Infertility is defined as the inability to conceive after 12 months of regular unprotected intercourse. It can be caused by problems with sperm, eggs, fertilization, or implantation. Common causes include ovulatory disorders, tubal damage, male factor issues, and unexplained infertility. Diagnosis involves medical history, physical exam, semen analysis, and tests of hormone levels and fallopian tube patency. Treatment may include lifestyle changes, ovulation induction, intrauterine insemination, in vitro fertilization, or assisted reproductive technologies.

1. INFERTILITY
Tariku Regea (BSc, MSC in CMw) July 2023

2. Objectives
At the end of these session, you will be able to
• Definition
• Causes
• Workup
• Principles of management

3. Introduction
• Pregnancy requires the effective function of at least
five systems or cell types:
A competent oocyte,
A competent sperm,
A favorable environment in which fertilization can
take place,
A transport system for passage of the fertilized oocyte to
uterus
A prepared endometrium that will accept the implantation
of the oocyte and nurture the growing embryo

4. Introduction
• Infertility affects both men and women with almost
equal frequency
• Women may bear the sole blame and lowers their social
status
• A socially acceptable basis for divorce in most of the
societies
• Public Health issue worldwide, including developed
countries

5. Introduction
• Fertility is defined as the capacity to conceive and
produce offspring.
• Since the fertility potential of the female partner decreases
after 35 years of age,
 Some recommend infertility evaluation after six
months of attempting conception in women 35–40
and
 Immediately in women over 40 years of age.

6. Definition and Terms
• Infertility is inability of a couple to conceive after 12 months
of regular intercourse without use of contraception in
women <35 years of age and
• After six months of regular intercourse without use of
contraception in 35 and more years of age.
• It is a common condition with important psychological,
economic, demographic, & medical implications.
• It is a unique medical condition because it involves a couple,
rather than a single individual.

7. • Subfertility to describe failure to conceive if the couple
has not been proven to be sterile.
• Fecund ability, the probability of achieving a
Pregnancy in one menstrual cycle,
 It is a more accurate descriptor because it recognizes
varying degrees of infertility.
• Infertility is reversible, but sterility is not.
Definition...

8. Types of infertility
• Primary infertility: A couple that has never conceived.
• Secondary infertility: occurs after previous pregnancy
regardless of its site & outcome.

9. CAUSES OF INFERTILITY
The cause may be present
• Male Infertility Factors
• Female Infertility Factors
• Male-Female Infertility factor
• Unexplained
9

10. Male Infertility Factors
Two defects: - Sperm production and delivery
1. Endocrine disorders
 Hypothalamic dysfunction
 Pituitary failure (tumor, radiation, surgery)
 Hyper-prolactinemia (drug, tumor) - Impotence
 Diabetes mellitus disease.
 Hypertrophy of the prostrate gland
10

11. 2. Structural Abnormalities
• Varicocele (most common), swollen veins surrounding the
testis w/c increases the temperature within the testes.
• Torsion, in which one testis is twisted
• Cryptorchidism - undescended testicles.
• Vas deferens may be blocked b/c of past infection or injury.
• Absence of vas deferens due to a congenital abnormality.
• Bilateral obstruction of epididymis or ducts
• Abnormal position of urethral orifice:- Hypospadias &
epispadias
11

12. 3. Sperm Abnormalities
• Low sperm count (oligospermia)- count < 20 million/mL
• Absence of living spermatozoa in the semen
(azoospermia)-due to obstruction in outflow tract.
• Poor motility will prevent sperm from swimming.
• Sperm that have structural deformity will also have
problems penetrating an egg.
• Male may produce antibodies to his own sperm- due to
damage blood testis barrier
• Chromosomal abnormalities- eg. klinefelter syndrome
(47,XX) 12

