Primary infertility is defined as a couple never conceiving after one year without contraception. Secondary infertility involves at least one prior conception. Infertility causes include female factors like tubal issues (35%) and ovulatory disorders (15%), male factors like azoospermia (35-40%), and couple factors like age, smoking, and sexual frequency. Evaluation involves history, physical exams, semen analysis, and tests to document ovulation and check for cervical and tubal patency issues. Treatment depends on the etiology but may include ovulation induction drugs, surgery, assisted reproduction techniques like IVF, and donor gametes.

1. Infertility

2. Rationale
The evaluation and management of an
infertile couple requires an understanding
of the processes of conception and
embryogenesis, as well as sensitivity to
the emotional stress that can result from
the inability to conceive.

3. Definition
Primary
 Couple has never conceived
 No conception during first year without
contraception
Secondary - couple has had at least one
prior conception

4. Etiology of infertility
20-40% of couples will have multiple causes
Female - about 60%
 Tubal - 35%
 Ovulatory - 15%
 Cervical - 5%
 Other - 5%

5. Etiology of infertility
20-40% of couples will have multiple causes
Male - 35-40%
 Azoospermia
 Compromised spermatogenesis

6. Etiology of infertility
20-40% of couples will have multiple causes
Couple
 Age (rates vary with female age)
 Sexual life, i.e. frequency
 Cigarette smoking - delays time to
conception

7. Evaluation
History and physical

8. Evaluation
Male Factor - semen analysis
 Normal morphology (>60%)
 Liquefaction - 1-20 min.
 Possible etiologies
 Genetic disorders, i.e. Klinefelter Syndrome
 Endocrinopathies
 Varicoceles
 Obstruction
 Infection
 Hypogonadism
 Idiopathic
 Defect in spermatogenesis

9. Evaluation
Female Factors
 Document ovulation
 Basal body temperature chart (sustained rise >10
days)
 Day 21 serum progesterone (>5ng/mL)
 FSH on Day 3 of cycle - if >15 mIU/mL, abnormal
and fertilization of eggs unlikely - ovarian failure,
diminished ovarian reserve
 Exclude cervical factors - post-coital test (Sims-
Huhner Test) - look for five or more actively
motile sperm in cervical mucus
 Tubal factors
 Hysterosalpingogram to look for tubal patency
 Laparoscopy to look for peritoneal factors

10. Therapy
Male factor
Urology consult
Donor sperm insemination
Intrauterine insemination (IUI)
In Vitro Fertilization- Embryo Transfer
(IVF-ET)
IVF with ICSI (intracytoplasmic sperm
injection)

11. Therapy
Female factors
Poor or lack of cervical mucus Consider
IUI Low-dose estrogen
Tubal occlusion - corrective surgery
and/or IVF
Anovulation - ovulation inducers

12. Therapy
Ovulation Inducers
Rate of
Ovulation
Pregnancy
Clomiphene 80% 40%
HMG 90% 70-80%
Bromocriptine 90% 70-80%
GnRH 80% 50-80%
Ovarian drilling 70-80% 45-60%

13. Therapy
Assisted reproductive technology
 Requires
 Controlled ovarian hyperstimulation
 Retrieval of oocytes
 In vitro fertilization and embryo transfer
 Procedures
 IVF-ET (In Vitro fertilization-embryo transfer)
 GIFT (Gamete intrafallopian transfer)
 ZIFT (Zygote intrafallopian transfer)
 ICSI (Intracytoplasmic sperm injection)