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1. INFERTILITY
INTRODUCTION
For pregnancy to occurevery part of complex humans reproduction process has to
take place just right .the step in this process has follow –
1 One of the two ovaries release a mature egg .
2The egg is picked up by the fallopian tube
3 Sperm swim up the cervix ,through the uterus and into the fallopian tube to reach
the egg for fertilization .
4 the fertilized egg travel down the fallopian tube to the uterus .
5 the fertilized egg implants and grow in the uterus .
In woman, no. of factors can disrupt this process at any step .female infertility is
caused by this one or more factor like anatomical and physiological . some of
these are treated.
Definition
INFERTILITY= ACCORDING TO WHO “Infertility can be described as the
inability to become pregnant,maintain a pregnancyor carry a pregnancyto live
birth .”
ACCORDING TO ICMART“ It is a disease of
reproductive system defined by the failure to achieve clinical pregnancyafter 12
month or more of regular unprotected sexual intercourse
Femaleinfertility =”femaleinfertility refers to a female inability to conceive by a
fertile male or maintain pregnancyor carry a pregnancytolive birth . in human it
account for 40-50%
Type
Primary = infertility denotes those patient who have never conceived .
Secondary= infertility indicate previous pregnancy but failure to conceive
subsequently.
PREVALENCE=Female infertility varies widely by geographic location around
the world .in2010,there was an estimated 48.5 million infertile couple worldwide

2. CAUSES OF FEMALE INFERTILITY the responsible causes percentage
ovulatory factor (30 – 40%), tubal and peritoneal factor (25- 35%),and
endometriosis (1-10%)
OVULATION FACTOR=
 ANOVULATION OR OLIGOOVULATION =the ovarian activity totally
depend on the gonadotrophins and the normal secretion depend upon the
GnRH From hypothalamus .
Ovarian dysfunctional is liked to be linked with disturbed hypothalmo-
pituitary- ovarin AXIS
 LUTEAL PHASE DEFECT = IN this condition there inadequate function
of the corpus luteum . there is inadequate progesterone secretion . the life
span of corpus luteum is shortened to less than 10 days .as a result there is
inadequate secretory changes in the endometrium ,which hinder implantation
 LUTENISED UNRUPTURED FOLLICULAR SYNDROME (TRPPED
OVUM) In this condition the ovum is trapped inside the follicle which get
lutinised
 DECREASE OVARIN RESERVE
TUBAL AND PERITONEALFACTORS =
 Perituabal adhesion
 Endosalpingeal damage
 Previous tubal surgery
 Tubal endometriosis
 Polyps or mucus debris within the tubal lumen ,or tubal spasm
 Peritoneal infection
UTERINE FACTOR
 Uterine hypoplasia
 Inadequate secretory endometrium ,
 fibroid uterus
 endometritis
 congenital malformation of uterus

3. CERVICAL FACTOR=
 ANATOMIC=anatomic defect preventing sperm ascent may be due to
congenital elongation of the cervix ,second degree uterine prolapse and acute
retroverted uterus. These condition prevent the external OS to bathe in the
seminal pool, or polyps
 PHYSIOLOGIC=the fault lies in the composition of the cervical mucus , so
much that the spermatozoa fail to penetrate the mucus . the abnormal
constituents include excessive , viscous purulent discharge as in chronic
cervicitis , presence of antisperm Ab
VAGINAL FACTORS =
 Atresia vagina
 Transverse vaginal septum,
 septate vagina or narrow introitus causing dysparenia
 vaginitis and purulent discharge
OTHER FACTOR =
1. ADVANCE AGE- more than 35 years the reproductive year progress , the
no. and quality of the egg diminish . the chance of having a baby decreaseby
3 -5 % .
2. CHRONIC ILL HEALTH
3. HORMONAL FACTOR-pituitary gland dysfunction
Hyperprolactinaemia and hypothalamic disorder
4. COMBINED FACTOR = Anxiety, apprehension , inadequate or infrequent
inter course, sexual intercourse , immunological factor .&psychological and
substanceabuse , education ,STI,
INVESTIGATION OF INFERTILITY
OBJECTIVE OF INVESTIGATION
 TO Detect the etiological factor factor
 To rectify the abnormality in an attempt
to improve the fertility .
 To give assurance with explanation to the couple if no abnormality detect .

