Infertility Obstetrics and gynaecology

1. INFERTILITY
PRESENTED BY –
PREETI KULSHRESTHA
M.SC. NURSING PREVIOUS YEAR

2. DEFINITION
• INFERTILITY IS DEFINED AS FAILURE TO CONCEIVE
WITHIN ONE OR MORE YEARS OF REGULAR
UNPROTECTED COITUS.
• INFERTILITY IS A DISEASE OF THE REPRODUCTIVE
SYSTEM DEFINED BY THE FAILURE TO ACHIEVE A
CLINICAL PREGNANCY AFTER 12TH MONTH OR MORE OF
REGULAR UNPROTECTED SEXUAL INTERCOURSE.

3. TYPES
.
infertility
Primary
infertility
Secondary
infertility

4. CONTD.
PRIMARY INFERTILITY –
IT DENOTES THOSE PATIENTS WHO HAVE NEVER
CONCEIVED.
SECONDARY INFERTILITY –
IT INDICATES PREVIOUS PREGNANCY BUT
FAILURE TO CONCEIVE AFTERWARDS.

5. INCIDENCE
• MALE - 35%
• FEMALE - 35%
• BOTH - 20%
• UNKNOWN - 10%
• THIS PROBLEM AFFECTS 1 IN 7 COUPLES.

6. CAUSES
Faults in male
faults in female
Combined factors

7. FAULTS IN MALE
Defective
spermatogenesis
Obstruction of
the efferent
duct system
Failure to
deposit sperm
high in the
vagina
Errors in the
seminal fluid

8. CONTD.
1. DEFECTIVE
SPERMATOGENESIS –
ORCHITIS
UNDESCENDED TESTIS
(CRYPTORCHIDISM)
GENETIC OR CHROMOSOMAL
DISORDERS LIKE 47, XXY
ENDOCRINAL FACTORS E.G.
THYROID DYSFUNCTION (
ABNORMALITIES OF THYROID
GLAND )

9. CONTD.
2. OBSTRUCTION OF THE EFFERENT DUCT
SYSTEM :
IT CAN BE OF TWO TYPES -
A. CONGENITAL = IT CAN BE DUE TO ABSENCE OF
VAS DEFERENS.
B. ACQUIRED = IT CAN BE DUE TO INFECTION
- TUBERCULOSIS
- GONORRHEA
- SURGICAL TRAUMA

10. CONTD.
3. FAILURE TO DEPOSIT
SPERM HIGH IN THE
VAGINA –
IMPOTENCY
EJACULATORY FAILURE
HYPOSPADIASIS
BLADDER NECK SURGERY
PSYCHOSEXUAL

11. CONTD.
4. ERRORS IN THE SEMINAL FLUIDS –
ASPERMIA/ AZOOSPERMIA (FAILURE TO PRODUCE SEMEN
OR ABSENCE OF SPERM IN SEMEN)
OLIGOSPERMIA/ OLIGOZOOSPERMIA (FEW SPERM IN
SEMEN)
ASTHENOSPERMIA (REDUCED SPERM MOTILITY)
NECROZOOSPERMIA (DEAD SPERM )
TERATOZOOSPERMIA (SPERM WITH ABNORMAL
MORPHOLOGY)
POLYZOOSPERMIA (SPERM COUNTS >250 MILLION/ML)

12. FAULT IN FEMALE
Ovarian
factor
Tubal
factors
Peritoneal
factors
Uterine
factors
Cervical
factors
Vaginal
factors

13. CONTD.
1.OVARIAN FACTORS –
ANOVULATION / OLIGO-OVULATION (LACK OR
ABSENCE OF OVULATION)
LUTEINIZED UNRUPTURED FOLLICLE (LUF) –
INADEQUATE GROWTH AND FUNCTION OF
CORPUS LUTEUM.

14. CONTD.
2. TUBAL FACTORS –
SALPINGITIS (TUBAL INFECTION)
3. PERITONEAL FACTORS –
ENDOMETRIOSIS
4. VAGINAL FACTORS –
VAGINAL ATRESIA (CLOSED VAGINA)
VAGINAL SEPTUM (FEMALE REPRODUCTIVE
SYSTEM DOES NOT FULLY DEVELOP)

15. CONTD.
5. UTERINE FACTORS –
FIBROID UTERUS
UTERINE HYPOPLASIA
ABNORMAL / IRREGULAR MENSTRUAL CYCLE
CONGENITAL MALFORMATION OF UTERUS
RETROVERTED UTERUS

16. CONTD.
6. CERVICAL FACTORS –
CONGENITAL ELONGATION OF CERVIX
SECOND DEGREE UTERINE PROLAPSE
COMBINED FACTORS
IT MAY INCLUDE BOTH MALE AND FEMALE FACTORS.

