kirkuk university collage of medicine

1. Subfertility
By: jwan Abdullah
Ushana shamshon

2. Fertility
 Fertility is the natural capability of producing offspring.
 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 cycle.
 Depends on factors:
 Nutrition
 Sexual behavior
 Culture
 Endocrinology
 Timing
 Emotions

3. What is
Subfertility?

4. What is Subfertility?
 Subfertility is defined as the failure to conceive within 1 year
of unprotected regular sexual intercourse.
In the general population, conception is expected to occur
in 84% of women within 12 months and in 92% within 24
months

5. Primary and Secondary
Subfertility
 Primary
 Couples who have had NO previous conception.
 Secondary
 Difficulty conceiving after already having conceived (and either
carried the pregnancy to term or had a miscarriage).

6. Data from population-based studies suggest that 10–15% of
couples in the Western world experience infertility Half of them
(8%) will subsequently conceive with out the need for a
specialist

7. Approximately 50 per cent of couples will conceive
after receiving advice and simple treatment, but the
remainder require more complex assisted conception
techniques, and 4 per cent of couples will remain
involuntarily childless.
The most important factor in determining fertility is the age of the female
partner, with fertility reducing rapidly in women over 35 years of age

8. Conception
 For a woman to conceive, certain things have to happen:
 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.

9. Factors affecting fertility in
women.
1. Ovulation Disorders
2. Tubal Damage
3. Age (>37 years)
1. Reduce chance of a spontaneous conception.
4. Low coital frequency or inappropriate time of intercourse to ovulation.
5. No previous pregnancy
6. Smoking
7. Malnutrition
1. Obesity
2. Underweight
8. Endometriosis, Fibroids, PID (Pelvic Inflammatory Disease).

10. Table 45.1 Diagnostic categories in infertility
Primary (%) Secondary (%)
Anovulation 20 15
Male 25 20
Tubal 15 40
Endometriosis 10 5
Unexplained 30 20

11. Ovulation Disorders
 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
 Hyperprolactinaemia (as seen in women with
a prolactinoma), renal failure, hepatic dysfunction
and phenothiazine medication impair the pulsatile
release of GnRH, leading to anovulation.

12. Polycystic Ovarian Disease
 Most commonest cause of anovulatory infertility accounts for over 75% of all
women with anovulation (Adams et al. 1986)
.
 Symptoms:
 Menstrual Cycle Disturbances.
 Obesity
 Hirsutism
 Acne and INFERTILITY!
 Diagnosis:
 Low Sex Hormone binding Globulins.
 Ultrasound Appearance of an enlarged ovary with multiple sub capsular follicles and
a dense stroma.

14. namely the presence of two out of the following three criteria:
1 Oligo- and/or anovulation;
2 Hyperandrogenism (clinical and/or biochemical);
3 Polycystic ovaries (The Rotterdam ESHRE/ASRMsponsored
PCOS consensus workshop group, 2004).
Other aetiologies of hyperandrogenism and menstrual
cycle disturbance should be excluded by appropriate
investigations, The morphology of the polycystic ovary, has been redefined
as an ovary with 12 or more follicles measuring 2–9 mm in
diameter and increased ovarian volume (>10 cm3) on transvaginal
ultrasound.

17. PCOS Treatment for subfertility
 Diet & Exercise
 PCOS diet book by Colette Harris
 Clomid* – Anti-oestrogen
 days 2-6 of cycle
 with follicle tracking
 Metformin
 start at 250mg od increase to max 500mg tds
 GnRHa*
 Laparoscopic ovarian drilling
 * Risk of OHSS

18. Premature Ovarian Failure.
 Total failure of the ovaries in women under the age of 40
years.
 Characterized by:
 Amenorrhoea.
 Raised FSH.
 Decreased Estradiol.
 Linked to genetic causes.
 Sex Chromosome abnormality.
 Acquired from damage by viruses and toxins.
 Pelvic Surgery, irradiation or autoimmune.

19. Tubal Dysfunction
 Impaired oocyte pick-up mechanisms by the fimbriae or
damaged tubal epithelium.
 Tubal Damage following:
 Pelvic Infection.
 Endometriosis.
 Pelvic Surgery
 Pelvic sepsis following appendicitis or peritonitis.
 STD’s – Leading to tubal damage.
 Chlamydia trachomatis
 Gonocci

21. Disorders of Implantation
 Defects related to endometrial development and
maintenance.
 Submucous Fibroids - benign or non-cancerous tumors
found in the muscular wall of the uterus distorting the
endometrial cavity.

23. Endometriosis
Endometriosis is most simply defined as the presence of
endometrial surface epithelium and/or the presence of
endometrial glands and stroma outside the lining of the
uterine cavity.
It is estimated that between 30 and 40 per cent ofpatients
with endometriosis complain of difficulty in conceiving. In
many patients there is a multifactorial pathogenesis to this
subfertility.
In the severe stages of endometriosis there is commonly
anatomical
distortion, with peri-adnexal adhesions and destruction
of ovarian tissue .