13. 4. Medical Disorders
• Infection – Usually childhood disease (Mumps orchids) or TB
orchids.
• STI- Sterility after infections like gonorrhea.
• Impotence- Erectile dysfunction.
• Ejaculatatory d/o – Retrograde and Premature ejaculation.
• Thyroid disorders- Hypothyroidism.
• Psychological factors like
 Job and financial stress, Fatigue, depression,
 Anxiety surrounding sexual intercourse,
• Illness, Trauma to the testes, Drug or alcohol abuse.
13

14. Diagnostic Evaluation
• History of both partners and separate private consultation.
• Age, Lifestyle – smoking, alcohol.
• History of too tight fitting pant for long time.
• Medical history (trauma, mumps, chronic medical illness).
• Occupation – excess heat, radiation, toxins
• Previous paternity
• Sexual history (technical difficulty), history of STI.
• Surgical history (mainly inguinal and scrotal).
14

15. Physical examination
 General appearance
 Testicular size and Epididymis, Scrotum
 Malformation of penis- Hypospadias and epispadias
 Varicocele
15
Diagnostic Evaluation...

16.  Semen analysis is a routine test that is the single most
important lab indicator for male infertility.
 Teach client how to collect specimen after a period of
abstinence.
 Better results if done after 2-3 days of abstinence.
 It should be analyzed within 1 hour of collection in the lab.
 If abnormal result repeat semen analysis in 3 months.
16
Laboratory Semen analysis

17. Normal Findings of seminal analysis
• Volume:- 2 mL or more
• PH :- 7.2-7.8
• Total sperm count :- more than 20 million/mL
• Liquefaction:- Complete in 1 hr.
• Motility:- 50% or more
• Morphology:- 30% or more normal forms.
• WBC:- Fewer than 1 million/ml
17

18. Laboratory tests
• A male with less than 5 million sperm per milliliter
warrants an endocrinology evaluation including:
• FSH and LH
• Testosterone
• Prolactine
• Thyroid function T3/T4 Extended
• Skull X-ray tests
• Sperm anti body testing
18

19. • Transurethral ultra-sonography, which detects ejaculatory
duct obstructions.
• Testicular biopsy –to determine if cancer cells.
• Once evaluation is complete, treatment of infertile couple is
directed by the findings.
19
Laboratory tests...

20. Treatment
 Eliminate alterations of thermoregulation.
 Hormonal manipulation to raise testicular testosterone
levels. Eg. GnRH – given in a pulsatile (to prevent down
regulation of receptors), hCG, testosterone.
 Clomiphene citrate is occasionally used for induction of
spermatogenesis-20% success.
 Artificial insemination.
 Medications to counter retrograde ejaculation.
20

21. Female Infertility Factors
• Structural Abnormality: the most common identifiable
female factors, w/c accounts for 81% of female infertility
• Ovulatory disorders (25%): Infrequent ovulation (oligo-
ovulation) or absent ovulation (anovulation)
• Oocyte aging — With advancing female age, there is an
increase in the percentage of infertility.
• The decrease in fecundability with aging is likely due to a
decline in both the quantity and quality of the oocytes.

22. Female Infertility...
• Endometriosis (15%): interfere with tubal transport
• Fallopian Tubal blockage (11%) / Pelvic Adhesions (12%):
• Prevent normal transport of the oocyte and sperm through
the fallopian tube.
• The primary cause of tubal factor infertility is pelvic
inflammatory disease (the most cause ).
• Ux D & C, previous Ux surgery and IUD complicated with
infection causes Pelvic Adhesions.

23. Female Infertility...
• Cervical factor: Congenital malformations and trauma to
the Cx (including surgery)
 May result in stenosis and inability of the Cx to produce
normal mucus, impairing fertility.
• In addition, other factors such as leiomyoma.
• A reduction in coital frequency with increasing age
• UNEXPLAINED: is the Dx given to couples after a thorough
evaluation has not revealed a cause.
• Many cases of unexplained infertility may be due to small
contributions from multiple factors.

