3. Infertility is defined as a failure
to conceive within one or more
years of regular unprotected
coitus.
DEFINITION
4. • Is defined as the probability of
achieving a pregnancy within one
menstrual cycle.
• Healthy Young Couple – 20%
• Probability to achieve livebirth within
a single cycle.
FECUNDABILITY
5. PRIMARY
- Patients who have never conceive
SECONDARY
- Indicates previous pregnancy but failure
to conceive subsequently
TYPES
6. Depends on Fertility Potential of both Male & Female
Partners
• Male : 30 – 40%
• Female : 40 – 55 %
• Both : 10 %
• Unexplained : 10 %
• 4 out of 10 patients of unexplained category become
pregnant within 3 years without having any specific
treatment.
CAUSES
7. DEFECTIVE SPERMATOGENESIS
• Approximately 74 days are required to complete the process of
spermatogenesis.
• Sertoli cell function is controlled by FSH and testosterone.
• Scrotal temperature should be 1–2°F less than the body
temperature
• Additional 12–20 days are needed for spermatozoa to travel the
epididymis.
Any Changes in these events leads to Defect in Sperm Formation
CAUSES IN MALES
8. CONGENITAL:
• Undescended testes: The hormone secretion remains
unaffected, but the spermatogenesis is depressed. Vas
deferens is absent (bilateral) in about 1–2% of infertile
males.
• Kartagener syndrome (autosomal disease)—Loss of
ciliary function and sperm motility.
• Hypospadias causes failure to deposit sperm high in
vagina.
CAUSES OF MALE INFERTILITY
9. • Thermal factor: The scrotal temperature is raised in
conditions such as varicocele. Varicocele probably interferes
with the cooling mechanism or increases catecholamine
concentration.
• Infection:
• (a) Mumps orchitis after puberty may permanently damage
spermatogenesis.
• (b) The quality of the sperm is adversely affected by chronic
systemic illness like bronchiectasis. Bacterial or viral infection
of the seminal vesicle or prostate depresses the sperm count.
CAUSES OF MALE INFERTILITY
10. • General factors: Chronic debilitating diseases, malnutrition or
heavy smoking reduce spermatogenesis.
• Endocrine: Testicular failure due to gonadotropin deficiency
(Kallmann’s syndrome) is rare. Hyperprolactinemia is
associated with impotence.
• Genetic: Common chromosomal abnormality in azoospermic
male is Klinefelter’s syndrome (47 XXY).
CAUSES OF MALE INFERTILITY
11. • Iatrogenic: Radiation, cytotoxic drugs, nitrofurantoin,
cimetidine, beta- blockers, antihypertensive,
anticonvulsant, and antidepressant drugs are likely to
hinder spermatogenesis.
• Immunological factor: Antibodies against spermatozoal
surface antigens may be the cause of infertility. This
results in clumping of the spermatozoa after ejaculation.
CAUSES OF MALE INFERTILITY
12. The efferent ducts may be obstructed by infection
like tubercular, gonococcal or by surgical trauma
(herniorrhaphy) following vasectomy.
In Young’s syndrome, there is epididymal obstruction
and bronchiectasis.
OBSTRUCTION OF EFFERENT DUCT SYSTEM
13. • Erectile dysfunction
• Ejaculatory defect—premature, retrograde
or absence of ejaculation
• Hypospadias.
FAILURE TO DEPOSIT SPERM HIGH IN THE
VAGINA (COITAL PROBLEMS)
14. • Unusually high or low volume of ejaculate
• Low fructose content
• High prostaglandin content
• Undue viscosity.
ERRORS IN THE SEMINAL FLUID
15. OVULATORY DYSFUNCTION
The ovulatory dysfunctions (dysovulatory) are:
• Anovulation or oligo-ovulation
• Decreased ovarian reserve
• Luteal phase defect (LPD)
• Luteinized unruptured follicle (LUF).
CAUSES IN FEMALES
16. Tubal and peritoneal factors are responsible for about 30–40%
cases of female infertility.
The obstruction of the tubes may be due to—
• Peritubal adhesions
• Endosalpingeal damage.
