Infertility is typically defined as the inability to achieve pregnancy after one year of unprotected intercourse. If you have been trying to conceive for a year or more, you should consider an infertility evaluation.

1. Dr. Laxmi Shrikhande MD; FICOG; FICMCH;FICMU
 Director-Shrikhande Fertility Clinic, Nagpur
 Senior Vice President FOGSI 2012
 Chairperson HIV Committee FOGSI 2009-12, Received best FOGSI
committee award
 Peer Reviewer-The Journal of OB / GY of India FOGSI
 Publications-Eleven National & seven International
 Editor-FOGSI Focus on HIV in women
 Editor-FOGSI Focus on SUI- Myths & Facts
 Presented Papers at FIGO, AICOG,
SAFOG, AOFOG conferences

2. Overview of Infertility

3. Infertility – A Global ProblemInfertility – A Global Problem

4. Approx 1
in 6
couple
are
affected
by
infertilit
y

5. Causes of Infertility-Couple

6. Causes of Infertility-Women

8. Infertility increases with aging
25-29 30-34 35-39 40-44 years
51015202530
Average incidence of infertility is 10%
Aging
•Less ovulation
•More LPD
•Less uterine
receptivity
Infertilitypercent

9. Terminology
• Primary infertility
• Secondary infertility
• Sub fertility
• 80% of couples will conceive within 1 year of
unprotected intercourse
• 86% will conceive within 2 years

10. Causes of Infertility
• Finding a particular cause of infertility for a particular
couple is the basis of fertility care.
• Causes are shared 50 : 50 by men and women.
• Male factor
• Female factor
• Both Male & Female factor

11. How to evaluate?

12. Overview of Evaluation
• Female
– Ovary
– Tube
– Corpus
– Cervix
– Peritoneum
• Male
– Sperm count and function
– Ejaculate characteristics, immunology
– Anatomic anomalies

13. The Most Important Factor in the
Evaluation of the Infertile Couple
Is:HISTORY

14. History-General
• Both couples should be present
• Age
• Previous pregnancies by each partner
• Length of time without pregnancy
• Sexual history
– Frequency and timing of intercourse
– Use of lubricants
– Impotence, anorgasmia, dyspareunia
– Contraceptive history

15. Smoking
and Alcohol
intake
Stress
• TV
• Computer
• Mobile
Male Infertility – Personal History

16. Male Infertility – Medical History
• irreversible damage – mumps, torsion, undescended
testes.
• Correctable systemic illnesses and factors causing
azoospermia – small pox in childhood,
• surgery for hernia or hydrocele ( causing iatrogenic
blocks ).
• A recent history of fever is important since semen
quality can be suppressed for up to 3 months after
fever or illness

17. History-Female
• Previous female pelvic surgery
• Cervical and uterine surgery
• PID / Endometriosis
• IUD use / Ectopic pregnancy
• detailed menstrual history
• Stress
• Weight changes

18. Physical Exam-Male
• Size of testicles
• Testicular descent
• Varicocele
• Outflow abnormalities (hypospadias, etc)
• Only when SA shows abnormalities

19. Overall Guidelines for Work-
up
• Timing of tests
• Don’t over test
• General-BMI
• Thyroid
• Local examination
• TVS
• HSA

20. Work-up by Organ
Unit

21. Ovary

22. Ovarian Function
• Document ovulation:
– BBT
– Luteal phase progesterone
– LH surge
– Endometrial secretory phase biopsy
• FSH-If POF suspected
• FSH, LH, PRL,Testosterone , DHEAs-PCOS
• TSH
• AMH
• The only convincing proof of ovulation is
pregnancy

23. BBT
• Cheap and easy, but…
– Inconsistent results
– May delay timely diagnosis and treatment
– 98% of women will ovulate within 3 days of the nadir
– No correlation with increased pregnancy rate

24. Luteal Phase Progesterone
• Pulsatile release, thus single level may not be useful
unless elevated
• Performed 7 days after presumptive ovulation
• Done properly, >15 ng/ml consistent with ovulation

25. Urinary LH Kits
• Very sensitive and accurate
• Positive test precedes ovulation by ~24 hours, so
useful for timing intercourse
• Downside: price, obsession with timing of
intercourse

26. Endometrial Biopsy
• Invasive, but the only reliable way to diagnose LPD
• ??Is LPD a genuine disorder???
• Pregnancy loss rate <1%
• Perform around 2 days before expected
menstruation (= day 28 by definition)
• Lag of >2 days is consistent with LPD
• Must be done in two different cycles to confirm
diagnosis of LPD

