2. Infertility
Infertility – apparent failure of a couple to
conceive after 1 year of regular unprotected
sexual intercourse in women <35 years of age /
after 6 months in women >35 years of age.
Sub fertility- women or couples with decreased
reproductive efficiency.
Prevalence of infertility – 10-15% couples of
reproductive age group
80% of women conceive within 1 year of
marriage/ 90% within 2 years.
3. Contd.,
Fecundability – probability of achieving
pregnancy within one menstrual cycle
Fecundity – probability of achieving pregnancy
within 1 menstrual cycle that will result in live
birth.
For a pregnancy to occur ,ovulation, ovum
transport by the tubes, presence of normal
sperms, fertilization and implantation in uterine
cavity are all essential.
4. Types of infertility
Primary infertility Secondary infertility
Inability to conceive in a couple who
had no prior pregnancies
Inability to conceive in a couple who
had at least 1 prior conception , which
may have ended in a live birth, still
birth, miscarriage, induced abortion or
ectopic pregnancy.
2 years after pregnancy without
contraception including lactation.
7. Ovulatory dysfunction
Associated with abnormalities of production of
ovarian hormones, which can interfere with
preparation of endometrium for implantation and
luteal support thereafter.
Classified into
1. Decreased ovarian reserve
2. Disorders of ovulation
Anovulation & infrequent ovulation are common
causes for infertility.
8. Ovarian reserve
Ovarian reserve is referred to number of resting or
non growing primordial follicles.
Fertility decreases with decreasing ovarian reserve.
Causes Tests to determine
ovarian reserve
Advanced maternal age
Primary ovarian
insufficiency
Resistant ovary
Serum FSH(D3 -
>15mIU/ml)
Serum AMH(<8.1pmol/l)
Serum Inhibin(<400pg/ml)
Transvaginal USG
-Antral follicle count
(>10follicles of 2-10mm
diameter)
-Mean ovarian
volume(>3ml)
CLOMIPHENE CITRATE
challenge test
9. Disorders of ovulation
WHO classification
Type I Type II Type III
Hypogonadotroph
ic hypogonadism
Normogonadotrop
ic hypogonadism
Hypergonadotropi
c hypogonadism
Low FSH/LH
Low oestradiol
Normal FSH
Normal oestradiol
High FSH / LH
Low oestradiol
Congenital /
acquired
Primary ovarian
failure
Functional
causes-
stress/weight
loss/gain/ trauma
m/c- PCOS m/c – Turner
syndrome/ Turner
mosaic
Sheehan
syndrome/
hyperprolactinae
mia
Rare – late onset
CAH/ adrenal &
ovarian tumors
Primary ovarian
insufficency(POI)
Ovarian radiation/
chemotherapy
10. Tubal factors
Patent tubes with normal motility & normal ciliary
action of the inner lining are essential for
conception.
Tubal factors are common causes for secondary
infertility.
Causes Pathology
Pelvic infection
m/c-
Chlamydia/gonococcal
Postabortal /puerperal
Genital tuberculosis
Scarring/ adhesion
>>>tubal occlusion >>>
hydrosalphinx destruction
of cilia >>> interference
with tubal motility
Endometriosis Anatomical distortion of
tubes > peritubal adhesions/
kinking/tubal occlusion
Pelvic surgery/tubal
pregnancy
11. Uterine factors
Implantation of fertilized ovum & further growth of
embryo takes place in uterus.