4. When to investigate ?
As per definition infertile couple should be investigate after one year of regular
unprotected sex. The interval is shortened to 6 month after the age of 35 years of
the woman. And 40 years of man.
What to investigate ?
1 semen analyasis
2 confirmation of ovulation
3 confirmation of tubalpatency
FEMALE INVESTIGATION
HISTORY TAKING-
1 A genral medical history
2 Surgical history
3 Menstrual history
4 Previous obstetric history
5 Contraceptive practice
6 Sexual problem
EXAMINATION –
1 General examination
2 Systemic examination
3 Gynaecological examination
4 Speculum examination
SPECIAL INVESTIGATION-
Noninvesible or minimal invasive method are to be employed prior to major
invasive one .
OVARIAN FACTORS-Diagnosis of ovulation are as follow
Indirect , direct , conclusive
Indirect –menstrual history

5. Evalution of peripheral or endogens changes
A) BASAL BODY TEMPERATURE
B) CERVICAL MUCUS STUDY
C) VAGINAL CYTOLOGY
D) HORMONE ESTIMATION
Serum progesterone
LH
Oestradiol
Urine LH
Endometrial biopsy
E)Sonography
Direct
Laproscopy
Conclusive
Pregnancy
MANAGEMENT OF FEMALE INFETILITY
the treatment of female infertility are groued as follow according to disorder
identified
Ovulatory
Tubal
Associated disorderlike endometriosis
Cervical
Immunological
Unexplained infertility
Utero vaginal canal
Assisted reproductive technology
General drugs surgery

6. General
 Psycho terapy
 Reduction of weight in obesity or improve the weight if low weight.
Drugs
STIMULATION OF OVULATION
 Clomiphene citrate
 Letrozloe
 h MG(PERGNOL)
 FSH(METRODIN)
 h CG(PROFSI)
 GnRH
 GnRH Agonist
CORRECTIONOF BIOCHEMICAL ABNORMALITY
Hyperinsulinaemia- metformin
Androgen excess-dexamethasone
Prolactin raised –bromocriptine
SUBSTITUTION THERPY
Hypothyrodism-tyroxin
DM-antidibetic drugs
Surgery
ovarian
 Laproscopic ovarian drilling OR laser vaporisation
 Surgery for pituitary prolactinomas
 Surgical removal of ovarian or adrenal tumour

7. Tubal and peritoneal factors
 by laproscopy or laprotomy
 cannulation and ballon tuboplasty .
 fimbrioplasty –release of fimbrial adhesion or dilation of fimbrial phimosis.
 Neosalpingostomy- to create a new tubal opening in an occulded tube .
 Tubotubalanastomosis
 Adjuvant therapy – include antibiotics , hyrotubation
Endometriosis
Treated by surgery or medication
Cervicalfactor
Oestrogen1.25 mg orally daily starting on day 8-5 days
Antibioticsif infection occurdoxycycline 10 mg twice daily
Immunological factor Dexamethasone 0.5 mg at bed timein the follicular phase
Gillian type operation to correctthird degree retroversion inunexplained infertility
UTEROVAGINALSURGERY
MYOMECTOMY
METROPLASTY
ADHESIOLYSIS with insertion of IUCD
FENTON OPERATION –enlargement of the vaginal-oitus
Unexplained infertility
the recommended treatment for unexplained infertility are- INDUCTIONOF
OVULATION

8. INTAR UTERINE INSEMINATION / ARTIFICAL INSEMINATION
FALLOPIAN TUBE SPERM PERFUSION
ASSISTED REPRODUCTIVE TECHNOLOGY
IVF –ET=IN VITRO FERTLIZATION AND EMBRYO TRANSFER
GIFT = GAMETE INTRA – FALLOPIAN TRANFER
ZIFT= ZYGOTE INTRA FALLOPIAN TRANSFER
ICSI = INTRA CYTOPLASMIC SPERM INJECTION
EMBRYO OR OCCYTE TRANSFER
GESTATIONAL SUROGACY
Prevention
Some strategies suggested or proposed foravoiding female infertility include the
following:-
 Avoiding stress as it changes hormonal function.
 Avoiding substanceabuse& alcohol use.
 Make a proper sexual relationship with her partner .
 IF the female don’tconceive ,take adequate treatment
 Avoid false contraceptive and any mediaction practice.