24. male subfertility
 • Disorders of spermatogenesis
 • Impaired sperm transport
 • Ejaculatory dysfunction
 • Immunological and infective factors

25. Male Subfertility
 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 Ciliary Dyskinesia.

27. WHO criteria for Semen
Analysis
Semen Analysis
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

29. Causes of male subfertility :
1- Varicocele : in 12 % of normal men and 25% of men with semen
abnormalities.
- Increase scrotal Temp.
- Hypoxia .
- Raised testicular pressure.
2- Genetic causes : azoospermia is associated with karyotypic
abnormalities in 15 % of cases of which 90% r 47XXY ( Klinfilter
syndrome ).
Structural abnormalities of chromosome.
Deletion of genes on the Y chromosome.
10/99
29

30. 3- Cryptochidism:
 Untreated for 2 years.
 4 – 10 folds increase in the risk of testicular cancer.
4- Orchitis :
 Mumps most cmn coz.
 17 % of orchitis r bilateral.
 It coz atrophy of seminiferous tubles.
5- Occupational & enviromental factors:
 Tobacco & alcohol .
10/99
30

31. 6- Iatrogenic :
 Hormonal tx , cimetidin, colchicine chemotherapeutic agents.
7- Genital tract obstruction:
* 2% associated with cystic fibrosis.
8- Hypogonadotropic hypogonadism.
9- Coital dysfunction1- ( impotence ) : majority is psychological,2-(
Hypospedis)
10- Immunological cause; ( sperms move around there selves or
agglutinated ).
11- Idiopathic impairment of semen quality.
10/99
31

32. WHO classification of Semen Variables
Normozoospermia Normal ejaculate
Oligozoospermia Sperm concentration fewer than
20x106/ml.
Asthenozoospermia Less than the normal value for motility.
Teratozoospermia Fewer than 30% spermatozoa with
normal morphology
Oligoasthenoterato-zoospermia
Signifies disturbance of all three
variables.
Azoospermia No spermatozoa in the ejaculate
Aspermia No ejaculate

34. Unexplained infertility
Unexplained infertility is diagnosed where routine
investigations
including semen analyses, tubal evaluation and tests of
ovulation yield normal results. Intrinsic differences within
populations and variations in investigation protocols have led
to a wide range in the reported prevalence of unexplained
infertility, but most clinics now report incidences of 20–30%.
Failure of routine tests to detect any obvious contributory
factors has led clinicians to speculate about numerous factors
contributing to a diagnosis of
unexplained infertility

35. Contributory factors to
unexplained infertility
 Luteal phase deficiency
 Luteinized unruptured follicle (LUF) syndrome
 Hyperprolactinaemia
 Occult infection
 Immunological causes
 Psychological factors

36. Management
of subfertility

37. History
 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?

38. Specific History Questions for
Women?
 Gynecological History?
 Details of Menarche, Menstrual Cycle, and Menstrual
Frequency.
 Women with Irregular Menstruation?
 Symptoms of PCOS?
 Thyroid Disorder?
 Hyperprolactinaemia?

39. Specific History Questions for
Men?
 Fathered any previous pregnancies?
 History of mumps or measles?
 History of testicular trauma, surgery to testis?

40. Examination
 Examination of both partners is essential to ensure normal
reproductive organs.
 Males:
 Assess testicular size, consistency, masses, absence of
vasdeferens, varicocele, evidence of surgical scars.
 Small Testes:
 Primary testicular failure
 Female:
 Full general and pelvic examination.

42. INVESTIGATIONS
FOR ANOVULATION
progesterone tracking.
 Where the cycle length is either longer or shorter than 28
days a single day-21 progesterone level may be insufficient
to pinpoint ovulation and serial progesterone checks may
be needed (progesterone tracking). For example, in a 28–35
day cycle progesterone tracking could be started from day
21 and continued weekly until the next period begins.

43. INVESTIGATIONS
Where periods are either very irregular or absent
it may be impractical to estimate progesterone
levels. Instead, additional biochemical investigations
are indicated to establish a possible endocrine cause
of oligo/anovulation

44. INVESTIGATIONS
These include early follicular phase FSH and LH, prolactin, TSH,
and where PCOS is suspected, serum testosterone .
Where an adrenal cause is to be excluded,
DHEA and DHEAS, 17–OH progesterone need to be checked.
FSH and LH levels should be checked in the early follicular
phase(days 1–3) in order to avoid the normal Mid cycle surge
which can lead to abnormally high values.
Where accurate timing of the test is impossible(as in
amenorrhoeic women), a serum sample can be obtained at
any time and the results interpreted with reference to the
following period.