27. Fallopian Tubes

28. Tubal Function
• Indications-
– PID
– Previous pelvic surgery
– Secondary infertility
– Fibroids / endometriosis / polyp
• Tests
– HSG
– Sonosalpingography
– Laparoscopy

29. HSG
• in early proliferative phase (avoids pregnancy)
• Low risk of PID except if previous history of PID
(give prophylactic doxycycline or consider
laparoscopy)
• Oil-based contrast
– Higher risk of anaphylaxis than H2O-based
– May be associated with fertility rates

30. HSG
• Can be uncomfortable
• Pregnancy test is advisable
• Can detect intrauterine and
tubal disorders but not
always definitive

31. Laparoscopy
• Invasive; requires OR or office setting
• Can offer diagnosis and treatment in one sitting
– Lysis of adhesions
– Diagnosis and excision of endometriosis
– Myomectomy
– Tubal reconstructive surgery

32. For Tubal occlusion
• Recanalization
• Laparoscopic microsurgery.

33. PCOS

34. Uterine Corpus

35. Corpus
• Asherman Syndrome
– Diagnosis by HSG or hysteroscopy
– Associated with hypo/amenorrhea,
recurrent miscarriage
• Fibroids, Uterine Anomalies
– Rarely associated with infertility
– Work-up:
• Ultrasound
• Hysteroscopy
• Laparoscopy

36. Hysteroscopy

37. Cervix

38. Cervical Problems
Cervical stenosis
Thickening of cervical mucus
Presence of sperm antibodies

39. Peritoneum

40. Peritoneal Factors
• Endometriosis
– relative risk of infertility
– Diagnosis (and best treatment) by
laparoscopy
– Medical options remain suboptimal

41. Anovulation
• Clomiphene- total 6 cycles in her entire
lifetime
• Letrozole
• Gonadotrophins
Baseline scan

42. Male Factors

43. • Patient semen collection
• Clinical semen collection
Semen analysis

44. Male Factors-Semen Analysis
• Collected after 3 days of abstinence
• Evaluated within one hour of ejaculation
• If abnormal parameters, repeat twice, 2
weeks apart

45. Semen collection from home
• Bottle not to be washed with soap
• Routine wash-dry bottle thoroughly
• Transit within 30min -one hour
• In the shirt pocket
• Without spill
• No exposure to sunlight

46. Clinical semen collection
• MESA
• TESA
• PESA
• TESE
• Vas deferens aspiration
• Spermatocele aspiration

47. Sperm

48. Semen Analysis: WHO
Guidelines
Parameters Normal range
Volume 1.5 - 5 mL
Sperm conc. >20 million/mL
Sperm motility >50%
Sperm morphology >30% normal forms
Leukocyte density <1 million/mL
• Need at least 2 S/As
• Fructose
Fresh sample (to lab within 30 mins.) –most sperm in initial ejaculate
Male should be abstinent for 48 to 72 hours

49. WHO Grading of sperm
motility
• Grade A : fast progressive
Sperms swim forwards and fast in a straight line
• Grade B : slow progressive
Sperms swim forward, in a curved or crooked line or slowly ( slow linear
motility ).
• Grade C : nonprogressive
Sperms move their tails, but do not move forwards ( local motility only ).
• Grade D : immotile Sperms do not move at all.
Grade C and D are considered Poor

50. Male Factors
• Serum T, FSH, PRL levels
• Testicular biopsy
• Sperm penetration assay (SPA)

51. • Drug treatment-
– role of antioxidants
– Hormonal
– Antibiotics
• Surgical repair of reproductive organs
• Assisted reproductive techniques
90% treatable by medical therapies

52. Unexplained Infertility
• 5-10% of couples
• treatment:
– Ovulation induction
– IUI
– IVF and its variants
• Adoption

53. Assisted Reproductive Techniques

54. • First choice for male immunological infertility
Male
• Severe oligoasthenospermia
• Ejaculatory incompetence
• High anti-sperm antibodies
• Idiopathic infertility
Female
• Cervical hostility
• Cervical injuries or anomalies causing
obstruction to sperm passage.
IUI-H

55. •Superovulation
•One vs 2 IUI
•Technique
•Luteal Phase
support
IUI

56. non obstructive azoospermia
PESA

57. Microsurgical Epididymal Sperm Aspiration (MESA)
Microsurgical technique to obtain sperms from
epididymis in cases of obstructive azoospermia
Indications –
• Congenital absence of vas
• Bilateral non-constructible ejaculatory duct
obstruction
• Obstructive azoospermia following radical
prostatectomy and radical Cystectomy.
• Failed vasoepididymostomy.
• Fructose in SA-vital

