Infertility in the 21st Century (Male & Female Factors) by Dr. Abayomi Ajayi

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FERTILITY AWARENESS IN THE 21ST
CENTURY(MALE& FEMALE FACTORS)
BY Dr. Abayomi Ajayi (M.D.
Nordica Fertility Centre)

HISTORY
 Infertility is a problem through out history,
however increasing rates noticed.
 The first successful birth of a "test tube baby“,
Louise Brown occurred in 1978 in Oldham
General Hospital, U.K.
 Robert G. Edwards; the physiologist who
developed the treatment, was awarded the
Nobel Prize in Medicine in 2010

In order for a woman to become pregnant:
 Egg must be released from one of her ovaries
Egg must go through the fallopian tube toward
the uterus.
 Sperm must join with the egg in the fallopian
tube (fertilization)
 Fertilized egg must attach to the uterine wall
(implantation)

WHAT IS INFERTILITY?
 Couples that have been unable to conceive a
child after 12 months of regular sexual
intercourse without birth control.
 Women who have repeated miscarriages are
also said to be infertile.

YOU’RE NOT ALONE
 About 10 – 15% of couples are infertile in Western world
 20 – 25% couples in Africa are infertile.
 1 in 4 Nigerian Couples are infertile

CAUSES OF INFERTILITY
 Male Factor – 30%
 Female factor – 30%
 Combined factor – 30%
 Unexplained – 10%

WHEN SHOULD YOU GO SEE A DOCTOR?
 Women below 35 = 1 year
Women above 35 = 6 months
Women with the following issues should speak to their doctors as soon as possible:
 irregular periods or no menstrual periods
 Very Painful periods
 Endometriosis
Pelvic Inflammatory disease

THE AGE FACTOR
 A woman’s fertility naturally starts to
decline in her late 20’s.
 After age 35 a woman’s fertility
decreases rapidly.
 A woman is born with all the eggs
she’ll have, and with time, the supply
diminishes.
The remaining eggs also age along with
the rest of the body.

COMMON CAUSES OF FEMALE INFERTILITY
 Severe endometriosis
 Pelvic Inflammatory Diseases (PID)
 Ovulation disorders
 Polycystic ovary syndrome (PCOS)
 Early Menopause
Benign Uterine fibroids
 Pelvic adhesion

ENDOMETRIOSIS
 Occurs when the uterine tissue
implants & grows outside of the uterus,
affecting the function of the ovaries,
uterus and fallopian tubes.
 Scar tissue can block the fallopian
tubes and prevent the egg from
entering the uterus.
There is a 25-35% rate of infertility in
moderate to severe cases of
Endometriosis

UTERINE FIBROIDS & PELVIC ADHESIONS
 Fibroids are benign tumors in the wall
of the uterus.
 May cause infertility by blocking
fallopian tubes.
 Pelvic adhesions are bands that bind
organs after pelvic infection,
appendicitis or abdominal or pelvic
surgery.
 This scar tissue formation may impair
fertility.

PCOS (POLYCYSTIC OVARY SYNDROME)
 Produces too much androgen hormone
(male hormones).
 Causes an irregular or no menstrual
cycle.

EARLY MENOPAUSE
 Absence of menstruation
 Early depletion of ovarian follicles before age 35
 Although the cause is unknown, certain conditions are associated with early
menopause.
 Including immune system diseases, radiation or chemotherapy treatment and
smoking etc.

MALE FACTOR INFERTILITY
 Male infertility is infertility traceable solely to
the male.
 It is alarmingly on the rise, up to 50% of
infertility is related to the male.
 A 2012 study showed that only 1 in 4 men
have optimal semen quality.
 Male infertility is commonly due to
deficiencies in the semen & semen quality is
used as a surrogate measure of male fecundity.

CAUSES OF INFERTILITY
 Pre testicular – Lifestyle factors e.g smoking, alcohol, obesity
 Testicular factors
 Post testicular

TESTICULAR FACTORS
Testicular factors- refers to conditions where the testes produce semen of low
quality and/or poor quality despite adequate hormonal support and this include:
1. Age
2. Genetic defects on Y-chromosome
3. Abnormal set of chromosome(klinefelter syndrome)
4. Orchitis(infective or traumatic)
5. Neoplasm
6. Vascular(Torsion and Varicocele)
7. Idiopathic

DNA DAMAGE
Common inherited variants in genes that encode enzymes employed in DNA
mismatch repair are associated with increased risk of sperm DNA damage and male
infertility.

