Definition, types, causes, diagnsois , management

1. Infertility
Mr. Mahesh Chand
Nursing Tutor

2. Definition
• Infertility is defined as a failure to conceive
within one or more years of regular unprotected
coitus
• Primary infertility denotes those patients who
has never conceived
• Secondary infertility indicates previous
pregnancy but failure to conceive subsequently

3. Causes of male infertility
Pre testicular Testicular Post testicular
Endocrine
•Gonadotrophin
deficiency
•Thyroid dysfunction
•hyperprolactinaemia
Cryptorchidism
Infection
Toxins: drugs, radiation
varicocele
Obstruction of efferent
duct
Congenital:
•Absence of vas deferens
Psychosexual
•Erectile dysfunction
•Impotence
Immunological
Sertoli-cell-only
syndrome
Acquire infection
•Tuberculosis
•gonorrhoea
Drugs
•Antihypertensive
•Antipsychotic
Primary testicular failure Surgical:
vasectomy
Genetics
•47 XXY
•Y chromosome deletion
Others:
Ejaculatory failure
Bladder neck surgery

4. Causes of female infertility
Ovarian factors: (30-40%)
• Anovulation or oligo ovulation
• Luteal phase defect
• Luteinised unruptured follicle
Tubal and peritoneal factors: (25-30%)
Obstruction of tube due to
• Pelvic infections
• Previous tubal surgery or sterilization
• Salpingitis isthmica nodosa
• Tubal endometritis

5. Continue….
Uterine factor:
• Hypoplasia
• Inadequate secretory endometrium
• Fibroid uterus
• Endometritis
• Congenital mal formation of uterus
Vaginal factors:
• Atresia vagina
• Transverse vaginal septum
• Vaginitis or purulent discharge

6. Continue….
Cervical factors:
• Anatomical defects that prevent entry of the sperm
like elongation of cervix, second degree uterine
prolapse,
• The fault lies in the composition of the cervical
mucus , so much that the spermatozoa fails to
penetrate the mucus.
• The mucus may be scanty following amputation,
deep cauterisation of the cervix
• The abnormal constituents include excessive,
viscous or purulent discharge as in chronic cervicitis

7. Investigation for infertility: Male
• History collection
• Examination
• Investigation:
▫ Routine investigation
▫ Seminal fluid analysis: the semen is collected in a clean wide
mouthed dry glass jar. It should be send to laboratory as early as
possible. The coitus should be avoided for 2-3 days prior to the
test
• In selected cases, biochemical test of creatine, phosphokinase
and reactive oxygen species are done as sperm function test
• In depth evaluation: serum FHS, LH, testosterone, prolactin,
and TSH; Fructose contain in seminal fluid; Testicular biopsy;
Transrectal ultrasound; vasogram; Karyotype analysis

8. Investigation: Female
• History:
▫ A general medical history
▫ The surgical history
▫ Menstrual history
▫ Previous obstetric history
▫ Contraceptive practice
▫ Sexual problem
• Examination:
▫ General examination
▫ Systemic examination
▫ Gynecological examination
▫ Speculum examination

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• Diagnosis of ovulation:
1. Indirect:
Menstrual history
Sonography
Evaluation of peripheral or endorgan changes
▫ BBT (Basal body temperature)
▫ Cervical mucus study
▫ Vaginal cytology
▫ Endometrial biopsy
▫ Hormone estimation
 Serum progesterone
 Serum LH
 Serum oestradiol
 Urine LH
2. Direct: Laparoscopy
3. Conclusive: Pregnancy

10. Treatment for male infertility
• To improve spermatogenesis the following measures
should be useful
General care:
• Improvement of general health, reduction of weight
in obese, avoidance of alcohol and heavy smoking
• Avoidance of tight and warm undergarments or
occupation that may elevate testicular temperature
• Use of vitamin E,C,D, B12 and folic acid and
antioxidant to improve spermatogenesis
• Medication that interfere spermatogenesis should be
avoided

