then inserted into the vagina to inspect the uterus for
abnormalities such as septal deviation or the presence
of myoma.
 infertility
Hysterosalpingography

A radiologic examination of the fallopian tubes using a

radiopaque medium, is the most frequently used
method of assessing tubal patency.
This is scheduled immediately after the menstrual flow
to avoid reflux of menstrual debris up the tubes and
unintentional irradiation of a growing zygote, it is
contraindicated if infection of the vagina, cervix, or
uterus is present
It is contraindicated if infection of the vagina, cervix, or
uterus is present
 infertility
Advanced Surgical Procedures
Uterine endometrial Biopsy
May be used as a test for ovulation or to reveal an
endometrial problem such as luteal phase defect.
If the endometrium resembles a corkscrew, this
suggests that ovulation has occurred.
Endometrial biopsies are being performed less
commonly, having been replaced with serum
progesterone level evaluations.
 infertility

Hysteroscopy

Is visual inspection of the uterus through the

insertion of a hysterosope, a thin hollow tube,
through the cervix. This is helpful if uterine
adhesions or other abnormalities were discovered
on the hysterosalpingogram.
 infertility
Laparoscopy

Is the introduction of a thin, hollow, lighted tube (a

fiberoptic telescope or laparoscope) through a small
incision in the abdomen, just under the umbilicus, to
examine the position and state of the fallopian tubes
and ovaries.
It is rarely done unless the results of
uterosalpingography are abndormal.
It is scheduled during the follicular phase of a
menstrual period and is done under general anesthesia
because if the pain caused by extensive maneuvering.
 infertility
Infertility Management
Correction of the Underlying Problems
The overall management involves treating such
underlying causes such as chronic disease,
inadequate hormone production, emdometriosis, or
infection.
If correction of these problems are not successful,
infertility management focuses on achieving
conception through an assisted reproductive
technology such as IVF and sperm donation.
 infertility
Increasing Sperm Count and Motility
If sperm are not motile because the vas deferens is obstructed, the
obstruction is most likely to be extensive and difficult to relieve by
surgery. If sperm are present but the total count is low, a man might be
advised to abstain from coitus for 7 to 10 days to increase the count.
Ligation of a varicocele (if present) and changes in lifestyle may be
helpful to reduce a scrotal heat and increase the sperm count.
Sperm can be extracted by syringe from a point proximal to the
blockage and used for intrauterine insemination. If the problem
appears to be that sperm are immobilized by vaginal secretions due to
an immunologic factor, the response can be reduced by abstinence or
condom used for about 6 months.
To avoid this prolonged time interval, washing off the sperm and
intrauterine insemination may be preferred. The administration of
corticosteroids to the woman may have some effect in decreasing
sperm immobilization because it reduces her immune response and
antibody production.
 infertility
 
Reducing the presence of infection

If a vaginal infection is present, the infection will be

treated according to the causative organism
based on culture reports. Vaginal infections such
as trichomoniasis and moniliasis tend to recur,
requiring close supervision and follow-up.
 infertility
Hormone Therapy

If the problem is a disturbance of

ovulation, administration of GnRH is
a possibility
 infertility
Surgery
If a myoma (fibroid tumor) is interfering with infertility,
a myomectomy, or surgical removal of the tumor, may
be necessary.
Myomectomy may be done by hysteroscopic
ambulatory procedure if the growth is small. Uterine
adhesions may also be lysed by hesteroscopy.
After this procedure, the woman is prescribed estrogen
for 3 months to prevent adhesions from reforming, and
an IUD is inserted to help prevent the uterine sides
from touching. This treatment can be difficult for a
woman to accept, because preventing pregnancy (using
an IUD) is exactly what she does not want to.
 infertility
Assisted Reproductive Techniques
Artificial Insemination
Artificial insemination by the husband – husband’s
sperm
Artificial insemination by donor or therapeutic donor
– donor’s sperm
These techniques can be used if the man has
inadequate sperm count or if the woman has vaginal

or cervical factor that interferes with sperm motility.