• Previous tubal surgery or sterilization.
• Salpingitis isthmica nodosa
• Tubal endometriosis
• Polyps or mucous debris within the tubal lumen.
• Tubal spasm.
TUBAL DISEASES
17. The endometrium must be sufficiently receptive enough
for effective nidation and growth of the fertilized ovum.
The possible factors that hinder nidation are uterine
hypoplasia, inadequate secretory endometrium, fibroid
uterus, endometritis (tubercular in particular), uterine
synechiae or congenital malformation of uterus.
UTERINE FACTORS
18. ANATOMIC:
• Anatomic defects preventing sperm ascent may be due to
congenital elongation of the cervix and second degree
uterine prolapse.
PHYSIOLOGIC:
• The fault lies in the composition of the cervical mucus, so
much that the spermatozoa fail to penetrate the mucus.
• Antisperm or sperm immobilizing antibodies may be
implicated as immunological factor of infertility.
CERVICAL FACTORS
20. • General factors: Advanced age of the wife beyond 35
years is related but spermatogenesis continues
throughout life although aging reduces the fertility in
male also.
• Infrequent intercourse, lack of knowledge of coital
technique and timing of coitus to utilize the fertile
period are very much common even amongst the
literate couples.
COMBINED FACTORS
21. • Apareunia and dyspareunia
• Anxiety and apprehension.
• Use of lubricants during intercourse, which
may benspermicidal.
• Immunological factors.
COMBINED FACTORS
22. OBJECTIVES
• To detect the etiological factor(s)
• To rectify the abnormality in an attempt to
improve the fertility
• To give assurance with explanation to the
couple if no abnormality is detected.
INVESTIGATIONS
23. HISTORY
• Age
• Duration of marriage
• Contraception used
• History of previous marriage
• Sexual dysfunction
• Anosmia.
CLINICAL APPROACH MALE
24. GENERAL MEDICAL HISTORY –
• Special reference to sexually transmitted
diseases
• Relevant surgery such as herniorrhaphy
• Operation on testes
• Sexual history
• Erectile dysfunction
• Social habits - smoking or alcohol.
CLINICAL APPROACH MALE
25. EXAMINATION
• Physical examination
• BMI
• Hair, growth and gynecomastia—inspection and
palpation of the genitalia.
• Size and consistency of the testicles.
• Testicular volume (measured by an orchidometer)
CLINICAL APPROACH MALE
26. INVESTIGATIONS
• Routine investigations include urine and blood
examination including postprandial sugar.
• Semen analysis: This should be the first step in
investigation because, if some gross abnormalities are
detected (example being absence of sperm), the couple
should be counseled for the need of assisted
reproductive technology.
CLINICAL APPROACH MALE
27. • Volume 2.0 mL or more (1.5 mL)
• pH 7.2–7.8
• Viscosity < 3 (scale 0–4)
• Sperm concentration 20 million/mL (15 million/mL)
• Total sperm count > 40 million/ejaculate (39 million/ ejaculate)
• Motility > 50% progressive forward motility (Progressive motility = 32%)
• Morphology > 14% normal form (4%)
• Viability 75% or more living (58%)
• Leukocytes Less than 1 million/mL
• Round cells < 5 million/mL
• Sperm agglutination < 10% spermatozoa with adherent particles
SEMEN ANALYSIS (WHO–2010)
28. • Serum FSH, LH, testosterone, prolactin and TSH
• Fructose content in the seminal fluid
• Testicular biopsy
• Transrectal ultrasound (TRUS)
• Karyotype analysis
• Immunological tests
• Presence of plenty of pus cells
INVESTIGATIONS
29. HISTORY
• A general medical history should be taken with
special reference to tuberculosis, STD
• The surgical history should be directed specially
towards abdominal or pelvic surgery.
• Menstrual history - hypomenorrhea,
oligomenorrhea to amenorrhea are associated
with disturbed hypothalamo-pituitary ovarian axis
CLINICAL APPROACH FEMALE
30. HISTORY
• Previous obstetric history—It is including number
of pregnancies, the interval between them and
pregnancy related complications are to be
enquired.
