The attached presentation is related to male and female infertility.

1. Infertility : How to
Approach?
Dr. Akram H. Shalabi
Senior Consultant ObGyn
&
Reproductive Medicine
E-mail
:drakram_ivf@yahoo,com

2. Introduction
• Infertility : Inability to conceive after one year of regular
unprotected intercourse
• Sub-fertility : Delay in conceiving
•
Fecundability : Probability of getting pregnant within one cycle
≈ 20%
• Fecundity : probability of having a live birth within a cycle
• 80% get pregnant within 1 y
• 90 % within 2 y
• 10 % / 1 in 7 fail to conceive after 2

3. Types
• Primary: 60 %
• Secondary: 40 %
• Unexplained 10 - 20 % ( some reported 40%)
• Absolute : Sertoli- only cell syndrome. Absent ovaries
• Male factor infertility 30%
• Female factor 30%
• Combined 30%
• Unexplained 10%

4. Prerequisites of
Pregnancy
• Male factor :
Healthy sperm deposited in the vagina
SFA WHO 10 mil. /ml 40 % mot.
above 4% normal forms 50% viable
• Female factors :
1- Normal cervical secretions to facilitate sperm capacitation,
acrosome reaction and appropriate motility
2- Normal regular ovulation with receptive endometrium and
adequately functioning CL
3- Patent Fallopian tubes ( at least one ) with healthy lining

5. Male Infertility :
Causes
• Pre-testicular :
• Endocrine :Gns deficiency, DM ( retrograde ejaculation ),
increased PRL , thyroid dysfunction ,obesity
• Psychosexual: Erectile dysfunction , impotence
• Drugs : antideppressants, antipsychotics . Beta blockers
• Genetic: XXY, Y deletions, single gene disorders

6. Male Infertility : Causes cont.
• Testicular: immotile cilia ,mumps, undescended
testes,toxins, smoking , radiation, variecocele, SCS,
primary testicular failure,OATS, antisperm
antibodies
• Post-testicular : Absent vas, cystic fibrosis, Young’s
Syndrome ( sinusitis –infertility ), TB, gonorrhea,
Trauma( herniorrhaphy, bladder surgery, vasectomy
, ejaculatory failure, hypospadius

7. Female Infertility : Causes
• Ovulatory disorders 25%
Hypothalamic: Excessive exercise / stress/ wt loss , Kalman’s S ,
idiopathic
• Pituitary: Hypopitutarism ( Sheehan’s S , Simmond’ dis. Premature
aging loss of sexual function , decreased metabolic rate )
Cerebral irradiation
Hyperprolactinemia 7%
Craniopharyngioma
• Ovarian : PCO, LUF LPD
Turner. Radiation / chemo
Surgical menopause

8. Male Infertility : Causes cont.
• Tubal : 11% blockage after infections PID , surgery
11% Hypoplasia
15% endometriosis
12% adhesions
• Uterine: Malformations Asherman’s
TB Fibroids
• Cervix: absence stenosis antibodies
• Vagina: absence septum dyspareunia

9. WHO Classification of Anovulation
Class 1 : Hypogonadotropic hypogonadal ( Hypothalamic amenorrhea )
Low (FSH, E2 , GnRH) or
GnRH insinsitivity
Class 2: Normogonadotropic normoestrogenic
Normal Gns & E2 , but
Follicular phase FSH - subnormal
Includes PCOS
Class 3: Hypergonadotropic hypoesrogenic
POF
Ovarian resistance
Hyper-prolactenemic

10. Approach to Female
Infertility
• Ovulation tests : Indirect
regular periods biphasic BBT pattern
cervical mucus (ferning , Spinbarkeit )
Serum P4.LH , E2, urinary LH, endometrial bx
Vaginal US ( collapsed fol. & fluid in Cul de sac)
• LH surge : Ovulation occurs within 48 hrs of urinary LH surge
• Direct: laparoscopy ( Stigma of ovulation, recent CL, presence of
the ovum in aspirated peritoneal fluid )

