Infertility

2014/07/23 1
INFERTILITY
Dr Taiwo Aremu

INFERTILITY
By: DR TAIWO AREMU
State House Medical Centre,
Aso Rock, Abuja.

content
• Introduction/Definition
• Epidemiology
• Anatomy & Physiology
• Factors affecting
infertility
• Requirements for
infertility
• Causes
• Evaluation
• Investigations
• Treatment
• Unexplained infertility
• Assisted Reproductive
Technology (ART)
• Psychological support
• Case History
• Summary
• Reference
2014/07/23 3Dr Taiwo Aremu

Introduction/Definition

It is becoming more and more common
these days for young newlywed
couples to have difficulties when it
comes to childbirth, unlike in the days
of our parents when getting pregnant
as soon as you were married was
taken for granted.

2014/07/23 7
• Infertility is “a disease of the
reproductive system defined as the
inability of a couple of
childbearing/reproductive age group to
achieve a clinical pregnancy/conception
after 12 months or more of regular
unprotected sexual intercourse.”… (WHO-
ICMART glossary1).
Dr Taiwo Aremu

• Regular intercourse = 2 – 3 times per week
• On an average, 25% conceive within the
first month, 60% within 6 months ,75% by
9 months, 80% by 12 months and 90% by
18 months.
• The average time fertile couples take to
conceive is 6 months.

Types of Infertility
1. Primary infertility
2. Secondary infertility

has never been pregnant

has never been pregnant
previous history of pregnancy irrespective
of duration and outcome
now unable to conceive

Epidemiology

2014/07/23 13
One in every four couples in developing
countries had been found to be affected
by infertility, [when an evaluation of
responses from women in Demographic
and Health Surveys from 1990 was
completed in collaboration with WHO in
2004. ]
Dr Taiwo Aremu

The burden remains high. A WHO study,
published at the end of 2012, has shown
that the overall burden of infertility in
women from 190 countries has remained
similar in estimated levels and trends from
1990 to 2010.

• Ironically, infertility and sub-fertility are
prevalent within the high fertility zones in
Africa.
• In Nigeria, over 800,000 couples are said
to have difficulty in achieving desired
pregnancy.

• Infertility accounts for more than half of
the cases seen in gynaecology clinics in the
developing countries of the world.
• The incidence varies between and within
countries. An analysis of the most recent
World Fertility Survey (WFS) or
Demographic and health Survey (DHS),
the range of infertility is between 8.6% and
21.5%

• Eastern Africa tends to have the lowest rate
while Southern Africa has the highest.
• West Africa contains areas of high
infertility rates (e.g. Mauritania) and low
infertility rates (e.g. Niger).
• The sub-Saharan infertility rate is between
12.5% and 16.0% (mid-point is 14.5%).

• However, there is evidence of a declining
trend in infertility rates in parts of sub-
Saharan Africa such as Cameroon and
Nigeria.

Sex/Gender
The female factors are widely studied in
Africa than the male factors because it is
commonly assumed that the woman is
primarily responsible for infertility.
However, studies have shown that the
contributing male factor to infertility is
also high (20-40%). The male factor is
associated with a greater percentage of
cases of primary rather than secondary
infertility.2014/07/23 19Dr Taiwo Aremu

Age
• The occurrence of infertility also varies by
age.
• The prevalence of infertility increases with
age. For instance, female fertility is highest
in the age range 20-24 years, and declines
gradually after the age of 35 years. While
in men, ageing has only a minor effect on
fertility

2014/07/23 21
Residence
• In Nigeria, the prevalence of infertility is
lowest in the Southwest, and highest in the
Northeast. It has been suggested that the
regional variation may be a reflection of
differences in the prevalence of STDs.
Dr Taiwo Aremu

• Urban residence is an important socio-
cultural factor in infertility. Urban dwellers
are at greater risk of infertility than rural
dwellers. This is because of high reservoir
of infection and greater chances of having
sex with infected partners.