58. Percutaneous Epididymal Sperm Aspiration
(PESA)
• Simple, convenient and inexpensive
• Sperms are sucked from epididymis after
puncturing it with a fine No 6 needle.
• Advantages – less expensive
• Disadvantages – blind procedure
• accidental injury to blood vessels and
hematoma formation
amount of sperms obtained is less

59. Testicular Sperm Extraction (TESE)
It is an open procedure performed under mild sedation
and direct vision thus minimizing the complications.
Advantages –
• TESE is procedure of choice for men with non
obstructive azoospermia
• Performed under LA in office procedure room
• Open biopsy TESE is more effective than needle
biopsy TESE. It is the second best way to collect
sperms.
• Sperms harvested using TESE can be stored for
future use.
Disadvantages –
• Amount of sperms obtained is less than MESA
• Many andrology labs find it difficult to work with
TESA sperms.

60. SPERM DONATION
• AIDS, artificial donor insemination has been
performed exclusively with frozen and
quarantined sperm.
• Current FDA and ASRM guidelines
recommend that sperm be quarantined for at
least six months before being released for use

61. When to evaluate for IVF & its
variants
• Bilateral tubal block
• Failed 6 IUI
• Young woman with irregular or no menses
• Premature ovarian failure
• Woman more than 35 years
• Azoospermia but testicular biopsy-spermatogenesis
• Sperm count less than 10 million

62. IVF & its variants
• IVF
• ICSI
• Egg donation
• Embryo donation
• TESA / PESA
• Surrogacy

63. What is Egg Donation?What is Egg Donation?
• Eggs are retrieved from a young woman ( < 30 yrs ) called the donor.Eggs are retrieved from a young woman ( < 30 yrs ) called the donor.
• These eggs are then fertilized with the sperms of the recipient’s husband.These eggs are then fertilized with the sperms of the recipient’s husband.
• Resultant embryo is inserted into the uterus of the recipient.Resultant embryo is inserted into the uterus of the recipient.

64. oocyte donation: Indications
Advanced Reproductive Age(attained Menopause)
Hypergonadotropic hypogonadism
Resistant Ovary Syndrome
Ovarian Failure-------Malignancies, Surgical Castration, POF
Poor oocyte or embryo quality
Recurrent IVF failure
Recurrent pregnancy loss
Genetic disorder (affected or carrier)

65. Embryo donation
• embryos created by couples undergoing fertility
treatment
or
• that were created from donor sperm and donor eggs
specifically for the purpose of donation to be transferred
to infertile patients in order to achieve a pregnancy.

66. Embryo donation-Indications
• untreatable infertility that involves both partners,
• untreatable infertility in a single woman,
• recurrent pregnancy loss thought to be related to
embryonic factors, and
• genetic disorders affecting one or both partners.

67. Embryo donation vs adoption
• Woman carries pregnancy in her uterus
• Delivers
• Breast feeds
• Better bonding even though no genetic linkage

68. SURROGACY

69. Indications
 Women with absence of uterus
 Women with hysterectomy for various reasons
 Women who suffer repeated miscarriages
 Repeated IVF failure – due to nonreceptive uterus
 Women with certain medical conditions – severe
heart disease, kidney disease , severe obesity
 Women for whom the prospect of carrying a baby to
term is very remote
 Single father
 GAY COUPLES..???
 LESBIANS …???

70. SURROGACY OR ADOPTION

71. SURROGACY
“Each couple has the right to have at least one
baby.’’
- specifically of their own ,
- specially if they have the capacity.

72. Surrogacy vs adoption
• At least 50% genetic material
• Couple involved with pregnancy from day 1
• Baby handed over to them immediately after birth
• Birth certificate in their name
• Better emotional bonding

73. Counseling
Fertile period
Ovulation study and timed intercourse
IUI
Hyst-laparoscopy
IVF
ICSI
Egg donation
Embryo donation
TESA/PESA
Surrogacy

74. Summary
• Infertility is a problem of couples
• Psychological support is important
• Evaluation must be thorough, but individualized
• Guide the couple Step by step from basic
evaluation to surrogacy
No need to loose hope

75. Take Home Message
We can help a couple to have
baby even if he doesn’t have
sperm & she doesn't have egg
and or uterus

76. Dr. Laxmi Shrikhande
Shrikhande Fertility Clinic
Ph-8805577600 / 8805677600
shrikhandedrlaxmi@gmail.com