Infertility is a significant global medical and social issue affecting both genders, with an increasing incidence, particularly in developing countries. Assisted reproductive technology (ART) has sparked ethical debates centered around moral status, liberty, utility, and justice. Successful conception depends on various biological factors, and treatment options range from medical interventions to surgical procedures, highlighting the need for comprehensive evaluation and counseling for couples.

2.  Infertility is a problem through out history,
however increasing rates noticed.
 The first successful birth of a "test tube
baby“, Louise Brown occurred in 1978 in
Oldham General Hospital, U.K.
 Robert G. Edwards; the physiologist
who developed the treatment, was
awarded the Nobel Prize in Medicine in 2010.

3. Robert G. Edwards
27/09/1925 To 10/04/2013

5.  WHO has calculated that over 10% of women
are inflicted – women who have tried
unsuccessfully, and have remained in a stable
relationship for five years or more..
 Average incidence of infertility is about 15%
globally
Varies in different populations

6.  “Failure to conceive after regular unprotected
sexual intercourse for two years in the
absence of known reproductive pathology.”
By National Institute of Clinical Excellence (NICE 2004b, p 10)
 Infertility is “a disease of the reproductive
system defined by the failure to achieve a
clinical pregnancy after 12 months or more of
regular unprotected sexual intercourse.”
By World Health Organization

7. Primary infertility:
Primary infertility
refers to couples
who have not
become pregnant
after at least 1 year
having sex without
using birth control
methods.
(https://medlineplus.gov/ency/art
icle/001191.htm)
Secondary infertility:
Secondary infertility
refers to couples
who have been able
to get pregnant at
least once, but now
are unable.
(https://medlineplus.gov/ency/articl
e/001191.htm)

8.  Main events necessary for pregnancy to occur
are:
 Ovulation
 Fertilization
 implantation
Any condition that interferes with these events may result in
infertility

9.  Frequency Intercourse:
 Every 2 to 3 days optimizes the chance of pregnancy
 Coital frequency is positively correlated with pregnancy
rates
Frequency of intercourse Probability of conception
(within 6 months)
1 time per week 17 %
3 times per week 50 %

10.  Timing of Intercourse
Intercourse just before ovulation maximizes
the chance of pregnancy
 Sperm survives as long as 5 days in the female genital
tract
 Ovum life expectancy is about 1 day if not fertilized
 Sperm should be available in the female genital tract at
or shortly before ovulation

11.  STI s and Other Infections
 Gonorrhea and chlamydia can cause:
- In women: pelvic inflammatory disease (major cause of tubal
infertility) and cervicitis
- In men: urethritis, epididymitis, accessory gland infection
 Mumps, leading to orchitis, may cause
secondary testicular atrophy
 Other infections that may affect fertility include
tuberculosis, toxoplasmosis, malaria,
schistosomiasis and leprosy

12.  Age of the woman:
- after 40 the fertility rate decreases by 50% while the risk of
miscarriage increases
 Age of the man:
- increased age affects coital frequency and sexual function
 Nutrition
- For women, weight 10% to 15% below normal or obesity may
lead to less frequent ovulation and reduce fertility

13.  Obesity:
Women who have BMI of over 30 should be informed that they
are likely to take longer to conceive and will affect treatment
success rates.
 Low body weight
- Women with BMI less than 19 and irregular menstruation
should be counseled to gain weight.
 Smoking
- Strong association between smoking and fertility in both
partners.
- Affects success rates of ARTs (ASSISTED REPRODUCTIVE TECHNOLOGY).

14.  Caffeinated beverages:
- No evidence on effect of caffeine on fertility.
 Alcohol
- Female patients should be informed that 1 or
2 units of alcohol once or twice per week
reduces risk of harming a developing fetus.
- Intoxication may affect semen quality.