11. • Anovulation : FSH,LH,E2 Day 2-5 Low in hypo –
hypo
TSH, PRL, Testo
• Vag, US detects PCO
• Patency tests :
• Insufflation : ( fall in CO2 pressure after rise to
120mm Hg , hissing sounds over iliac fossae , shoulder
tip pain )
• HSG , SSG, Hycosi, Laparoscopy & dye test .
Hysteroscopy
• Endometrial Bx: TB , chronic endometritis
• Serology: Anti-chlamydial abs

12. Approach
• Hx: smoking drinks, lifestyle profession
work environment sexual practice STDs
erectile /ejaculatory dysfunction
drugs
surgery
systemic dis.
• Exam.: Testicular size Hypospadius
Undescended testes Scars
Variecocele, Secondary sex. characteristics
Gynecomastia Arm span(> 1.05 in Marfan’s)

13. • Semen analysis :3 days abst., clean sterile container ,
report any spillage, 1h of collection at body T
• Two sperm tests 2-3 weeks apart / computer assisted test
• Volume color pH viscosity count motility
morphology WBCs agglutination viability
• Volume 1.5- 5ml
Decreased in obstructive conditions
Seminal vesicles aplasia
Ejaculatory dysfunction
• Viscosity: affected by dehydration, prostatitis , drugs.

14. • pH 7.2-8 :Increases in infections, decreases with low volume &
prostatitis
• Count : >15mil./ml
• Motility : T 1 - 4 ( progressive & non- progressive) , non-motile
> 40% ( all types) , > 32 % progressive within 1 h of collection
• Viability :viable sperm does not take eosin Y stain (> 58 % )
• Morphology: > 4% normal forms ( WHO 2010 ): small / giant heads
, defective mid-piece , absent / incomplete acrosome
• WBCs < 1 mil./ml
• Absence of fructose indicates absent vas or obstruction of
ejaculatory ducts

15. Laparoscopy
As a diagnostic tool decreased remarkably Tulandi 2017
Its benefit in patients with no risk factors for intra-abdominal/
pelvic adhesions is small
Treatment of stage 1 or 2 endometriosis laparoscopically showed
small increase in PR
Alternative treatment options of infertility are available
OS + IUI
IVF

16. What is Next?
• No action if SFA parameters are normal
• If 2 or more tests ( done 1 month apart) are abnormal go for
hormonal profile FSH , LH ,Testo , PRL . TSH
• In azoospermia : FNA, Epididymal aspiration, , TESE , Micro TESE
Genetic study
• Azospermia: Normal spermatogenesis 27%
Germ cell aplasia 29%
Spermatogenic arrest 26%
Generalized fibrosis 18%
Antisperm antibodies ( direct/ indirect sperm mixed antiglobulin
reaction MAR & immunobead tests IgG ,IgM, IgA )
Testicular ultrasound : eididymal cysts, variecocele , cryptorchidism

17. Summary
 Important causes of male infertility :
Defective spermatogenesis Obstruction of efferent ducts .
 Important causes of female infertility :
Tubal 25-35 % Ovulatory 20 - 25 %
Endometriosis 0 - 10 %
 Initial investigations of infertile couple should include SFA , then
 Hormonal female profile ( FSH/AMH, LH. PRL, Testosterone . TSH ,
midluteal phase P4 ,HSG, Laparoscopy +/- hysteoscopy
 The role of a proper counseling team is crucial ( relieves stress,
provides support , helps decision making)
 Multidisciplinary approach is essential : Nurse, radiologist,
ultrasonographer, endocrinologist, urologist, geneticist., pathologist.
embyologist., gynecologist

18. Summary
 Important causes of male infertility :
Defective spermatogenesis Obstruction of efferent ducts .
 Important causes of female infertility :
Tubal 25-35 % Ovulatory 20 - 25 %
Endometriosis 0 - 10 %
 Initial investigations of infertile couple should include SFA , then
 Hormonal female profile ( FSH/AMH, LH. PRL, Testosterone . TSH ,
midluteal phase P4 ,HSG, Laparoscopy +/- hysteoscopy
 The role of a proper counseling team is crucial ( relieves stress,
provides support , helps decision making)
 Multidisciplinary approach is essential : Nurse, radiologist,
ultrasonographer, endocrinologist, urologist, geneticist., pathologist.
embyologist., gynecologist

19. Thank
You