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• In hypogonadotrophic hypogonadism, the disorder of
spermatogenesis can be treated with
▫ hCG 500 IU intramuscularly once or twice a week is given
to stimulate endogenous testosterone production
▫ hMG is added to hCG when there is no sperm in the
ejaculate with hCG alone
▫ Dopamine agonist is given in hyperprolactinamia to restore
normal prolactin and testosterone level
• Clomiphene citrate 25-50 mg orally daily for 25 days
with rest for 5 days for 3 cycles is given. It increase
serum level of FSH, LH and testosterone
• Genital tract infections need antibiotic like doxycycline
or erythromycine for 4-6 weeks depending on response

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• In retrograde ejacuation- phenylephrine is used to
improve the tone of internal urethral spincter
• In teratospermia, asthenospermia no treatment is
available. Donor insemination is the option
• In genetic abnormalities, artificial insemination with
donor sperm is the option
Surgical:
• Vasoepididymostomy or vasovasostomy
• Hydrocele is corrected by surgery
• Orchidopexy in undecended testes should be done
between 2-3 years of age

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Impotency:
• Psychosexual treatment
• For erectile dysfunction, sildenafil 25-100 mg or
tadalafil 10-20 mg is currently advised. A single
dose orally one hour before sexual activities
should be given

14. Treatment for female infertility
Ovulatory
Associate disorders like
endometriosis, infection
Unexplained
infertility
Immunological
ART

15. Ovulatory dysfunction
:
• It may be present in otherwise normal menstrual
cycle or may be associated with oligomenorrhoea or
amenorehoea
:
• General:
▫ Psychotherapy
▫ Reduction of weight in obesity
Anovulation LPD LUF

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• Drugs:
Stimulation of ovulation:
• Clomiphene citrate
• Letrozole
• FSH
• hCG (Profasi, Pregnyl)
• GnRH

17. Continue…..
Correction of biochemical abnormality:
• Hyper insulinaemia- Metformin
• Androgen excess- Dexamethasone
• Prolactin raised- Bromocriptine
Substitution therapy:
• Hypothyroidism- Thyroxin
• Diabetes mellitus- Antidiabetic drug

18. Continue…..
• Surgery:
• Laproscopic overian drilling or laser
vaporisation: done by multiple puncture of the
cysts in polycystic ovarian syndrome by
diathermy or laser
• Wedge resection: Bilateral wedge resection of
the ovaries is done in PCOS cases where
clomiphane citrate fails to induce ovulation

19. Endometriosis, cervical factors
• Treated with drugs or surgery or both
• Cervical factors:
• The cervical mucus quality can be improved by
conjugated oestrogen 1.25 mg orally daily starting
on day 8 for 5 days
• In proved cases of Cl. Trachomatis or M. hominis,
doxycycline 100 mg twice daily for 14 days is to be
given to both the partners.
• Cervical factors when cannot be treated, is overcome
by ART procedures like IUI, IVF, GIFT.

20. Immunological factors
• In the presence of antisperm antibodies in the
cervical mucus, dexamethasone 0.5 mg at bed
time in the follicular phase may be given
• In antisperm antibody positive pateint COH and
IUI or IVF or ICSI is recommended

21. Unexplained infertility
• It is for the couples who have undergone
complete basic infertility work up and in whom
no abnormality has been detected and still
remain infertile
• The recommended treatment are induction of
ovulation, IUI, superovulation combined with
IUI and ART
• The fault detected in both the partners should be
treated simultaneously and not one after the
other

22. Assisted Reproductive Technology(ART)
• ART comprise all the procedures that involve manipulation of
gamates and embryos outside the body for the treatment of
infertility
• Different methods of ART
▫ IVF-ET- In vitro fertilization and embryo transfer
▫ GIFT- Gamate intra fallopian transfer
▫ ZIFT- Zygote intra fallopian transfer
▫ POST- Peritoneal oocyte and sperm transfer
▫ SUZI- Subzonal insemination
▫ ICSI- Intracytoplasmic sperm injection
• Methods of sperm recovery
▫ TESE- Testicular sperm extraction
▫ MESA- Microsurgical epididymal sperm aspiration
▫ PESA- Percutaneous epididymal sperm aspiration

23. Prognosis
• The pregnancy rate within 2 years after the start
of investigation, ranges between 30-40%
• The rate will increase up to 50-60% if AID cases
are included
• Adoption is the alternative for many couples