• Contraceptive practice should be elicited. IUCD
use may cause PID.
• Sexual problems such as dyspareunia, and loss of
libido are to be enquired.
CLINICAL APPROACH FEMALE
31. - General examination must be thorough—special
emphasis being given to obesity or marked reduction
in weight (BMI), Underdevelopment of secondary sex
characters, Polycystic ovary syndrome (PCOS)
- Systemic examination may accidentally detect
such abnormalities like hypertension, organic heart
disease, chronic renal lesion, thyroid dysfunction,
and other endocrinopathies.
EXAMINATIONS
32. - Gynecological examination includes adequacy of
hymenal opening, evidences of vaginal infections,
presence of unilateral or bilateral adnexal masses,
presence of nodules in the pouch of Douglas.
- Speculum examination may reveal abnormal
cervical discharge. Cervical smear is taken as a
screening procedure as a routine or in suspected
cases.
EXAMINATIONS
33. • Major defect is detected in female by
Noninvasive or minimal invasive methods
• Pregnancy following laparoscopy and dye
test
• Genital tuberculosis
SPECIAL INVESTIGATIONS
35. Menstrual history
Evaluation of peripheral or endorgan changes
• BBT
• Cervical mucus study
• Vaginal cytology
• Hormone estimation
– Serum progesterone – Serum LH
– Serum estradiol – Urine LH
• Endometrial biopsy
Sonography (TVS)
DIAGNOSIS OF OVULATION (INDIRECT)
36. DIRECT
Laparoscopy - Laparoscopic visualization of recent
corpus luteum or detection of the ovum from the
aspirated peritoneal fluid from the pouch of Douglas
is the only direct evidence of ovulation.
Conclusive
Pregnancy is the surest evidence of ovulation.
DIAGNOSIS OF OVULATION
38. Diagnosis of LPD is difficult. However, it is based on the
following:
• BBT chart—(a) Slow rise of temperature taking 4–5 days
following the fall in the midcycle.
(b) Rise of temperature sustains less than 10 days.
• Endometrial biopsy—Biopsy done on 25–27th day of the
period reveals the endometrium at least 3 days out of
phase
• Serum progesterone estimated on 8th day following
ovulation is less than 10 ng/mL.
LUTEAL PHASE DEFECT (LPD)
40. • Luteinized unruptured follicle (LUF) syndrome
refers to an infertile woman with regular menses
and presumptive evidences of ovulation without
release of the ovum from the follicle (trapped
ovum).
• Features of ovulation formation of corpus luteum
and its stigma are absent.
LUTENIZED UNRUPTERED FOLLICLE (LUF)
46. This in vitro cross over test is performed using
midcycle cervical mucus of the wife and semen of
the husband under question and compare with
donor sperm and donor cervical mucus.
Postcoital test for diagnosis of cervical factor
for infertility is no longer recommended
Sperm Cervical Mucus Contact Test
(SCMCT)
48. Treatment should be given against the following
conditions
• Hypergonadotropic-hypogonadism
• Presence of antisperm antibodies
• Leukocytospermia
• Retrograde ejaculation
• Teratospermia, asthenospermia
• Genetic abnormality
TREATMENT OF MALE INFERTILITY
49. SURGICAL
• Microsurgery—vasoepididymostomy or
vasovasostomy. After vasovasostomy patency is
obtained in about 80% of cases and pregnancy rate
is about 50%.
• Hydrocele is corrected by surgery.
• Orchidopexy in undescended testes should be done
between 2–3 years of age to have adequate
spermatogenesis in later life.
TREATMENT OF MALE INFERTILITY
50. GENERAL
Psychotherapy to improve the emotional
causes, if any.