POST-TESTICULAR CAUSES
 It decrease male fertility due to conditions that affect the male genital system after
testicular sperm production and include defects of the genital tract as well as
problems in ejaculation:
 Vas deferens obstruction
 Lack of vas deferens, often related to genetic markers for Cystic Fibrosis
 Infection e.g. Prostatitis
 Retrogade ejaculation
 Ejaculatory duct obstruction
Hypospadias
Impotence

DIAGNOSIS
 History from couple
 Examination/ Pelvic scan
 Semen analysis
 Ovarian reserve/function tests
 Tubal patency tests
 Others- Endoscopy

SEMINAL FLUID ANALYSIS
 Volume - 2-5 mls
 Sperm concentration - at least 20 million/mL
 Motility – at least 50% or more with forward progression
 Morphology - At least 30% or more normal forms
 White blood cells - Fewer than 1 million/mL

TREATMENT OPTION I
 Conventional fertility treatment
Ovulation induction
Artificial insemination
Tubal surgery(Obsolete)
 SUCCESS RATE: 5-10%

INTRAUTERINE INSEMINATION
 It is artificial introduction of semen
inside the female’s uterus.
 Success rate varies, lie between 10% to
15% per cycle/

INTRAUTERINE INSEMINATION
Who is it for?
 Women < 38yrs
 Patent fallopian tubes
 Normal Hormones
 Normal semen parameters

TREATMENT OPTION II
 Assisted Reproductive Techniques (ART): Processes that increase the chance of
conception by laboratory manipulation of sperm and eggs.
 In-Vitro Fertilization (IVF)

INDICATIONS FOR IVF
 Recommended for tubal damage/blockage
 Unexplained infertility
 Endometriosis
 Recurrent Abortions
 Some sperm problems
 Advanced maternal/paternal age

THE PROCESS OF IVF
 Controlled ovarian stimulation
 Follicular tracking → OPU
 Egg Retrieval and fertilization
 Fertilized eggs transferred to new dish and cell
division occurs in incubator
 Embryos transferred into uterus
 PT done 2 weeks later

FERTILIZATION PROCESS
 Poor fertilization rates in couples with
sperm abnormalities.
 Magnification/microinjection
 Intracytoplasmic Sperm Injection (ICSI)

FERTILIZATION PROCESS: TREATMENT
OF MALE INFERTILITY
 IMSI (Intracytoplasmic Morphologically
selected Sperm Injection)
 PICSI (Physiological Intra-Cytoplasmic
Sperm Injection)

SUCCESS RATES
Varies widely, depending on several factors. With the Age factor, success rates are
broadly as follows:
 <30 yrs - 40-50%
 30-35 yrs - 30-35%
 35-37 yrs - 20-25%
 37- 40 yrs - 10-15%
 >40 yrs - <10% (using own eggs)

CONCLUSION
Infertility is a distressing condition with a high prevalence in our environment.
Access is still poor due to low level of awareness and cost.
 Also a sensitive issue that should be handled with great care and with continuous professional counseling
Treatment options are diverse but most people will require advanced fertility treatment, which though
expensive and time consuming, has changed many lives
Early referrer is KEY to optimal outcome

THANKS FOR READING!

REFERENCES
 Nice guideline, CG156, February, 2013.
The Human Fertilization and Embryology Authority, HFEA website.
ESHRE recommendation, ESHRE conference 2012.
Anderson AM, Jorgensen N, Main KM, et al. Adverse trends in male reproductive health: we may have reached a crucial
'tipping point'. Int J Androl. 2008 Apr;31(2):74-80
Feki NC, Abid N, Rebai A, et al. Semen quality decline among men in infertile relationships: experience over 12 years in the
South of Tunisia. J Androl. 2009 Sep-Oct;30(5):541-7
 Nordkap L, Joensen UN, Blomberg Jensen M, Jørgensen N. Regional differences and temporal trends in male reproductive
health disorders: semen quality may be a sensitive marker of environmental exposures. Mol Cell Endocrinol. 2012 May
22;355(2):221-30. Epub 2011 Nov
Carlsen E, Giwercman A, Keiding N, Skakkebaek NE. Evidence for decreasing quality of semen during past 50 years. BMJ.
1992 Sep 12;305(6854):609-13.
Marcello Cocuzza and Ashok Agarwal. Nonsurgical treatment of male infertility: specific and empiric therapy. Biologics.
2007 September; 1(3): 259–269.Published online 2007 September.
Siddiq FM, Sigman M. A new look at the medical management of infertility.Urol Clin North Am. 2002 Nov;29(4):949-63

Infertility in the 21st Century (Male & Female Factors) by Dr. Abayomi Ajayi

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