24. Hormonal Imbalance
• Frequent cause of infertility in women is abnormal ovulation.
• Abnormal ovulation can be caused by a number of disorders
of the endocrine system:
• Problem to hypothalamus-pitutay-ovarian axes.
• Including thyroid disease- both hypothyroidism &
hyperthyroidism affects reproduction.
• Diabetes mellitus – affects ovulation, fertilization &
implantation.
• Polycystic ovarian syndrome- oligomenorrhea &
hyperandrogenism.
24

25. Other Factors
• Nutritional status:- being over or underweight.
• Functional abnormality of cervical mucus.
• The cervical mucus may be too thick for the sperm to
penetrate, or it may be chemically hostile to the sperm.
• Immunologic factor –development of antisperm antibodies
by the women or her partner.
25

26. Evaluation of female factors
• History- age, length of time with current partner,
• Menstrual history,
• Age at menarche,
• Menstrual cycle pattern
• Recent change in cycle
• Duration of flow
• Ovulation pain
• Dysmenorrhea
• Contraceptive hx (duration, type, date of last use)
26

27. Evaluation of female factors...
 Obstetric history:- abortion, ectopic Px, PPH.
 Sexual history- frequency, regularity, timing around mid
cycle, STI, PID
 Medical history-medical illness
 Surgical history-pelvic operation
 Drug history - (type, duration)
 Review history- diet, weight (b/c when over wt steroid
hormones increase in body fat), strenuous exercise.
27

28. Physical examination
• Routine PE is an essential component of general medical care.
• General appearance, thyroid, 20 sexual characteristics
• Abdominal scars, tenderness, adenexial masses.
• Uterine enlargement, position, motility.
• Vaginal exam: state of introitus, position /direction of Cx,
• Speculum exam: condition of cervix, cervical secretion in
relation to time in menstrual cycle.
• Basal body temperature (biphasic shift) for 3 cycle.
• Cervical mucus examination after expected time of ovulation-
thick, yellowish.
28

29. Laboratory investigation
• VDRL
• T3/T4
• FSH, LH
• Vaginal pH
• Estradiol, Prolactin levels
• Fasting blood sugar
• Urinalysis
• Liver enzymes, renal function
• Progestrone mid luteal phase (>25mg/L)
29

30. Laboratory investigation...
 Post-coital test (day 12-14, sperm motility in cervical
mucus 2-6 hours after intercourse).
 A satisfactory result is finding of >10 motile
spermatozoa with good forward movement
 under high power field in the presence of adequate
cervical mucus.
 Determination of sperm anti bodies
 Laparascopy
 Hystrosalpingography (HSG)
30

31. TREATMENT
 Education - timing of intercourse
 Anovulation:- ovulation induction by clomiphene
citerate-via increased pituitary gonadotropins.
 Bromocriptine if increased prolactin.
 Tubal factor- surgical correction.
 Cervical factor- antibiotic Rx for infection
31

32. TREATMENT...
 If anovulatory cycle is a cause induce ovulation using
• Clomiphen citrate:
- It is indicated primarily in pts with adequate levels of
estrogen & normal levels of FSH & prolactin.
- It is generally ineffective in hypogonadotropic patients who
already have a poor estrogen supply
- Bromocriptine
• 1-2 mg BID in the first week then
• 2.5 mg BID for 01 month
- Thyroxine:- 0.2 mg/d until response 32

33. Month Dose of clomiphene
1 50mg/d for 5 days in the first cycle beginning on the
third to fifth day of menstrual or withdrawal bleeding.
2 100mg/d for 5 days
3 150 mg/d for 5 days
4 200 mg/d for 5 days
6, 7, 8 No treatment
9 Clomiphene 150 mg/day + HCG 5000 IU 7 days after
10 Clomiphene 150 mg/d + HCG 5000 IU 7 days after
TREATMENT...

