Female Infertility

dr Jaqueline Sudiman, PhD

 Objectives

• To define primary and secondary infertility

• To understand hypothalamus-hypophysis-
gonadal axis, ovulation and menstrual cycle
• To describe the causes of infertility
• To diagnosis infertility
• To manage the causes of infertility
 Infertility

Definition:
• Primer : the inability to get pregnant after
a year of unprotected intercourse (<35
years old) or six months (>35 years old)
• Seconder: infertility that occurs after
previous pregnancy regardless of
outcome

Affects 15% of reproductive couples

Men and women equally affected
 Requirements of conception

• Production of healthy egg

and sperm
• Unblocked tubes that allow
sperm to reach the egg
• The sperms ability to
penetrate and fertilize the
egg
• Implantation of the embryo
into the uterus
• Finally a healthy
pregnancy
 Cause of infertility
• Ovulation disorders:
- Hypothalamus-hypophysis-gonadal axis disorder
- Polycystic ovary syndrome (PCOS)
- Premature ovarian Failure (POF)

• Non-patent fallopian tube:

- infection, endometriosis

• Uterus abnormalities:
- Myoma, polyp, asherman syndrome

• Genetic abnormality
- Androgen insensitivity syndrome
- Turner syndrome (XO)
• Age
• medicines and drugs
• unexplained
Hypothalamus-hypophysis-gonadal axis disorder
PCOS (Polycystic ovary syndrome)
• Increased serum concentration of LH, increased LH/FSH
ratio, increase in amplitude and frequency of pulsatile LH
secretion

• Rotterdam consensus:
- infrequent or prolonged menstrual periods (oligo-
and/or anovulation)
- signs of hyperandrogenism (excess hair growth,
acne)
- polycystic ovaries

• Related with:
- obesity
- associated with type II DM (insulin resistance) and
hypertension
Premature ovarian failure (POF)
• The main characteristics are absence of ovulation,
amenorrhoea and high levels of serum gonadotropins
(hypergonadotropic hypogonadism)

• Potential causes: iatrogenic (ovarian surgery,

radiotherapy or chemotherapy), environmental
factors, viral infections, metabolic and autoimmune
diseases, and genetic alterations

• The traditional indicators to evaluate ovarian ageing

are age, serum hormonal levels, anti-Mullerian
hormone, antral follicle count, and ultrasonography of
ovaries.
 Non-patent fallopian tube
• Unable to let oocyte and sperm converge

Obstructions:
- Proximal: Near the uterus
- Medial: In the middle of the tube
- Distal: At the end of the tube, near the fimbrea

• Mostly caused of Chlamydia trachomatis, pelvic

inflammatory disease (PID), septic abortion, endometriosis,
peritonitis, appendicitis

• evaluation: hysterosalpingogram and laparascopy

 Severe Endometriosis
• Tissue similar to the uterine lining (endometrium)
attaches to organs in the pelvis and begins to
grow (adhesion in many organs)

• Sampson’s theory: In menstrual period, the

uterine lining and blood is shed through the
cervix and vagina. However, some of this tissue
enters the pelvis through the fallopian tubes
(backflow/retrograde menstruation)

• Symptoms: menstrual cramps, chronic pelvic

pain, or painful intercourse and infertility
 Uterus Abnormalities
• Myoma:
- A uterine myoma (myoma uteri) is a solid tumor made
of fibrous tissue.
- Myomas vary in size and number, slow-growing.
- Myomas are the most frequently diagnosed tumor of
female pelvis and the most common reason for a woman
to have a hysterectomy
• Related with pain during sexual intercourse and
endometrium receptivity

• The cause of myomas has not been determined, but most

uterine myomas develop during reproductive years (related
with estrogen production).
Androgen Insensitivity
Syndrome
Androgen Insensitivity Syndrome
• Complete androgen insensitivity syndrome
- genotype: 46, XY
- phenotype: female, breast, primary amenorrhea,
shorten vagina, absent uterus, ovaries
- Infancy: labial swelling or inguinal hernia containing
testis
- Endocrine profile: Elevated testosterone and LH, lower
estradiol

• Partial androgen insensitivity syndrome

- phenotype: could be female or male (depend on degree
of responsiveness of external genetalia to androgens).
Male usually has micropenis, severe hypospadias, bifid
scrotum contain gonads

• Mild androgen insensitivity syndrome

- phenotype: male with reduced fertility and gynecomastia
 Turner Syndrome
• True syndrome: 45XO
• Mosaics chromosome: 45X/46XX, 46XXq, 46XXp
deletions

https://healthjade.com/turner-syndrome/
 Others

• In general, reproductive potential decreases as

women get older. Woman has been expected
to get pregnant in the age below 35 years old

• Other factors such as obesity, lack of exercise,

alcohol, nicotine and stress also reduce
fecundity of women

• Few cases of infertility are still unexplained

 Investigation of infertility
• clinical anamnesis
• physical examination
• laboratory finding
 Anamnesis
• parity
• duration of infertility
• cycle length and characteristic
• coital frequency
• past surgery
• exposure of sexually-transmitted infection
• occupation
• intake of tobacco, alcohol, and other drugs
• dyspareunia and stress related factors
 General physical and local evaluation

General physical
• weight and body mass index
• any thyroid enlargement
• breast secretion
• signs of androgen excess: acne and
hirsutism

Local Evaluation
• pelvic or abdominal tenderness
• vaginal or cervical abnormality and discharge
 Laboratory findings
• Ultrasonography (transvaginal sonography)
to evaluate the ovarial reserve, follicle development and
ovulation, and uterine patology

• Laboratory medical machine

to evaluate the hormonal status

• hystrerosalphingography (HSG)
to evaluate tubal patency and pathology of uterine cavity

• hysteroscopy and laparoscopy

to evaluate abnormalities of ovarium, uterine cavity,
tubal patency and any abnormalities of pelvic cavity
 Infertility care units
• Primary infertility care unit: basic investigations, treatment of minor
anatomical defect, medical management of minimal and mild
endometriosis, induction ovulation in non-ovulation women and
referring couples to secondary or tertiary infertility care units

• Secondary infertility care unit is responsible for further

investigations such as immunological test for infertility,
hysteroscopy, laparoscopy and transvaginal sonography (TVS),
and extending treatments of infertility such as repairing tubal
obstruction

• Tertiary infertility care unit is responsible for advanced diagnostic

procedures, therapeutic and research such as examine endocrine
assay for hormonal profile, use Color Doppler for growing follicles,
perform all varieties of assisted reproductive technologies including
conservative intrauterine insemination (IUI), intracytoplasmic sperm
injection (ICSI), sperm or oocyte banking and embryo
cryopreservation