EVALUATION OF THE INFERTILITY COUPLE

INTRODUCTION
Infertility is a world wide problem affecting (5 – 20)% of couple.
Africa is perculia because it has both a high population density and
infertility and Africa is the poorest of the continents with low
capacity and technologies to handle these two problems.

DEFINITION
Infertility is the inability to achieve and sustain a pregnancy to
delivery after at least 1 year of regular (evenly spread 2-3 time,
weekly) unprotected (i.e. without any contraception) and orgasmic
vaginal sexual intercourse with an adult of the opposite sex.
 CONTD
Pregnancy will occur when motile and potent sperm are deposited
at the appropriate period in the cycle. The procedure is as
follows:
(c) History – Emphasizing several areas –
- Age, previous pregnancies and outcome.
- Menstrual cycle – regularity and cyclicing from menache.
- All attempts at previous treatment with traditional and
orthodox approach
- No of wives in the marriage and her position.
- Coital frequency per week
- Whether staying together in same house
 CONTD

In general there is often a degree of infertility in either partner once

there has been consultation for infertility because the partner of
sufficient fertility will compensate for the other partner’s minor
subfertility before there is significant anxiety except there is a major
infertility factor in one partner.
- Evaluation aims to identify the general and specific factors in
either male or female or both for subsequent treatment to facilitate
the occurrence of a pregnancy.

FEMALE
Principle: Fertility will be normal in the female with intact and
functional uterus (corpus and cervix) ;fallopian tubes and ovaries in
which situations menstruation and ovulation occur normally and
 CONTD
Causes are as follows in a general scale –
Female factor 30%
Male factor 30%
Female and male 30%
Idiopathic 10%
The causes will vary from this general scale according to the
locality.

EVALUATION OF THE COUPLE

Principle: Establish the contribution from male and female
partner. Infertility is a problem of the couple rather than of the
man or woman.
 CONTD
- inability to sustain pregnancy to viability is called fecundity
which may be primary or secondary
- Often infertility may be a special case of infertility when there are
deliveries but no having child alive
- Infertility may be primary or secondary
- In our environment, infertility is mainly often secondary (80%)
- with primary being 20% which in the contrast with the
developed countries where primary is 80% as against secondary of
20%.
- This reflect marked differences in the consertive factors which
are mainly intrisic factors in Europe and America but in Africa.
Environmental factors after an initial pregnancy in our
environment.
 CONTD
- Some evidence of disease viz dysmenorrhoa or dyspareunia.
- Clinical Examination – Complete are usually from head to
toe
- Eye and neck anomalies
- Breast size contour and discharges
- Hair partter and distribution to identify the male pattern.
- Other evidence of Androgenism – Achne and waist to hip
ratio
- Detail abdominal and pelvic examination.
(ix) General lab investigation
- According to how dictated by the clinical state and status.
- No place for wasteful general investigation without focus.
 CONTD
-
-Mucus production by the cervical glands can be assessed by the
method of Isler often recorded as scores from Zero to 15 maximum
which score is an assessment of the endogenous estrogen status with
the highest score representing peak estrogen production about the
peri ovulation period
-The mucus volume and quality varies according to the phases of the
cycle. In the first half under the dominance of F.S.H. and estrogen
in increasing doses, mucus production volume and consequential
Isler score increase with quality varying from the thick and opague
impenetrable to the more watery thin and glassy penetrable and
stretechable mucus around peri ovulatory period which is under the
dominance of the much higher estrogen and LH.
 CONTD
-About the mid cycle or peri ovulatory period the mucus volume and
score is maximum being easily penetrable, motile sperm can pass
through it which is visible at a post coital test often done around the
peri ovulastory period. A normal post coital test will show motile
sperm in the mucus of mid cycle.
-Mucus volume and score falls rapidly after ovulation under the
dorminace of progresterous which now alter the mucus quality to
thick and opague with specific crystalisation called ferning.
-Thus, a typical mucus score assessment show a risisng score to a
peak at mid cycle with a positive p.c.v. and thereafter falling score
with the mucus now showing characteristic ferning where there has
been progesterone influence following ovulation. The typical mucus
score compartible with significant estrogen status is a score of 8 and
above .
 CONTD
Clinical application of cervical mucus assessment score (CMA)
3. To assess the adequacy of the cervical mucus production
which is essential for sexuality and fertility to diagnose faulty
endocervical gland mucus production
4. As a part of the post coital test (PCT)in which the mucus
permits sperm penetration and survival.
5. To assess the endogenous estrogen status in Amenorrhoea
cases especially secondary Ammenorrhoea to facilitate
diagnosis and treatment.
6. To assess the anticipated length of the cycle in cases of grosss
menstrual irregularity especially to time some investigation
like assay etc.
 CONT
2. As a follow-up regimen to assess response to treatment in which
ovulation is the focus
3. As a follow-up in super ovulation regimen to assess whence to
begin close pelvic ultrasound follicular growth assessment.
Such may often be when the CMA score attains at least 8 or
more
4. A crude and very indirect assessment of ovulation in response
poor setting such as primary Health Care Level ,if the CMA is
efficiently performed after an appropriate and knowledgeable
timing.
Problems of CMA/PCT
6. Wrong time and thus false negative
7. Clumsy techniques at the performance
8. Inappropriate preparation of the woman
 CONTD
• False positive from some high estrogen Anovulatory states like
poly cystic ovary disease and obesity with extra ovarian
estrogen production.
• Other Special Investigations
d. Mid luteal phase hormone assay of reproductive hormones, viz
estadiol, progesterone, testosterone F.S.H, L.H, and prolactin.
In special cases assay for thyroid gland functions. F.S.H;
Thyroxine and bound thyroxine.
e. E.U.A. Hydrotubation and premenstrual D & C for secretory
phase endometrium.
f. Follicular growth monitoring with serial ultrasound both
abdominal and vaginal
g. Skull x-ray for view of the Pitulary fossa
 CONTD
b. Abdomino – pelic ultrasound in some special cases
c. Testicular biopsy for males suspected with primary testicular
failure
d. Testicular exploration for perm cell deposite for I.C.S.I

