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Biochemical tests for infertility
- 2. What is Infertility? Defined as a failure to achieve clinical pregnancy after 12 month(≥35yrs old)/6 months(<35yrs old) or more of regular unprotected sexual intercourse. Primary Infertility: A couple that has never conceived Secondary Infertility: Infertility that occurs after previous pregnancy regardless of outcome.
- 3. Requirements for Conception: a. Healthy Egg and Sperm b. Unblocked Tubes c. Sperms ability to penetrate and fertilize the egg d. Implantation of embryo in Uterus e. Finally a healthy pregnancy
- 4. Causes for infertility Male Causes (17%) • Hypogonadism • obstruction • oligospermia • failure of seminiferous tubules
- 5. Female Causes (58%) • Amenorrhea • Polycystic Ovary Syndrome • Uterine tract disorder • Hypothalamic pituitary disease Endometriosis Unexplained (17%)
- 6. Male Infertility and Biochemical Tests Factors leading to male infertility: a. Anabolic Steroid Use b. Diseases causing inflammation of testis, STDs c. Chronic Health issues d. Trauma e. Testicular Torsion f. Tobacco g. Environmental Factors (pesticides, lead) Endocrine causes of infertility in males are rare. Most infertile males are eugonadal with oligospermia due to failure of seminiferous tubules.
- 7. Semen Analysis • The most important test for infertility in male. • Semen obtained after abstaining from ciotus for 2-3 days, but not more than 5 days. • Analyzed within 1 hour of collection
- 8. Normal Semen Analysis Volume - 2.0 ml or more Sperm Concentration- 20 million/ml or more Motility - 50% forward progression - 25% rapid progression Viscosity - Liquefaction in 30-60 min Morphology - 30% or more normal forms pH - 7.2-7.8 WBC - Fewer than 1 million/ml
- 9. Semen Analysis Normal Results Low Sperm Count No Hormone Tests needed Measure FSH, LH, Testosterone Azoospermia FSH or LH Gonadal Failure FSH or LH Hypothalamic or pituitary disorders Obstruction or gonadal dysgenesis?
- 10. Primary hypogonadism (low testosterone, high LH, FSH) • Klinefelter’s syndrome • Androgen resistance • Androgen synthesis defects • Epididimo-orchitis (mumps) • Trauma
- 11. Secondary hypogonadism (low testosterone, LH, FSH) • Hypothalamic-pituitary disease • Isolated Gn-RH deficiency • Panhypopituitarism
- 12. Female Infertility and Biochemical Tests Causes and Presentation: a. Amenorrhea or oligomenorrhea b. Anovulatory menstruation c. Ovarian Dysfunction d. Ovarian Tumors e. Tubal Obstruction f. Thyroid disease, Insulin resistance, obesity.
- 13. Diagnostic studies to confirm Ovulation • Basal body temperature – Inexpensive – Accurate • Endometrial biopsy – Expensive – Static information • Serum progesterone – After ovulation rises – Can be measured • Urinary ovulation- detection kits – Measures changes in urinary LH – Predicts ovulation but does not confirm it
- 14. In Women With normal Menstruation
- 15. Plasma(prolaction) (Prolactin)>700mU/L Normal Prolactin (Prolactin)>700mU/L Plasma concentrations of FSH, LH and oestradiol-17ß (FSH),(LH) (oestradiol-17ß) all Low-normal or ↓ (FSH),(LH) ↑ (oestradiol-17ß) ↓ (LH) ↑, (FSH) and (oestradiol-17ß) Normal or↓ Progesterone challengeOvarian Failure Prolactinoma or Pituitary tumour? Hypothalamic or pituitary disorder? Polycystic ovary syndrome? Radiology? Pituitary function tests Measure serum (testosterone): +[SHBG]
- 16. Other Tests • Antisperm Antibody test: for antibody against the sperm in the semen, vaginal fluid or blood can be done. • Post coital test: Checks cerivical mucus to see if sperms are alive or not and are moving properly or not. • Karyotyping or Genetic test
- 17. Menstruating female Hormone Males Early follicula r Mid- cycle Luteal Postmenopaus al FSH (IU/L) 1.5-9.0 3.0- 15.0 <20 3.0- 15.0 30-115 LH (IU/L) 1.5-9.0 2.5-9.0 <90 2.5-9.0 30-115 Oestradiol -17β (pmol/L) <200 110- 180 550- 1650 370- 700 <100 Progester one Mid luteal >30 nmol/l
Editor's Notes
- Infertility is a social and medical problem effecting couples worldwide.
- Abnormal semen analysis : Repeat in 30 days, undergo physical examination, LH FSH Testosterone levels to determine whether hypogonadism is caused by a primary defect in the testes or in the hypothalamic-pituitary region Testosterone level tested ideally at 9 a.m. In practice 7-11 a.m. Azoospermia with a raised FSH suggests severe seminiferous tubular damage while azoospermia with normal FSH and normal testicular volume indicates bilateral genital tract obstruction. Plasma [prolactin] should also be determined, as hyperprolactinaemia can lead to diminished libido, hypogonadism and impotence.
- Oligomenorrhoea, defined as an interval between periods of more than 6 weeks but less than 6 months, is often due to polycystic ovarian syndrome (PCOS). Amenorrhoea (no periodsfor more than 6 months)
- In patients who menstruate normally (Figure 17.6), it is important to establish whether the cycles are ovulatory or anovulatory. serum [progesterone] measured in a sample collected 7 days prior to the expected onset of menses. If the serum [progesterone] is greater than 30 nmol/L, this indicates an ovulatory cycle, whereas levels less than 10 nmol/L strongly suggest anovulatory cycles. In patients who have a serum [progesterone] between 10 and to nmol/L, it is thought that the cycles are ovula-lory, but that there may be a defect in the luteal phase leading to decreased fertility.
- Plasma [FSH], [LH] and [oestradiol-17 β] all low, or at the lower limits of their reference ranges. Weight loss, stress or the use of oral contraceptives should be firsl excluded as a cause. The patient may have hypothalamic, pituitary or other endocrine diseasebut, before this possibility is investigated, a progesterone challenge test should be performed. In this test, the patient takes 5 mg medroxyprogesterone daily for 5 days. Menstrual blleding in the week following progesterone withdrawal indicates that there has been adequate priming of the endometrium by oestrogens; in these patients, PCOS may be the diagnosis. in PCOS, the concentration of the SHBG often decreases which in turn tends to decrease [total testosterone] and increase [free testosterone]. Androstenedione and DHAS may also be increased in some patients with PCOS. The absolute concentration of LH is increased in about 60% of women with PCOS while the LH/FSH ratio may also be elevated in over 90% of patients
- This is called immunologic infertility. A man can make sperm antibodies when his sperm come into contact with his immune system. This can happen when the testicles are injured or after surgeries (such as a biopsyor vasectomy) or after a prostate gland infection. A woman can have an allergic reaction to her partner's semen and make sperm antibodies.
- Keypoints Endocrine causes of infertility in the male are rare. Abnormal menstruation and infertility in women car arise from disease of the hypothalamus, pituitary, ovary adrenal or thyroid. Pituitary and hypothalamic causes include stress anc anorexia, hyperprolactinaemia and hypopituitarism. Ovarian causes include polycystic ovary disease ovarian failure and tumours. Hirsutism is common, and is usually idiopathic unles accompanied by menstrual disorder or virilism. In women over 45 years, biochemical investigation will add little to the diagnosis of the perimenopause.