34. • Ovulation induction with Clomiphene citrate – increase
pulse & amplitude of:
- GnRH
- Gonadotropins – FSH & LH
 Dexamethasone: reduction of level of androgen
 Bromocriptine: reduction of prolactin
 Substitution therapy for hypothyroidism
TREATMENT...

35. Assisted Reproductive Technology (ART)
• If a woman does not become pregnant after treatment
with medical and surgical techniques,
 she may choose to undergo more complex
procedures, called Assisted Reproductive Technology

36. 1. Intrauterine insemination(IUI)
 IUI- is the procedure in w/c processed & concentrated
motile sperm are placed directly into the uterine cavity
 using a long tube.
 IUI is particularly useful in couples with some types of
severe sexual dysfunction
 (e.g. severe veganism's, ejaculatory dysfunction) or
discordant for STIs carriage (eg, HIV, hepatitis).

37. SPERM COLLECTION AND PROCESSING
• IUI is usually performed with fresh sperm from the partner.
• Semen collection- a semen specimen in the morning after
two or three days of sexual abstinence.
• Masturbation or withdrawal, ideally in a private room
designated for this purpose in the laboratory/office.
• The entire ejaculate is collected in a sterile cup to minimize
the risk of uterine infection from contaminants.
• Avoid the lubricants, as most are toxic to sperm.
• If a lubricant is needed, instruct the client to prevent
contact b/n the lubricant and glans.

40. • Sperm processing - sperm preparation maximizes the
number of motile sperm for insemination, removes cellular
debris & concentrates the specimen.
• Stimulated cycles - Controlled ovarian hyper-stimulation
plus IUI for Rx of infertility in couples with unexplained
infertility.
• Clomiphene citrate - For most women, the first-line
approach for ovarian stimulation is clomiphene citrate (CC)
100 mg for 5consecutive days beginning on cycle day 3 or
5, depending on the woman's natural cycle length.
SPERM COLLECTION AND .....

41. • Gonadotropin and HCG -women with diminished ovarian
reserve, induce ovulation with injectable gonadotropins
rather than clomiphene or perform IVF.
• Injectable gonadotropins (recombinant FSH) are given per
provider dosing preference beginning on cycle day 2 or 3.
• It is the standard of care to follow serum estradiol levels
and ovarian follicle size with trans-vaginal ultrasounds.
SPERM COLLECTION AND .....

42. • When at least one follicle has a mean diameter:15-18 mm,
the patient self administers 5000 to 10,000 units of HCG
 as a subcutaneous or intramuscular injection to
trigger ovulation.
• The minimum size (15-23 mm) of the leading follicle before
HCG injection is controversial.
• One IUI is performed 36 hours after HCG injection.
SPERM COLLECTION AND .....

43. IUI PROCEDURE
• Equipment
• Prepared sperm specimen
• Speculum
• 1 cc sterile syringe with blunt cannula
• Disposable polyethylene insemination catheter
• IUI is most effective for treating:
– women who have scarring or defects of the cervix
– men who have low sperm counts
– men who have sperm with low mobility
– men who cannot get erections
– men who have retrograde ejaculation

44. 2. Invitro fertilization
• IVF refers to a procedure designed to overcome infertility
and produce a Px as a direct result of the intervention.
• In general, the ovaries are stimulated by a combination of
fertility medications and then one or more oocyte(s) are
aspirated from ovarian follicles.
• These are fertilized in the laboratory ("in vitro"), after
which, one or more embryo(s) are transferred into the Ux.
• These steps occur over about a two-week interval of time,
which is called an IVF cycle.

45. 2. Invitro fertilization...
• IVF is for women with other causes of infertility, including
one or more of the following:
 Tubal factor-completely blocked.
 Severe male factor infertility
 Diminished ovarian reserve (time to conception is critical)
 Failed Rx with less invasive therapies (eg, ovulatory
dysfunction, endometriosis, unexplained infertility).
 Ovarian failure (donor eggs must be used in this case).
 Uterine factor (Asherman syndrome or distortion of the
Ux cavity, gestational surrogacy in conjunction with IVF).