Congenital causes Acquired causes
Uterovaginal agenesis-
MRKH syndrome
Complete AIS
Leiomyoma-
submucous/cornually
located myoma
Outflow obstruction-
Imperforate hymen
Transverse vaginal septum
Endometrial polyp
Bicornuate / Septate uterus-
recurrent miscarriage
Surgical correction of
congenital anomalies >
infection/ endometriosis>
infertility
Intrauterine
adhesions(Asherman
syndrome)
Tuberculous endometritis
12. Cervical factors
Congenital Acquired Cervical mucus
changes
Cervical stenosis
Pin hole os
Post surgical-dilatation
of Cx
LEEP/Conization /
Amputation of Cx /
Fothergill surgery
due to scarring/
stenosis/ hormonal
abnormality /
anti estrogenic effect of
drugs/ anti sperm
antibodies
|
Sperm motility
13. Peritoneal factors
Causes Pathophysiology
Endometriosis
Stages of the disease does not
correlate with risk of infertility
Moderate & severe – tubal damage /
adhesions/kinking
Minimal – immunological alterations/
coital dysfunction
LPD / LUFS are also common
Pelvic inflammatory disease(PID) m/c – chlamydia /
gonococcal/M.hominis/
U. Urealyticum/Genital TB
Postabortal/puerperal sepsis-
secondary infertility
14. Immunological factors
Anti sperm antibodies-
IgG /IgM /IgA
10-15% of infertile couples but also in normal
men/ women
Present in semen/ cervical mucus/ ovarian
follicular fluid/ serum
Affects the semen quality & interferes with sperm
capacitation/ motility/ fertlization.
15. Male infertility
Structurally and functionally normal sperms in
sufficient numbers must be deposited in vagina
for fertilization of ovum.
Any defect in production / maturation/ transport of
sperms can lead to infertility.
Testicular causes for male infertility are
associated with oligo spermia / azoospermia
Spermatogenesis is normal in Post testicular
pathology.
16. Spermatogenesis
• Sertoli cells (spermatogenesis/ inhibin)
• Leydig cells (testosterone)
• Spermatogenesis- genes on Y chromosome
Testes
• FSH/LH stimulate spermatogenesis & testosterone
production
• Maturation of spermatozoa occurs in Epididymis &
transported through vas deferens
spermatogenesis
• Seminal vesicle(fructose/PG/bicarbonates)
• Prostatic gland(enzymes/Zn/phospholipids)
• Sperms undergo capacitation when they come in
contact with cervical mucus
Seminal fluid
18. Causes for Male infertility
Pre testicular Testicular Post testicular
Hypothalamic disorders
•Hypogonadotropic
hypogonadism
•Tumors
•Infiltrative lesions- TB
Sarcoidosis/Histiocytosi
s
•Drugs
Chromsomal
abnormalities
m/c- Klinefelter
syndrome
•Mixed gondal
dysgenesis
•Partial AIS
•Genetic disorders of
spermatogenesis
•Abnormalities of
Epididymis
•Congenital block in
duct
•Acquired block in
ejaculatory ducts(
trauma/ infection)
Pituitary disorders-
congenital/radiation/tu
mors/ granulomas
Local causes-
Varicocele/cryptorchidis
m/orchitis/trauma/radiat
ion/Chemotherapy/
tight underclothing
•Congenital bilateral
absence of vas
deferens
Peripheral organs-
Adrenal disorders/Liver
failure
•Substance abuse-
alcohol / smoking/
caffeine
•Anitsperm antibodies
•Erectile dysfunction
•Idiopathic
19. Unexplained infertility
Diagnosed when all investigations are NORMAL.
Causes Pathophysiology
Luteal phase defect(LPD) Deficient progesterone in
luteal phase>inadequate
secretory changes in
endometrium>unsuitable for
implantation
Lutenised unruptured follicle
syndrome(LUFS)
Dominant follicle undergoes
luteinization without rupture
/ release of ovum>
progesterone production
occurs
Psychological &
Immunological
Minimal endometriois
Implantation failure/polyp
Hyperprolactinemia /Cx
20. Clinical evaluation
Both male & female partners should be
evaluated.
Male partner should be present at the first visit &
subsequently when treatment is planned .
Couples who are young , married for short
duration & unaware of fertile period can be
counselled and investigations can be undertaken
after 6 months or 1 year.