9. Male infertility
It refers to a male’s inability to cause pregnancy in a fertile female. In humans it
accounts for 40-50% of infertility.
Causes
1)Genetic
Abnormal Y chromosome& XXY in klinefelter’s syndrome
2) Disorders of spermatogenesis
a) Hormonal (pre- testicular)
 Hypothalamic disorder
 Pituitary secretion of FSH,LH
 Hyperprolactinaemia causing impotence or diminished libido
 Hypothyroidism, adrenal gland disorder& diabetes
b) Primary testicular disorders (testicular)
 idiopathic, varicocle
 chromosomaldefect, i.e. klinefelter’s syndrome
 cryptorchism
 drugs, radiation, calcium channel blockers, anticonvulsants,
antihypertensive, spironolactone & cimetidine
 orchitis (traumatic, mumps, TB, gonorrhea)
 chronic illness
 Immunological disorders (5%)
 Immobility due to absenceof dynein arms. Absent cilia in kartgener’s
syndrome (15%)
3) Duct obstruction ( post- testicular)
Congenital absence, inflammatory block (gonococcal, tubercular),
surgical trauma, young’s syndrome (inspissated mucus) associated with sinusitis &
bronchiectasis, chlamydial infection.

10. 4) Accessory gland disorders
Prostatitis, vesiculitis & congenital absence of vas in cystic fibrosis
5) Disorders of sperm & vesicularfluid
 Sperm antibodies & low fructose in seminal plasma. Immotile cilia
syndrome (kartagener’s syndrome)
 sperm acrosome defect
 zona pellucida binding defect
 zona penetration defect
 oocytefusion defect
6) Sexual dysfunctions
 low frequency coitus – wrong time
 impotence, hypospadias, decreased libido
 premature ejaculation
 retrograde ejaculation
7) Psychological & environmentalfactors
Like smoking, alcohol consumption, tobacco chewing, diabetes & drugs –
antihypertensive, antipsychotics, cimetidine, sex steroids (excess testosterone &
anabolic used by athletes) chemotherapy, nitrofurantoin, β- blockers,
spironolactone, oestrogen.
8) Other causes
 being in high heat for prolonged periods
 obesity
 older age
 strenuous riding (bicycle riding, horse riding)
Investigations
1) History
2) General examination
3) Local examination

11. 4) Special investigations
 Semen analysis
 Blood test to check hormone levels
 Ultrasound of the male genitals
 Testicular biopsy
 Immunological test
 Patency of vas
 Chromosomalstudy
 Post– coital test
 Sperm penetration test
 Semen cervical mucous
Managementofmale infertility
Management is mainly based on the assessment of coital functions, semen
examination & the result of the postcoital & immunological tests, as well as
hormonal reports.
i. Education
ii. Substanceabuse
Advice on avoidance of tobacco (smoking, chewing), moderation in
consumption of alcohol & avoidance of drug abuse.
iii. Reduce heat around the scrotum
iv. Correct endocrinopathies
Prompt attention to diabetes & thyroid disorders
v. Surgical
Surgical correction of varicocele, after the diagnosis has been confirmed
on ultrasound scanning helps to improve sperm motility.
vi. Antibiotics
Infection indicates the need for appropriate antibiotics to treat epididymo-
orchitis, prostatitis & STDs
vii. Prematureejaculation
Selective serotonin reuptake inhibitors take 2 week to reach the
therapeutic level

12. viii. Hormones
Testosterone, pituitary hormones & GnRH have all tried to improve
spermatogenesis with variable results. Bromocriptine is useful in
hyperprolactinaemia
Hormone therapy
Various regimens have been applied with variable results. Like:
hCG, testosterone, clomiphene, Human menopausal gonadotropine (hMG),
GnRH, tamoxifen, dexamethasone, sildenafil (Viagra)
ix) Artificial insemination
Managementofazoospermia
With oligospermia or abnormal semen, obstructive as well as non-obstructive
azoospermia, the couple may be offered:-
 In vitro fertilization (IVF)
 Gamete intrafallopian transfer (GIFT)technique
 Micro assisted fertilization (MAF) technique
 Microsurgical epididymal sperm aspiration (MESA) or percutaneous
epididymal sperm aspiration (PESA)
 Testicular biopsy, sperm retrieval & MESA supersede other methods in
modern treatment of male infertility & with improved success.
Prevention
Some strategies suggested or proposed foravoiding male infertility include the
following:-
 Avoiding smoking as it damages sperm DNA
 Avoiding heavy marijuana & alcohol use
 Avoiding excessive heat to the testis
 Sperm counts can be depressed bydaily coital activity and sperm motility
may be depressed by coital activity that take place too infrequently
(abstinence 10-14 or more)
 When participating in sports suchas baseball, football, cricket, hockey,
wrestling, karate etc. wear a protective cup & jockstrap to protectthe
testicles.