Artificial Insemination infertility
They can also be used if the man has a known genetic
disorder that he does not want transmitted to offspring or if
the woman has no male partner.
Useful for men who, feeling their family was complete,
underwent a vasectomy that cannot be reversed but who
now wish to have children
Today, sperm can be cryopreserved (frozen) in a sperm bank
before radiation or chemotherapy
Disadvantage: it tends to have slower motility, resulted in
ethical, legal, and religious dilemma
Advantages: can be used even after years of storage, but no
increase in the incidence of congenital anomalies in children
conceived by this method.
 infertility
Artificial Insemination
To prepare for artificial insemination, a woman must record
her BBT, assess her cervical mucus, or use an ovulation
predictor kit to predict her likely day of ovulation. On the day
after ovulation, the selected sperm are delivered to her cervix
using a device similar to a cervical cap or diaphragm, or they
are injected directly into the uterus using a flexible cathether.
If therapeutic donor insemination is selected, the donors are
usually volunteers who have no history of disease and no
family history of possible inheritable disorders. The blood
type, or at keast the Rh factor , can be matched with the
woman’s to prevent incompatibility. If a woman desires,
frozen sperm from sperm bank can be selected according to
desired physical and mental characteristics.
 infertility
In Vitro fertilization
One or more mature oocytes are removed from a woman’s
ovary by laparoscopy and fertilized by exposure to sperm under
laboratory conditions outside the woman’s body. About 40
hours after fertilization, the laboratory-grown fertilized ova are
inserted into the woman’s uterus, where ideally one or more of
them will implant and grow.
IVF is most often used for couples who have not been able to
conceive because the woman has blocked or damaged fallopian
tubes. It is also used when the man has oligospermia.
When an absence of cervical mucus prebvents sperm from
travelling to or entering the cervix, antisperm bodies cause
immobilization of the sperm, for a woman who does not
ovulate, who carries a sex-linked disease
 infertility
Gamete Intrafallopian transfer
In GIFT procedures, ova are obtained from
ovaries exactly as in IVF
Both ova and sperm are instilled within a matter
of hours using a laparoscopic technique into the
open end of a patent fallopian tube
Fertilization occurs in the tube, zygote moves to
the uterus for implantation
This procedure is contraindicated if the woman’s
fallopian tubes are blocked because this could
lead to ectopic pregnancy
 infertility
Zygote Intrafallopian Transfer
ZIFT involves oocyte retrieved by transvaginal,
ultrasound-guided aspiration, followed by culture
and insemination of the oocytes in the laboratory.
Within 24 hours, the fertilized eggs are transferred
by laparoscopic technique into the end of a waiting
fallopian tube.
ZIFT differs from GIFT in that fertilization takes place
outside the body,
A woman must have one functioning fallopian tube
because the zygotes are implanted into the
fimbriated end of a tube rather than into the uterus
 infertility
Surrogate Embryo transfer
Is an assisted reproductive technique for a woman who
does not ovulate
The process involves use of an oocyte that has been
donated by a friend or relative or provided by an
anonymous donor
The menstrual cycle of the donor and recipient are
synchronized by administration of gonadotropic hormones
At the time of ovulation, the donor’s ovum is removed by a
transvaginal, ultrasound-guided procedure
The oocyte is then fertilized by the recipient woman’s male
partner’s sperm (or donor sperm) and placed in the
recipient woman’s uterus by embryonic transfer
 infertility
Preimplantation Genetic Diagnosis

Before the oocyte is fertilized, the DNA of both the

sperm and oocytes can be examined for specific
genetic characteristics or other abnormalities
Couples participating in intrauterine transfer and
artificial insemination can have their sex of their
offspring predetermined using these methods.
 infertility
ALTERNATIVES TO CHILDBIRTH
SURROGATE MOTHERS
Is a woman who agrees to carru a pregnancy to term for an infertile
couple
The surrogate may provide the ova and be impregnated in the man’s
sperm
The ova and sperm both may be donated by the infertile couple or
donor ova and sperm may be used
Surrogate mothers are often friends or family members who assume
the role out of friendship or compassion
The infertile couple can enjoy the pregnancy as they watch it progress
in the surrogate
A number of ethical and legal problems can arise if the surrogate
mother decides at the end of pregnancy that she has formed and
attachment to the fetus and wants to keep the baby despite the
pregnancy agreement she signed
 infertility
Adoption

Is till a viable alternative for infertile couple

Often it takes longer to find a child for adoption
than it once did, unless the couple considers
foreign-born or physically or cognitively
challenged children or children of other races
 infertility
Child-free Living
A couple in the midst of fertility testing may begin
to re-examine their motives for pregnancy and may
decide that pregnancy and parenting are not worth
the emotional or financial cost of future treatments
Child-free living has advantages for a couple in that
it allows time for both to pursue careers
infertility