21. Investigations of Female partner
TESTS FOR OVULATION-
Regular cycles/Midcycle pain/spotting -ovulation
Tests for irregular cycles
Mid luteal Sr.Progesterone
test
( ovulatory cycles)
>3ng/ml (D21/28)- ovulation
>10ng/ml- adeq.luteal
support
BBT chart
( Progesterone –
thermogenic effect- 0.2 -
0.4C)
D1 (awakening/ before any
activity) & BIPHASIC
pattern (ovulatory cyc)
Urinary / serum LH
(LH surge- 36 hrs prior to
ovulation)
Serial urinary LH (3-4 days
prior to predicted LH surge)
- >40mIU/ml
Transvaginal USG D10-Dominant follicle
(18-20mm)
ET –8mm (trilaminar)
22. Tests for Tubal Patency
Tests
Hysterosalphingography (HSG)
(when only tubal factor is
suspected-first line test )
Radio opaque water or oil soluble
dye-
X- rays taken under fluoroscopy
Follicular phase(D6-D10)
Dx- uterine
polyps/hydrosaplhinx/site of tubal
block
Not reliable – peritubal adhesions/
tubal function.
C/I- active infection/menses
Complication-
perforation/infection/allergy
Hysterosalphingo contrast
sonography (HyCoSy)
High accuracy
Echogenic contrast medium is used
Saline infusion sonography Endometrial polyps/ septae
Spill of saline into peritoneal cavity
Falloposcopy
( flexible micro endoscope used
along with hysteroscopy)
Tubal lumen- lining/ tubal block
23.
24. Laparoscopic evaluation
For evaluation of peritubal/ ovarian/ peritoneal
factors.
More invasive & expenisve than HSG
Diagnostic Therapeutic Procedure
PID/ TO mass
Endometriosis/
myomas
Excision /ablation
of endometriosis
Methylene blue
dye
Prev h/o surgery
Peritubal
adhesions
Adhesiolysis Spill of dye-
fimbrial end-
patency
Fail to conceive
after initial
therapy
PCOS- ovarian
drilling
25.
26. Tests for Uterine factors
Uterine anomalies do not always interfere with
conception but more often causes recurrent
pregnancy loss.
Tests
HSG Uterine polyps/ septae
TVS Myomas (size/
location/number)
SIS Superior than HSG
Hysteroscopy BEST – to visualise uterine
cavity
Therapeutic use- Resection
of septum/ Polypectomy
27. Tests for Cervical factors
Postcoital tests
Done to assess the quality of cervical mucus and
also to look for anti sperm antibodies / sperm
mucus interaction.
Procedure
Done 1-2 days prior to ovulation within few hours
of intercourse.
Sperm mucus interaction Cervical mucus changes
•5 sperms/HPF – NORMAL
•Clumping /Absence of
sperms- ABNORMAL
(infection/ anti estrogenic
effect of CC)
•SPINBARKEIT effect
(E2– stretches to 8-10 cm)
•FERNING effect
(preovulatory E2 effect)
29. Investigations for Male partner
Based on history / physical examination / semen
analysis 70% of causes may be diagnosed.
Investigations
Semen analysis Sample collected after 2-3
days of abstinence
Endocrine evaluation FSH/LH/Prolactin/
Testosterone
Karyotyping / Genetic
testing
Klinefelter syndrome
Y micro deletions
Testicular biopsy Spermatogenesis / atrophy
TRUS Ejaculatory duct obstruction
SCROTAL usg Testes / epididymis
Vasography Patency of vas deferens
30. Semen analysis
Normal semen analysis WHO criteria (2010)
Volume 1.5 ml or more
pH >7.2
Sperm concentration 15 million /ml or more
Total sperm number 39 million/ ejaculate
Progressive motility 32% or more
Total motility(progressive+ non
progressive)
40% or more
Morphology
Viability
4% or more
58% or more
32. Abnormal semen analysis
Abnormality
Aspermia Absence of semen (no ejaculate)
Azoospermia Absence of sperm in semen
Oligozoospermia <15million sperms /ml of semen
Asthenospermia Decreased sperm motility(<32% pm,
<40% p+ np motility)
Teratozoospermia Abnormal sperm morphology
Hypospermia Low semen volume
33. Management of infertile couple
In young couples with duration of infertility <1 yr, if
no abnormality found in history/physical
examination/semen analysis, following
counselling may be given.
Lifestyle modifications
Weight reduction to ideal body weight(5-10%)
Cessation of smoking /alcohol
Avoidance of stress
Fertile period -3 days before & 3 days after
ovulation