Social
• Fertility is affected by many different
cultural, environmental and socio-
economic factors in Africa. Culture
influences sexual behaviour, marriage
practices and access to health services.
Poverty, poor access to maternal health
care and illegal abortion (usually
performed under unsafe conditions) all
contribute to the high prevalence of
infertility.2014/07/23 23Dr Taiwo Aremu

• It appears then that infertility will be more
common among low socio-economic
groups than among those of higher social
class, but the incidence of STDs is also
high among the latter. Also, a higher
prevalence is expected among cultural
groups with practices associated with high
risk of infertility.

• For example, female genital mutilation
could predispose women to infertility
secondary to infection and early marriage
leads to early childbearing which is
associated with an increase in the
incidence of complicated deliveries,
thereby increasing the risk of infection and
subsequently, infertility especially when
there is poor access to good maternal
services.2014/07/23 25Dr Taiwo Aremu

• The generally low status of women puts
them at disadvantage especially due to lack
of decision-making power. In a study of 27
African nations, it was found that infertility
is strongly associated with social,
behavioural and cultural factors which put
women at risk of STDs and other RTIs.

• There is an imbalance in the power
relations between men and women to such
an extent that the latter may be unable to
refuse sex with a partner or insist on the
use of condom, even in the face of
suspected infection in the male. This could
jeopardise the women’s fertility.

• Although the primary cause of infertility
may be an infection; some underlying or
contributing factors reflect social
disorganisation such as prostitution sequel
to rural-urban migration.

Anatomy and Physiology

2014/07/23 30
Human gamete
Oocyte Sperm
Dr Taiwo Aremu

2014/07/23 31oocyte
Normal ovulation
Dr Taiwo Aremu

 Ovulation occurs 13-14 times per year
 Menstrual cycles on average are 28 days with ovulation
around day 14
 Luteal phase
dominated by the secretion of progesterone
released by the corpus luteum
 Progesterone causes
Thickening of the endocervical mucus
Increases the basal body temperature (0.6° F)
 Involution of the corpus luteum causes a fall in
progesterone and the onset of menses
Ovulation

• A history of regular menstruation suggests
regular ovulation
• The majority of ovulatory women experience
– fullness of the breasts
– decreased vaginal secretions
– abdominal bloating
– mild peripheral edema
– slight weight gain
– depression2014/07/23 33Dr Taiwo Aremu

2014/07/23 34
sperm
Normal sperm production
•Spermatozoa are produced in the
seminiferous tubules and undergo further
maturation in the epididymis
•Production of mature spermatozoa takes
around 70 -80 days
•Requires an environment of 1℃ below
normal body temperature. And a slightly
elevated pressure from the surroundings
is necessary
•After swimming through the favourable
cervical mucus, spermatozoa are
transported to the ampullary portion of
the fallopian tube
•Penetration and fertilization of the
Oocyte takes place in the tubal ampulla.
Dr Taiwo Aremu

Conception and Fertility
 The chances of conceiving in any given
menstrual cycle is less than 20%
 Main events necessary for pregnancy to occur
are:
 ovulation
 fertilization
 implantation
Any condition that interferes with these
events may result in infertility

2014/07/23 37
Conception requires
• Juxtaposition of the male and female gametes at the optimal
stage of maturation
• Transportation of the conceptus to the uterine cavity at a time
when the endometrium is supportive of its continued
development and implantation.
Dr Taiwo Aremu

Factors affecting fertility

17%
Factors Affecting Fertility:
Frequency of Intercourse
Coital frequency is positively correlated with
pregnancy rates
Frequency of
intercourse
Probability of
conception
(within 6 months)
1 time
per week
3 times
per week
50%

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

STIs 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

Factors Affecting Fertility (Continued)
 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% to15% below normal or
obesity may lead to less frequent ovulation and
reduced fertility

Factors Affecting Fertility (Continued)
 Factors that can contribute to
fertility problems include:
 toxic agents, such as lead, toxic
fumes and pesticides
 smoking and alcohol
 All these factors may cause:
 in women: reduced conceptions and
increased risk of fetal wastage
 in men: reduced sex drive and
sperm count

