2. Definition
Any form or grade of reduced fertility in couples unsuccessfully to conceive.
Couple usually referred for assessment after inability to conceive following 1
year of unprotected coitus. Cumulative spontaneous pregnancy rate, in
couples with female partner <40 yo, is 80% in first year of marriage and
more than 90% after two years. So although some couples still conceive in
second year, initiation of investigation is justified. In Malaysia, it is estimated
1 in 7 couples are affected by infertility.
3. Type of infertility
Primary infertility: no previous
pregnancy
Secondary infertility: at least 1
previous pregnancy
In couples with female partner >
35 years old earlier referral (after
6 months) is usually advised.
Epidemiology
Cause of subfertility reported in
Maaysia (approximately)
Female factors 35% , Male
factors 25% unexplained 10%
Key points of investigating
couples are history, examination
and investigations
8. ž
—Previous children
—Infections: prostatitis, STD,
mumps orchitis
—Trauma to head or testicles
—Surgery to testicles or hernia
—Occupation (sitting, bio hazards)
—Chemo or Radio therapy
—Ethanol or Smoking
—Medication
—Medical history (DM, HTN)
—Previous investigations
History
(Male)
9. Physical
examination
Female Examination:
◦Thyroid - thyroid
dysfunction
◦Breast (milk) -
hyperprolactinemia
◦Abdomen (fibroid masses,
scars)
◦Vaginal (abnormalities)
◦Bimanual (Uterus - fixed
retroverted in endometriosis,
masses)
◦BMI
Male Examination
Physical
Testicular size - usually greater than 10ml
(Prader orchidometer)
small firm- damage prepuberty (Klinefelter)
small soft - damage post puberty
(endocrine)
Varicocele (valsalva)
Rectal exam (protatitis, discharge)
12. Investigations:
◦semen analysis
–Abstain 3-5 days prior
–At least 2 samples over different
period of time
◦If abnormal:
–Blood work: FSH, LH, TSH,
testosterone, PRL
–Testicular U/S
–Chromosomal analysis
◦
Investigations
Male
13. Semen analysis:
◦WHO (1992)
–Volume > 2.0 mL
–Sperm > 20 million/mL
–Motility
> 50% forward progression or
> 25% rapid progression within 60 min
–Morphology > 30% normal forms
–WBC < 1 million/mL
Semen analysis
16. IUI
Introduction of sperm into a female's
cervix or uterine cavity for the purpose of
achieving a pregnancy through in vivo
fertilization by means other than sexual
intercourse or in vitro fertilisation.
Technique include intracervical
insemination and intrauterine
insemination.
17. IVF
an egg is combined with sperm in vitro ("in glass"). The
process involves monitoring and stimulating a woman's
ovulatory process, removing an ovum or ova (egg or eggs)
from her ovaries and letting sperm fertilise them in a culture
medium in a laboratory. After the fertilised egg (zygote)
undergoes embryo culture for 2–6 days, it is implanted in the
woman or another woman's uterus, with the intention of
establishing a successful pregnancy.
18. IVF Success Rates
Stage - Number of Women
Cycle initiation 100
Ovulation 95
Oocyte retrieval 90
Fertilization 85
Embryo Transfer 70
Pregnancy 24
Birth 18
Drugs used for ovary
stimulation
Clomiphene (clomid)-anti-
estrogen
hMG (pergonal)-
menopausal gonadotropin
(FSH and LH)
FSH-(metrodin)
GnRH
GnRH agonists (lupron)-
FSH/LH first promoted,
then inhibited
hCG-acts like LH
19. Madam A, 25 years old nulliparrous with underlying involuntary subfertility for 3 years came to ED
at 4.30 am with suprapubic pain that just started at 3.00 am.
It was on & off pain, sharp in nature and non radiating.
She had 1 episode of vomitting at 10 pm and 1 episode of loose stool at 2am.
Her LMP was on 24 Oct 2021. Currently on Day 23 of her cycle. Claimed UPT x 2 positve 2 days ago.
However repeated UPT x2 yesterday was negative.
Upon further history, she is currently on fertility treatment under private GP.
She started taking clomid since July 2021-October 2021.
Pills were taken on her Day 2-Day 6 of menses.
Last clomid taken on 28 Oct 2021.
Upon review, abdominal pain has resolved without analgesia. She was mildly dehydrated. Abdomen
was soft and non tender.
TAS revealed right ovary 4.5 cm x 5cm with dominant follicle 1.5 x 2.0cm. Left ovary 2cm x 2cm.
Blood parameters are normal.
20.
21. Risk of Assisted
Reproductive Technology
•To woman
–Overstimulation of ovary syndrome
–Multiple pregnancies
–Risk of borderline ovarian cancer (clomid, pergonal)
•To baby
–ICSI associated with problems (XYY)
22. Take home message
Age is important factor for female
Hypothalamic-Pituitary-Gonadal axis central in working up both male and
female infertility
Investigations:
Male: Sperms
Female: Tubes (HSG) + Ovaries (FSH, LH, PRL, TSH)
