Fertility is the natural capability of producing
Women who are fertile experience a natural period of
fertility before and during ovulation, and they are
naturally infertile during the rest of the menstrual
Depends on factors:
◦ Sexual behavior
Subfertility is defined as the failure to
conceive within 1 year of unprotected regular
May also refer to the state of a woman who is
unable to carry a pregnancy to full term.
◦ Couples who have had NO previous conception.
◦ Difficulty conceiving after already having conceived
(and either carried the pregnancy to term or had a
In these cases abnormalities are likely to be
present but not detected by current methods.
Egg is not released at the optimum time for
fertilization, that it may not enter the fallopian
tube, sperm may not be able to reach the egg,
fertilization may fail to occur, transport of the
zygote may be disturbed, or implantation fails.
It is increasingly recognized that egg quality is of
critical importance and women of advanced
maternal age have eggs of reduced capacity for
normal and successful fertilization.
For a woman to conceive, certain things have
◦ Intercourse must take place around the time when
an egg is released from her ovary.
◦ The systems that produce eggs and sperm have to
be working at optimum levels.
◦ And her hormones must be balanced.
Age (>37 years)
◦ Reduce chance of a spontaneous conception.
Low coital frequency or inappropriate time of
intercourse to ovulation.
No previous pregnancy
Endometriosis, Fibroids, PID (Pelvic Inflammatory
Arise due to defects in the hypothalamus, the
pituitary or the ovary.
Factors that disrupt the release of GnRH:
◦ Stress and psychological disturbances.
◦ Weight change.
◦ Systemic Diseases and lesions of the hypothalamus.
◦ Hyper and Hypothyroidism.
Lead to Anovulation and Ammennorrhea
Most commonest cause of anovulatory infertility.
◦ Menstrual Cycle Disturbances.
◦ Acne and INFERTILITY!
◦ Low Sex Hormone binding Globulins.
◦ Ultrasound Appearance of an enlarged ovary with
multiple sub capsular follicles and a dense stroma.
Total failure of the ovaries in women under
the age of 40 years.
◦ Raised FSH.
◦ Decreased Estradiol.
Linked to genetic causes.
◦ Sex Chromosome abnormality.
Acquired from damage by viruses and toxins.
Pelvic Surgery, irradiation or autoimmune.
Impaired oocyte pick-up mechanisms by the
fimbriae or damaged tubal epithelium.
Tubal Damage following:
◦ Pelvic Infection.
◦ Pelvic Surgery
Pelvic sepsis following appendicitis or peritonitis.
STD’s – Leading to tubal damage.
◦ Chlamydia trachomatis
Defects related to endometrial development
Submucous Fibroids - benign or non-
cancerous tumors found in the muscular wall
of the uterus distorting the endometrial
The main cause of male subfertility is
low semen quality.
◦ Semen quality is a measure of the ability
of semen to accomplish fertilization. Thus, it is a
measure of fertility in a man. It is the sperm in the
semen that are of importance, and therefore semen
quality involves both sperm quantity and quality.
Subfertility associated with viable, but
immotile sperm may be caused by Primary
Volume 2-5 ml
Liquefaction time Within 30 minutes
Sperm Concentration 20 Million/ml
Sperm Motility >50% progressive motility
Sperm Morphology >30% normal forms
White Blood Cells <1 million/ml
WHO classification of Semen Variables
Normozoospermia Normal ejaculate
Oligozoospermia Sperm concentration fewer than
Asthenozoospermia Less than the normal value for
Teratozoospermia Fewer than 30% spermatozoa with
Signifies disturbance of all three
Azoospermia No spermatozoa in the ejaculate
Aspermia No ejaculate
Full medical and surgical history taken from
both the male and female partner:
◦ Drug History?
◦ Family History and Lifestyle:
Use of Alcohol, smoking, and recreational drugs?
◦ Coital frequency or any difficulties with coitus?
◦ Past operation?
◦ STDs, Past or Present?
◦ Details of Menarche, Menstrual Cycle, and
Women with Irregular Menstruation?
◦ Symptoms of PCOS?
◦ Thyroid Disorder?
Fathered any previous pregnancies?
History of mumps or measles?
History of testicular trauma, surgery to testis?
Examination of both partners is essential to
ensure normal reproductive organs.
◦ Assess testicular size, consistency, masses, absence
of vasdeferens, varicocele, evidence of surgical
◦ Small Testes:
Primary testicular failure
◦ Full general and pelvic examination.
Check for HPO dysfunction
◦ Follicular FSH, LH, estradiol
◦ Hysterosalpingogram, Hysterocontrastsonography
or an operative laparoscopy and dye test
◦ HSG and HyCoSy are used as screening tests and if
blockage is suggested, patient is counselled for an
operative laparoscopy for diagnosis and surgical
correction if possible.
◦ Low sperm count or azoospermia-Check
Testosterone levels; low levels suggest production
◦ LH/FSH – Hypogonadotrophic gonadism is treated
with FSH and hCG injections
◦ CF screening – Congenital bilateral Absence of Vas
◦ Karyotyping – Y chromosome deletion (AZF region);
can be surgically corrected.
Ovulation Induction (OI) – Clomiphene or FSH
◦ Anovulation- PCOS, idiopathic
Intrauterine insemination- with or without
stimulation with FSH
◦ Unexplained subfertility, Anovulation unresponsive to
OI, Minimal to mild endometriosis
Donor Insemination – with or without stimulation
◦ Patients with tubal pathology, patients who unresponsive
to above treatment
Donor Egg with IVF
◦ Previous surgery/chemo with decreased ovarian
function, women whose egg quality is poor
Adhesions, Endometriosis, Ovarian Cyst
Operative laparoscopy to treat disease and restore
◦ Myomectomy-Hysteroscopy, laparoscopy,
laparotomy, fibroid embolization
Blocked Fallopian Tubes amenable to repair
◦ Tubal Surgery
PCOS unresponsive to medical treatment
◦ Laparoscopic Ovarian Drilling