15.  Prescribed, over-the-counter and recreational
drug use
 Occupation
 Tight underwear
 - There is an association between elevated
scrotal temperature and reduced semen
quality

16.  Defective spermatogenesis
 Endocrine disorders
- Dysfunction – hypothalamus, pituitary, adrenals, thyroid
- Systemic disease – diabetes mellitus, celiac disease, renal
failure
 Testicular disorders
- Trauma
- Environmental – congenital, occupational, acquired
- Cancer treatment
(MYLES TEXT BOOK FOR MIDWIVES 5th Edition p. 181)

17.  Defective transport
- Obstruction or absence of seminal ducts
- Impaired secretions from prostate or seminal vesicles
 Ineffective delivery
- Psychosexual problems (impotence)
- Drug-induced (ejaculatory dysfunction)
- Physical disability or anomalies.
(MYLES TEXT BOOK FOR MIDWIVES 5th Edition p. 181)

18.  Defective Ovulation
 Endocrine disorders
- Dysfunction – hypothalamus, pituitary, adrenals, thyroid
- Systemic disease – diabetes mellitus, celiac disease, renal failure
 Physical disorders
- Obesity, low Body Mass index
 Ovarian disorders
- Hormonal, polycystic ovarian disease, ovarian endometriosis.
(MYLES TEXT BOOK FOR MIDWIVES 5th Edition p. 181)

19.  Defective transport
- Oocyte
- Tubal obstruction – previous surgery, fimbrial adhesions,
endometriosis, infection
- Sperm
- Hostile mucus
- Antisperm antibodies in mucus
- Psychosexual problems (vaginismus)
 Defective implantation
- Hormonal imbalance, congenital anomalies, fibroids of infection.
(MYLES TEXT BOOK FOR MIDWIVES 5th Edition p. 181)

20.  Psychological
 -sexual behavior may reflect couple’s desire not to have
children
 Immunological incompatibility
- may cause sperm agglutination
 Unknown causes

21. Evaluating both partners is essential
 Detailed history and Physical examination for
both
 Semen analysis
 Evidence of ovulation
 Evidence of fallopian tubes patency
 Postcoital test
- Still performed by some clinicians
- not found valid by some studies

22.  Couple should be informed about:
- different causes of infertility
- tests and procedures required to make a diagnosis
- various therapeutic possibilities
 Couple’s interview is conducted together as
well as separately to obtain confidential
information

23.  General history
 occupation and background
 use of tobacco, alcohol and drugs
 history of abdominal surgery and earlier diseases/infections
 Sexual history
 sexual disturbances or dysfunction such as vaginismus,
dyspareunia or erectile dysfunction
 sexually transmitted infections

24.  Reproductive history
 Gynecological history
 Age at menarche
 Menstrual periods: duration and intervals
 Previous contraceptive use
 Previous testing and treatment for infertility

25. Visual evaluation and
pelvic exam for women
to rule out:
Visual evaluation and
penile exam for men
to rule out:
Endocrinopathy Hypogonadism
Congenital anomalies Tumors
Uterine hypoplasia Epididymal cysts
Cervical lesions / injuries Cryptorchidism
Dyspareunia Hydrocele
Varicocele

26.  Ovulation can be established based on:
 Urine test:
- measures the LH in urine to detect if and when ovulation
occurred
 Basal body temperature chart
- temperature is measured every morning, before woman gets
out of bed
- elevation in temperature indicates ovulation

27.  Progesterone test
 Progesterone level in blood is measured on days 21 or 22 of
28-day cycle
 Endometrial biopsy
 Done during premenstrual phase detects if endometrium
undergoes expected changes (consistent with ovulation and
production of progesterone)

28.  Hysterosalpinogram (HSG)
- to determine whether fallopian tubes are blocked
 Laparoscopy
- to evaluate for pelvic disease, such as endometriosis, and to
evaluate for pelvic disease, such as endometriosis, and check
patency of fallopian tubes
 Hysteroscopy
- to evaluate condition of uterine cavity (polyps, fibroids)

29.  Semen is studied for a number of factors
including:
 Volume (1.5 cc to 5.0 cc)
 Number of sperm present (> 20 million/ml)
 Sperm motility (> 60%) and forward progression
(more than 2 on scale 1 to 4)
 Morphology (> 60% normal forms)
 Presence of any infection

30.  Urine analysis: to rule out infection
 Endocrine tests: to measure concentrations of
hormones testosterone, FSH and LH
 Anti-sperm antibodies
 Sperm penetration assay: to establish ability of
sperm to penetrate egg
 Postcoital test (low validity): to establish ability of
sperm to penetrate cervical mucus

31. Ovulation disorders
Hyperprolactinemia
Uterine and tubal
abnormalities
Cervical mucus problems
Endometriosis
Ovulation-inducing drugs
Prolactin-suppressing
drugs
Surgical procedures
Intrauterine insemination
Suppressing hormones
or surgical procedure

32.  Involves the use of medication to stimulate
development of one or more mature follicles
 Success rates vary considerably and depend
on age of the woman, the type of medication
used, whether there are other infertility
factors present in the couple and other
reasons