Male Infertility
Basic Concepts
(a) Sperm Production – Mature sperm comes from the
seminiferous tubular epithelism and the sertolic cells. Under
LH action the leudic cells produce testosterone which stimulate
the seminiferous epithelium to produce sperms. Also the
sertolic cells under direct FSH action produce mature sperms.
 CONTD
(b) Sperm maturation
Following sperm production they are transported to the
epididymis where they under go maturation which mainly
results in the motility of the sperms.
© Arounsal and Erection
Sexual arousal occurs naturally from the play of sense and
sensation and this is quickly followed by erection of the
phallus. Arousal and erection are essential for the deposition of
the sperm in the vaginal.
(f) Ejaculation
Following sustained erection after vaginal penetration the
sperm in the ep[ididymis is released to mix with the secretion
from the male accessory glands (prostrate, seminal vesicle and
bulbourethra glands) which secretion make up 95% of the
 CONTD
Volume of the ejaculate at the male orgasm. This is irrespect of a
concomitant female orgasm.
(c) Fertisation and conception will only occur if the mature and
activated sperms in the ejaculate are exposed to a fresh oocyte
in a normal female at the ovulation period.
Male infertility will occur if there is impairment at any level of
this cascade gevants viz sperm production sperm storage and
maturation, defect in the ejaculate or even problems in arousal
and erection which is the normal sperm discharge mechanism.
Evaluation of the male
- Follows the general pattern of History and clinical
examination followed by the general and special investigation.
History:- Particularly to exclude Diabetes, previous infections and
nature of any childhood diseases and operations.
 CONTD
Examination: Particularly, to note secondary sex characters and
testicular size with the orchidometer.
General Investigation
-Haemogram - PCO ) To assess the general Health status
-- M.P )
-Widal test
-Glucose test – Random blood sugar/fasting blood
sugar.
-Especially if body weight over 90kg
-- MSU – In appropriate cases
--SFA – Good instructions.
-Post – Ejaculatory Urine microscopy especially if
there is ejaculatory problems.
 CONTD
-Sperm culture if infection is suspected
-Assay of hormones if reduced testicular size or severe oligo –
Azoospermia
- Scrotal ultrasound for varicocoele
-Abdominal ultrasound to exclude prostrate enlargement/disease.
EVALUATION OF THE INFERTILE COUPLE
BY

PROFESSOR A. A. E. ORHUE (FRCOG; FMCOG; FRSM)

DIRECTOR
Human Reproduction Research Programme
Department of Obstetricss and Gynaecology
University of Benin Teaching Hospital
Benin City
Edo State, Nigeria
 CONTD
© Specialized investigation
(3) Semenimol fluid analysis. Using the light microscope –
Details later.
(4) H. S. G. for outline of the uterine cavity tubes and cervix.
(5) Linted phase laparoscopic pelvic assessment and dye
hydrotubation.
(6) Peri ovulatory cervical mucus assessment and post-coital test
(CMATPCT)
This is a particulate infertility tool to assess cervical factor and
endogenous estrogen status.
Principle - Estrogen specially stimulate the endocervical glands to
secrete mucus in linear relationship to the estroger dose and
estrogen dose is crearly related to the size and functions of the
follicles.