Reduction of weight in obesity as in PCOS
cases is essential to have a good response of
drug therapy for induction. This facilitates
spontaneous ovulation
TREATMENT OF FEMALE INFERTILITY
52. SURGERY
• Laparoscopic ovarian drilling (LOD) or laser
Vaporization
• Wedge resection
• Surgery for pituitary prolactinomas
• Surgical removal of virilizing or other functioning
ovarian or adrenal tumor
• Uterovaginal surgery
• Bariatric surgery
TREATMENT OF FEMALE INFERTILITY
53. IUI - INTRAUTERINE INSEMINATION
Husband’s semen is commonly used. The
purpose of IUI is to bypass the endocervical
canal which is abnormal and to place increased
concentration of motile sperm as close to the
fallopian tubes.
ARTIFICIAL INSEMINATION
55. INDICATIONS –
• Hostile cervical mucus
• Cervical stenosis
• Oligospermia or asthenospermia
• Immune factor (male and female)
• Male factor—impotency or anatomical defect
(hypospadias) but normal ejaculate can be obtained
• Unexplained infertility
IUI - INTRAUTERINE INSEMINATION
56. RESULTS
Cumulative conception rates after 12
insemination cycles is 75–80%.
IUI along with superovulation (induction of
ovulation with hMG/FSH, hCG) gives higher
result.
IUI - INTRAUTERINE INSEMINATION
57. Indications are same as that of IUI.
TECHNIQUE
Large volume of washed and processed sperm is
injected within the uterine cavity around the time of
ovulation. This causes perfusion of the fallopian tubes
with spermatozoa.
In conjunction with ovulation induction pregnancy
rate is 25–30% per cycle.
FALLOPIAN TUBE SPERM PERFUSION
58. IN VITRO FERTILIZATION & EMBRYO TRANSFER (IVF-ET)
The ART encompasses all the procedures that
involve manipulation of gametes and embryos
outside the body for the treatment of infertility.
ASSISTED REPRODUCTIVE TECHNOLOGY
60. INDICATIONS
• Tubal disease
• Unexplained infertility
• Endometriosis
• Male factor infertility
• Failed ovulation induction
• Ovarian failure (donor oocyte IVF)
• Women with normal ovaries but no functional uterus
(Müllerian agenesis)
• Women with genetic risk (IVF and PGD)
IN VITRO FERTILIZATION & EMBRYO
TRANSFER (IVF-ET)
61. In this procedure, both the sperm and the unfertilized
oocytes are transferred into the fallopian tubes.
Fertilization is then achieved in vivo.
The prerequisite for GIFT procedure is to have normal
uterine tubes. The indications are the same as that of IVF
except the tubal factor.
Result: The overall delivered pregnancy rate is as high as
27–30%.
GAMETE INTRAFALLOPIAN TRANSFER
(GIFT)
63. The placement of the zygote (following one day of in vitro
fertilization) into the fallopian tube can be done either through
the abdominal ostium by laparoscope or through the uterine
ostium under ultrasonic guidance.
This technique is a suitable alternative of GIFT when defect
lies in the male factor or in cases of failed GIFT.
Results (29–30%) are similar to that of IVF.
The risk of ectopic pregnancy is high for GIFT and ZIFT
compared to IVF.
ZYGOTE INTRAFALLOPIAN TRANSFER
( ZIFT )
65. INTRACYTOPLASMIC SPERM INJECTION ( ICSI )
One single spermatozoon or even a spermatid is injected
directly into the cytoplasm of an oocyte by micropuncture
of the zona pellucida. This procedure is carried out under a
high quality inverted operating microscope.
Results: Fertilization rate is about 60–70%.
Pregnancy rate is20–40% per embryo transfer.
MICROMANIPULATION
67. A woman without a functional uterus can be a mother
with the help of ART.
In this procedure of ART (IVF), a fertilized egg is placed into
the uterus of a surrogate (gestational carrier) but not into
“intended mother”.
Indications are:
A. Irreparable uterine factor
B. When pregnancy may cause significant health risks
C. Women with recurrent unexplained miscarriage
D. Prior hysterectomy.
GESTATIONAL CARRIER SURROGACY
68. HEALTH HAZARDS OF GCS
• Birth defects: fetal congenital malformations
• Increased miscarriage
• Perinatal mortality
• Ovarian hyperstimulation syndrome
• Fertility drugs and cancer
• Psychological stress and Anxiety
GESTATIONAL CARRIER SURROGACY