33. Clomiphene citrate induces release of gonadotropins
Gonadotropin releasing
hormone analogs
similar in structure to natural
GnRH, provoke a massive release
of GnRH into the circulation
Gonadotropins human menopausal gonadotropin
(HMG), which contains equal
quantities of FSH and LH
Bromocriptine suppresses production of prolactin

34.  A fertility procedure in which sperm are
washed, concentrated and injected directly
into a woman’s uterus
 Increases the number of sperm in the
fallopian tubes
 Not recommended in cases of tubal blockage,
poor egg quality, ovarian failure and severe
male factor infertility
 Most successful when coupled with drugs
inducing ovulation (success rates of 5% to
20% per cycle)

35.  Non-coital methods of conception
 Includes all fertility treatments in which both
eggs and sperm are manipulated
 Types of ART include:
- In Vitro Fertilization (IVF)
- Zygote Intrafallopian Transfer (ZIFT)
- Gamete Intrafallopian Transfer (GIFT)
- Intracytoplasmic Sperm Injection (ICSI)

36.  Involves retrieving eggs and sperm from female and
male partners and placing them in a lab dish to enhance
fertilization
 Fertilized eggs are transferred several days later into
the uterus
 Ovarian stimulation drugs are used prior to procedure
in order to retrieve several eggs and maximize chances
for successful fertilization
 Success rates are about 20% per egg retrieval

37.  GIFT is a procedure that involves:
- ovarian stimulation
- retrieval of eggs
- placing a mixture of sperm and eggs directly into the
woman’s fallopian tube
 GIFT does not allow visual confirmation of fertilization
 Success rates per egg retrieval are about 28% (higher
than for IVF)

38.  ZIFT, also called tubal embryo transfer, is another
variation of IVF
 As with IVF, the actual fertilization takes place in a lab
dish
 Fertilized eggs are placed directly into a fallopian tube
 Success rate is about 29% per egg retrieval

39.  Involves injection of single sperm into the egg
 The woman is administered fertility drugs prior to
the procedure to aid in the production of multiple
eggs
 Only active undamaged sperm are selected for
injections

40.  Eggs are observed to see if fertilization takes
place
- average fertilization rate is 65%
 Implantation into the uterus takes place
within 72 hours after ICSI
 Success rates range from 15% to 35% per egg
retrieval

41.  Surgical treatment in some cases (varicocele)
 Intrauterine insemination can be performed either with
patient’s or donor’s sperm
 ART procedures:
- GIFT
- IVF
- ICSI
Donor semen should be free from STDs/HIV

42.  Best Practice & Research Clinical Obstetrics &
Gynaecology, Vol. 43, Aug.2017 P.21-31 By Gamal I. Serour MD.
 Infertility is a global medicao-social-cultural
problem with gender-based suffering particularly
in developing countries.
 Assisted Reprodutive Technology (ART) has
initiated considerable ethical debate, disagreement
and controversy.

43.  3 Ethical Principles that provide an ethical basis of ART:
◦ 1. The Principle of Liberty
◦ 2. The Principle of Utility
◦ 3. The Principle of Justice
Medical ethics are based on the moral, religious and
philosophical ideas and principles of the society and are
influenced by economics, policies and law.
The moral status of the embryo is the key for all the ethical
considerations ad law regarding ART in different societies.

44.  To help reduce a woman’s anxiety, increase
her knowledge and validate the significance
of her experience throughout evaluation and
treatment
 To guide the woman through grief that
follows unsuccessful treatment and help her
determine when it is time to stop treatment
(Clapp, 2004)

46.  Giving anticipatory guidance
 Providing a quiet, private place for
consultation
 Allowing adequate time for questions and
discussion
 Giving patient-specific instructions
 Giving therapeutic touch, when appropriate

47.  Maintaining personal contact during and after
treatment cycles
 Recognizing the need for grief work
 Expressing positive and negative feelings
 Providing easy access to nursing care
 Follow up to discuss options and emotional
status

48.  Infertility is a significant medical and social
problem affecting couple worldwide.
 It is a sensitive issue that should be handled with
great care with continuous professional
counselling.
 Most young couples will conceive naturally within
2 years.
 Female and male factors are equally responsible
 Evaluation of both partners for causes is
essential.
 Treatment depends on the cause, and varies from
medical treatment to surgery to ART.