46. Thank you!

47. MENOPUASE AND
CLIMACTERIC

48. Learning Objectives
• To define climacteric and menopause
• To describe the physiologic changes of climacteric
• To describe the problems of climacteric
• To enumerate the causes of postmenopausal bleeding

49. Introduction
– A problem of developed countries because of increase
life expectancy and quality of life
– Hormone deficiency
– Associated with both gynecological and medical problems

50. Definitions
• Climacteric (critical life): is the phase of life for women that
marks transition
 from being able to reproduce to being non-reproductive.
• Menopause is cessation of physiologic uterine bleeding (the
last menstruation)
 It is diagnosed retrospectively.
 It is the most visible event marking climacteric.
 Average age at menopause is 51 years and is not
affected by
o race, number of pregnancies, contraceptive use, age
at menarche and physical characteristics. .

51. Definitions
• In practice these two terms are used interchangeably
• Pre-menopause is the period before menopause during
which the menstrual cycle is irregular and climacteric
symptoms are experienced.
• Post menopause is the period after menopause.
• Perimenoposal includes the premenopause and post
menopause and extends from 40-55years

52. Etiology
– Age = exhaustion of the stoke of primordial follicles
– Surgery ,radiation ,chemotherapy
– Premature ovarian failure
– Smoking =decrease by 1-2 years

53. Pathophysiology
• Atresia starts in utero at 20 weeks
• With each ovulation there is 1000 atresia
• As menopause nears, ovarian follicles get depleted and
become resistant to gonadothropin hormones.
↓
• Estradiol production diminishes which in turn results in
elevated FSH and later LH levels.
↓
• Oligoovulation/anovulation results in menstrual irregularity
and unopposed estrogen action on the endometrium.
↓
• Later, there will not be any follicles to be stimulated
resulting significant drop in estrogen not capable of
stimulating the endometrium causing menopause.
• The hypo estrogenic state that follows menopause results in
a number of medical conditions

54. Changes in menopause
I. Hormonal changes
• Change in FSH and LH levels is the most striking hormonal
change of climacteric.
– Both exceed 40 IU/liter and continue to rise for 2-3years
and thereafter remain stable or slightly decrease.
– FSH levels are higher than LH levels for the first time in
the woman’s life.

55. Changes in menopause...
• Changes in estrogen levels are the last hormonal change in
climacteric
– Estradiol levels become very low and levels of
<20pg/liter is diagnostic of climacteric.
– The predominant estrogen is estrone, a result of
peripheral conversion of androgens.
• Progesterone levels are very low in climacteric.
• Levels of androgen like dehydroepiandrosterone sulfate, and
rostendione and testosterone fall.

56. II. Reproductive organs
• Effect depends on the level of endogenous estrogen.
• In typical hypo estrogenic states of climacteric atrophic
changes occur.
– Atrophy of the vagina results in thinning of the epithelium
and flattening of the rugae which
• gives it the appearance of smooth, shiny pale surface.
• will be narrow
• Change of flora as there is no desquamated cells = infection
• Causes Sexual trauma as it is dry
Changes in menopause...

57. II. Reproductive organs...
– Atrophy of the cervix reduces its size creating shallow fornices.
– Vaginal dryness results from decreased cervical mucus production.
– Uterus decreases in size from reduction in myometrium thickness.
– The endometrium atrophies.
• Uterus atrophic = cervix to uterine ratio 1 : (1 – 1.5)
– The ovaries decrease in size
– Supporting structures and muscles lose their tone.
– The labia loosen fat and flatten
Changes in menopause...

58. III. Menstrual cycle
• Changes in menstrual cycle are the first clinical evidence of
climacteric.
• The usual pattern is gradual increase in cycle length and
reduction in amount and duration of flow.
• Heavy bleeding and abrupt cessation are unusual.
Changes in menopause...