17. CLINICAL MANIFESTATION
IN MALE –
CHANGES IN HAIR GROWTH
CHANGES IN SEXUAL DESIRE
PAIN OR SWELLING IN THE TESTICLES
SMALL, FIRM TESTICLES
PROBLEM WITH SEXUAL FUNCTION
DIFFICULTY WITH EJACULATION
HAVING A LOW SPERM COUNT

18. CONTD.
IN FEMALE –
 ABNORMAL PERIODS
 IRREGULAR PERIODS
 NO PERIODS
 PAINFUL PERIODS
 SKIN CHANGE INCLUDING MORE ACNE
 CHANGES IN SEX DESIRE
 DARK HAIR GROWTH ON THE LIPS, CHEST, AND CHIN
 WEIGHT GAIN
 PAIN DURING SEX

19. RISK FACTORS
FOR ALL GENDERS
OVER AGE (35 FOR FEMALE OR 40 FOR MEN)
SMOKING
OVER WEIGHT
OVER EXERCISE
SEXUALLY TRANSMITTED DISEASE
MENTAL STRESS
DIABETES
EATING DISORDER (ANOREXIA NERVOSA AND BULIMIA)
EXCESSIVE ALCOHOL USE
RADIATION THERAPY OR OTHER CANCER TREATMENTS

20. DIAGNOSTIC
PROCEDURES
IN MALES –
1.HISTORY –
o AGE OF MARRIAGE, DURATION
o MEDICAL HISTORY (ANY D/S)
o SURGICAL HISTORY (ANY GENITAL TRACT SURGERY, TESTICULAR
SURGERY)
o OCCUPATIONAL HISTORY (EXPOSURE TO RADIATION, EXCESSIVE HEAT)
o SMOKING AND ALCOHOL
o SEXUAL HISTORY (FREQUENCY, IMPOTENCY, LACK OF SATISFACTION)

21. CONTD.
2. EXAMINATION –
A. INSPECTION = WHOLE GENITAL AREA
B. PALPATION = TESTIS, GENITAL AREA,
TESTICULAR VOLUME IS CHECKED WITH
THE HELP OF ORCHIDOMETER.

22. CONTD.
3. GENERAL INVESTIGATION –
A. SEMEN ANALYSIS
• SPERM VOLUME
• SPERM COUNT
• PH-7.2 TO 7.8
• SPERM CONCENTRATION
• SPERM MOTILITY

23. CONTD.
B. HORMONAL STUDIES OR SPECIAL
INVESTIGATION
C. IN-DEPTH EVALUATION –
• SERUM FSH
• SERUM LH
• TESTOSTERONE
• TSH
• PROLACTIN LEVELS
• TESTICULAR BIOPSY
high
Defect in
testis

24. CONTD.
IN FEMALE –
1.HISTORY –
o PREVIOUS INFERTILITY
o MEDICAL HISTORY
o SURGICAL HISTORY
o MENSTRUAL HISTORY
o PREVIOUS OBSTETRIC HISTORY
o USE OF CONTRACEPTIVES
o SEXUAL HISTORY

25. CONTD.
2. EXAMINATION –
A. GENERAL EXAMINATION –
OBESITY
OVER WEIGHT
UNDERWEIGHT
ABNORMAL DISTRIBUTION OF HAIR (AXILLARY AND PUBIC)
DECREASED SECONDARY SEX CHARACTERISTICS

26. CONTD.
B. SYSTEMIC EXAMINATION – TO DETECT –
 HYPERTENSION
ORGANIC HEART DISEASE
RENAL PROBLEM
ENDOCRINOPATHIES ( DISEASE OF ENDOCRINE GLAND)

27. CONTD.
C. GYNECOLOGICAL EXAMINATION –
EVIDENCE OF VAGINAL INFECTION
ADEQUACY OF HYMENAL EXAMINATION
CERVICAL TEAR OR CHRONIC INFECTION
UNDUE ELONGATION OF CERVIX
UTERINE SIZE, AND POSITION

28. CONTD.
D. SPECULUM EXAMINATION –
TO CHECK ABNORMAL CERVICAL DISCHARGE .
IF PRESENT, IT IS SENT FOR SCREENING.

29. TREATMENT
IN MALE –
A. MEDICAL MANAGEMENT –
• IF THE INFERTILITY IS DUE TO HYPOGONADOTROPHIN – HYPOGONADISM
- TAB. CLOMIPHENE CITRATE = 25-50 MG ORALLY DAILY FOR 25 DAYS WITH
REST FOR 5 DAYS INTO 3 CYCLE. IT HELPS TO INCREASE THE SERUM LEVEL OF
FSH, LH AND TESTOSTERONE.
- INJ. HCG(HUMAN CHORIONIC GONADOTROPIN ) = 5000 IU, I/M ( ONCE OR
TWICE A WEEK). IT WILL STIMULATE THE ENDOGENOUS (INTERNAL)
TESTOSTERONE PRODUCTION.
- INJ. HMG(HUMAN MENOPAUSAL GONADOTROPHIN) = USED IN FAILED
CLOMIPHENE CITRATE CONDITION.
- TAB. TESTOSTERONE = 100-160 MG ORALLY DAILY FOR 3-4 MONTHS. IT
HELPS IN INCREASING THE SPERM COUNT.