46. Investigations
 Investigation tubal factors
1-Hysterosalpingography day 10 of
mc radio-opaque substance.
2-Hysterosalpingo contrast
sonography .galactose solution.
3-Laparoscopy.methylene blue

49. INVESTIGATIONS
Uterine factors
 Intra-uterine adhesion (Asherman‘s
syndrome),sub mucous fibroid,uterine
abnormality.
Cervical hostility
Sperm antibody . diagnosis is by
post coital test

50. Treatment
All couples trying for a pregnancy will benefit from some
general advice such as cessation of smoking and limiting
alcohol intake. Pre-treatment counselling should include
advice about general lifestyle measures including the need
to achieve an optimum BMI. This will involve weight loss
in women with a BMI of over 30

51. Ovulation problems
Ovulation induction can be performed using antioestrogen
medication, including clomiphene citrate
and tamoxifen or exogenous gonadotrophin, to stimulate the
development of one or more mature follicles.
Clomiphene citrate is administered during the follicular phase
of the menstrual cycle. It is thought to act by increasing
gonadotrophin release from the pituitary, leading to enhanced
follicular recruitment and growth. It is effective at inducing
ovulation in 85 per cent of women and can be used for a
maximum of a year.

52. Clomiphene citrate
 It is administerd orally for 5 days from 2nd
day of mc 50mg /d.
 Side effect:
 Hot flushes
 Bloating
 Multiple gestations
 Visual changes

53. Ovarian hyperstimulation
syndrome
(OHSS)
is a potentially serious side effect of ovulation
induction and is associated with large ovarian cysts. There
is increased vascular
permeability leading to ascites, pleural effusions and
intravascular
Hypovolaemia . Thrombosis may ensue. OHSS is found
particularly in patients with polycystic ovarian syndrome
and older women.
The mild form found in approximately 30% of patients,
responds to conservative management and no further
ovarian stimulation . The severe form (found in < 2%)
requires fluid replacement ,antithrombotic measures and
bed rest.

54. Ovulation can also be induced with exogenous
gonadotrophins given by daily injection from the
beginning of the cycle. The dose is titrated against the
individual response and is monitored by an ultrasound
assessment of follicular number and size. Ovulation is
usually triggered with an injection of human chorionic
gonadotrophin (hCG, which binds to the LH receptor)
when 1-3 follicles are 18 mm in diameter.

56. Tubal disease
The treatment of tubal disease aims to restore normal anatomy, but the
chance of success depends on the severity and location of the damage
as well as on the
skills of the surgeon. In-vitro fertilization (IVF) is an alternative to
surgery and would be recommended if there were extensire damage or
intrafallopian tubal
damage, or if surgery failed to restore patency. If peritubal or peri-ovarian
adhesions are present, they can be removed by a laparoscopic
adhesiolysis.
When thefimbriae are also involved, a fimbrioplasty to removethe
fimbrial adhesions and repair the fimbrial disease can be successful.
Although at least 5 per cent of the resulting conceptions will be
ectopic, intrauterine pregnancy
rates of 50 per cent can be seen after 6 months

57. Bromocriptine ; for hyper prolactinemia 2.5 mg bed
time.
Treatment of thyroid ,infection
And endometriosis.
Treatmeant of cervical hostility by IUI.
10/99
57
FOR male patient:
1-Surgical RX of varicocele&Obstructive defects.
2-Retrograte ejaculation by alph sympathomimetics.
3-Rx of secondary hypogonadism or
hyperprolactinemia.
4-Use of donar sperm.

58. Management : Assisted
conception
1-Gamete intrafallopian transfer(GIFT):
Extraction of the oocytes is folloed by the transfer of
gametes(sperm&oocyte) into a normal fallopian tube by laparoscopy.
2-Zygote intarafallopian transfer(ZIFT):refers to the placement of the
embryos into the tube via laparoscopy after oocyte retrieval and
fertilization.
3-Intracytoplasmic sperm injoction( ICSI):a single spermatozoon is injected
microscopically in to each oocyte, and the resulting embryos are
transferred transcervically into the uterus. The advent of ICSI has
revolutoinized fertility treatment for male factor.
4-In vitro fertilization(IVF):refers to controlled ovarian hyperstimulation,
ultrasonographically guided aspiration of oocytes laboratory
fertilization with prepared sperm, embryo culture, and transcervical
transfer of the resulting embryos into the uterus.

59.  Indications of IVF:
1-Tubal conditions like large hydrosalpings, absence of
fimbria, sever adhesive disease, repeated ectopic
pregnancies or failed recnstructive surgical therapy.
2-Endometriosis if tratmeant failed.
3-Unexplained subfertility.
4-Male type low sperm count and abnormal morphology.
5-HIV positve males.
6-Men and women seeking fertility presevation after
chemotherapy or irradiation
of their pelvic regions.

61. Surgical
 Adhesions, Endometriosis, Ovarian Cyst
 Operative laparoscopy to treat disease and restore anatomy
 Fibroid Uterus
 Myomectomy-Hysteroscopy, laparoscopy, laparotomy, fibroid
embolization
 Blocked Fallopian Tubes amenable to repair
 Tubal Surgery
 PCOS unresponsive to medical treatment
 Laparoscopic Ovarian Drilling