59. IV. Other organs
• Bladder and urethral epithelium atrophy
• Breasts decrease in size
• Generalized thinning loss of elasticity of the skin results
in wrinkling
 that is prominent on light exposed areas (face, neck
and hands).
• Accentuated bone loss
Changes in menopause...

60. • Changes before menopause
– At 35 years, follicular development decreases
– An ovulatory cycle
– Menstrual irregularity
– Low estrogen and progesterone
– Increase FSH
• Changes at menopause
– Failure of follicular development = decrease estrogen =
no menses
– Cyclic release of FSH and LH changed to continuous
Changes in menopause...

61. • Changes after menopause
– Estradiol metabolized to estrone
– Decrease estrogen
– No/little progesterone
– Androgen =normal or increased
– Gonadothropin FSH increased 3x LH 3x
• After 5-10 years
– All androgen ,estrogen and gonadothropin decreases
Changes in menopause...

62. Problems of climacteric
• These are related mainly to estrogen deficiency and
 rarely to estrogen excess.

63. Problems of estrogen deficiency
• Hot flush is the most common and characteristic
symptom of climacteric.
– It is an episodic Vasomotor disturbance consisting of
sudden flushing feeling of heat or burning in the
o face, neck and chest immediately followed by
outbreak of sweating affecting the whole body.
– It is seen in 75 % of women in climacteric
– In 25-50% it may persist for more than 5 years.

64. Problems of estrogen deficiency ...
Hot flush...
• In severe cases it may come as frequently as 1 - 2hours.
– These women suffer from insomnia, fatigue, night
sweating ,
• For severe cases treatment with conjugated estrogens or
progestin is recommended.

65. • Osteoporosis is the most important health hazard of
climacteric.
– It affects the trabecular bone.
– 10% loss starting from 35 years as the estrogen effect
of inhibition of osteocytes activity decreased
• Decrease height
• pathologic Fracture of vertebrae, femur ,callus
– Treatment of needs estrogen replacement, exercise and
adequate calcium intake.
Problems of estrogen deficiency ...

66. • Atherosclerotic disease of the heart
– Increase LDH and VLDL with decrease of HDL
• Dyspareunia arises from vaginal dryness and atrophic
vaginitis.
– Local treatment with estrogen cream relieves this
problem.
• Psychological problems may arise from estrogen deficiency
or from the effects of other climacteric problems (hot flush
and dyspareunia).
– Symptoms include anxiety, Insomnia, depression,
dementia and mood changes.
• UI and UTI, UVP, Restrictive lung diseases
Problems of estrogen deficiency ...

67. • It is defined as vaginal bleeding after 6 months of
menopause.
• It is an abnormal condition that always needs proper
investigation
• It could arise from benign of serious malignant conditions
of the genital tract.
Postmenopausal bleeding

68. • The causes are
– Vulvar dystrophy =bleeding after itching
– Atrophic vaginitis
– Atrophic endometritis
– Cervical, Endometrial, Vulvar, and vaginal cancer
– Endometrial hyperplasia and polyps
– Sarcoma of the uterus
– Estrogen producing tumors
– Exogenous estrogen therapy
Note: All women with postmenopausal bleeding should be
referred for identification and appropriate treatment
Postmenopausal bleeding...

69. • Diagnosis
– History and P/E
– Investigation (for Dx and see complications )
• U/A, vaginal smear
• D and C
• FSH
• Estrogen level
• Cholesterol level
• FBG

70. • Management
– Nutrition, water
– Exercise and Ca treatment
• to decrease bone resorpsion
– Hormonal
• Rx is estrogen cream:- For atrophic vaginitis
• Progesterone containing estrogen
• Indication
– Vasomotor symptoms ,Atrophic vaginitis , Premature
menopause Hyper lipidemia , frequent UTI

71. • Management:- Hormonal...
• Pre requisite
– Rule out cancer of breast, uterus
 CLD
 Thromboembolism
 Porphria
• NB diabetes and hypertension are not contraindicated