30. CONTD.
• GTI = ANTIBIOTICS (DOXYCYCLINE, ERYTHROMYCIN) FOR 4-6 WEEKS.
• HYPOTHALAMIC DYSFUNCTION = GNRH THERAPY IS GIVEN
• TERATOSPERMIA OR ASTHENOSPERMIA = NO TREATMENT,
ONLY DONOR INSEMINATION IS AVAILABLE.
• EJACULATORY PROBLEMS = PHENYLEPHRINE IS USED . IT
IMPROVES THE TONE OF INTERNAL URETHRAL SPHINCTER AND THE
MUSCLES .

31. CONTD.
B. SURGICAL
MANAGEMENT –
• OBSTRUCTION IN VAS =
VASOEPIDIDYMOSTOMY OR
VASOVASOSTOMY IS DONE.
• VARICOCELE = CORRECTED BY
HIGH LIGATION OF SPERMATIC
VEIN.
• HYDROCELE = CORRECTED BY
THE SURGERY
• UNDESCENDED TESTIS =
ORCHIDOPEXY AT THE AGE OF 2-3
YRS.

32. CONTD.
C. NURSING MANAGEMENT –
• IMPROVE THE GENERAL HEALTH OF THE PATIENT.
• REDUCE WEIGHT, IF THE PERSON IS OBESE.
• TELL TO AVOID HEAVY SMOKING AND ALCOHOL.
• TO AVOID TIGHT AND WARM UNDERGARMENTS.
• ENCOURAGE THE PT. TO TAKE COLD SCROTAL BATH AT LEAST
TWICE A DAY FOR 5 MIN.
• TO TAKE VITAMIN E, C, B12 AND FOLIC ACID AS THEY IMPROVE
SPERMATOGENESIS.
• GIVE THE PT. PSYCHOLOGICAL SUPPORT
• ADVICE AND TEACH THE COUPLE ABOUT THE PROPER TECHNIQUE
OF INTERCOURSE.

33. CONTD.
IN FEMALE –
A. MEDICAL MANAGEMENT –
• IF THE INFERTILITY IS DUE TO OVULATORY DISORDERS, THEN –
- T. CLOMIPHENE CITRATE
- INJ. HMG
• HYPOTHALAMIC DISORDER/AMENORRHEA/HYPOGONADOTROPHIN/
HYPOGONADISM –
- GNRH THERAPY IS GIVEN
• DEFECTIVE FOLLICULOGENESIS –
- INJ. HCG 5000IU: 10000IU I/M IS GIVEN
- VAGINAL SUPPOSITORIES100MG TDS
- HYPERPROLACTINEMIA – BROMOCRIPTINE THERAPY MAY GIVEN.

34. CONTD.
B. SURGICAL MANAGEMENT –
• TUBOPLASTY – TO REPAIR THE TUBES
• SALPINGOSTOMY – CREATION OF AN OPENING
INTO THE FALLOPIAN TUBE
• ADHESIOLYSIS(SALPINGO-OVARIO-LYSIS)
PROCEDURE PERFORMED TO BREAK UP AND
REMOVE ADHESIONS.
• TUBOTUBAL ANASTOMOSIS – WHEN THE
SEGMENT OF THE TUBE IS DISEASED.
• TUBAL CORNUAL ANASTOMOSIS – IN CASE OF
CORNUAL BLOCK.
• CANNULIZATION OF THE TUBE – IN CASE OF
TUBAL OBSTRUCTION
• MYOMECTOMY – SURGICAL REMOVAL OF
UTERINE FIBROIDS.

35. SUMMARY
• INFERTILITY IS A SIGNIFICANT SOCIAL AND MEDICAL
PROBLEM AFFECTING COUPLES WORLDWIDE.
• FEMALE AND MALE FACTORS ARE EQUALLY RESPONSIBLE .
• EVOLUTION OF BOTH PARTNERS IS ESSENTIAL .
• TREATMENT DEPENDS ON THE CAUSE OF INFERTILITY AND
VARIES FROM OVULATION- INDUCING DRUGS TO SURGERY
TO ART.

36. BIBLIOGRAPHY
• D. C. DUTTA, TEXTBOOK OF GYNECOLOGY,
NEW CENTRAL BOOK AGENCY (P) LTD
EDITION 5TH
PAGE NO. 220-234
• DR. SHALLY MAGON – SANJU SIRA
TEXTBOOK OF MIDWIFERY AND OBSTETRICS
LOTUS PUBLISHERS,
EDITION 4TH,
PAGE NO 875-882