Requirements for fertility

Requirements for Female Fertility
 Vagina capable of receiving sperm
 Normal cervical mucus to allow sperm passage
 Ovulatory cycles
 Patent fallopian tubes
 Uterus capable of developing and sustaining
pregnancy
 Adequate hormonal status to maintain pregnancy

Requirements for Female Fertility
(Continued)
 Adequate sexual drive and sexual function
 Normal immunologic responses to
accommodate sperm and conceptus
 Adequate nutritional and health status to
maintain nutrition and oxygenation of placenta
and fetus

Requirements for Male Fertility
 Normal spermatogenesis in order to fertilize
egg:
 sperm count
 motility
 biological structure and function
 Normal ductal system to carry sperm from the
testicles to the penis

Requirements for Male Fertility
(Continued)
• Ability to transmit sperm to
vagina achieved through
– adequate sexual drive
– ability to maintain erection
– ability to achieve normal
ejaculation
– placement of ejaculate in vaginal
vault

Causes of Infertility

2014/07/23 51
CAUSES PERCENTAGE
Female factors 60%
Male factors 30%
Both male and female
factors
10%
Dr Taiwo Aremu

MALE FACTORS

MALE
FACTORS
Pre-
Testicular
Hypothalamic
-Gonadotropin deficiency,
LH deficiency, FSH
deficiency
Pituitary
disease
-Pituitary insufficiency,
hyperprolactinemia, exogenous
hormones, GH deficiency
Testicular
-Chromosomal Causes (Klinefelter syndrome
(47,XXY)
-Gonadotoxins (radiation, drugs, chemotherapy)
-Systemic diseases (renal failure, liver cirrhosis,
SCD)
-Testis Injury (orchitis, torsion trauma)
-Cryptorchidism
-Varicocele
-Idiopathic
Post-
testicular
-Cystic fibrosis
-Bacterial infections
-Retrograde ejaculation
-Disorders of Sperm Function or Motility
-Disorders of Coitus: Impotence, Timing and
Frequency, Hypospadias

A. Gonadotropin Deficiency (Kallmann Syndrome)
 failure of GnRH neurons to migrate to the
proper location in the hypothalamus.
 Kallmann syndrome is associated with midline
defects such as anosmia, cleft lip and cleft palate,
deafness, cryptorchidism, and color blindness.
 Men can be fertile when given FSH and LH to
stimulate sperm production. Virilization can be
obtained with testosterone or human chorionic
gonadotropin (hCG)

MALE
FACTORS
Pre-
Testicular
Hypothalamic
LH deficiency, FSH
deficiency
Pituitary
disease
Testicular
(47,XXY)
SCD)
-Cryptorchidism
-Varicocele
-Idiopathic
Post-
testicular
-Cystic fibrosis

A. Pituitary Insufficiency
Pituitary insufficiency may result from tumours, infarcts,
surgery, radiation, sickle cell anaemia.
B. Hyperprolactinemia
most common cause is prolactin-secreting pituitary
adenoma.
Elevated prolactin results in decreased FSH, LH levels and
causes infertility.
Associated symptoms include loss of libido, impotence,
galactorrhea, and gynecomastia.
C. Exogenous or Endogenous Hormones
1. Estrogens, GH, androgens, glucocorticoids, Hyper- and
hypothyroidism2014/07/23 56Dr Taiwo Aremu

MALE
FACTORS
Pre-
Testicular
Hypothalamic
LH deficiency, FSH
deficiency
Pituitary
disease
Testicular
(47,XXY)
SCD)
-Cryptorchidism
-Varicocele
-Idiopathic
Post-
testicular
-Cystic fibrosis

Chromosomal Causes
• Klinefelter syndrome (47,XXY)
most common genetic reason for azoospermia. classic triad:
small firm testes; gynecomastia; and
azoospermia.
XX Male Syndrome
presents as gynecomastia at puberty or as
azoospermia in adults. Average height is below normal,
and hypospadias is common. Male external and internal
genitalia are otherwise normal.
XYY Syndrome
Typically, men with 47,XYY are tall. Semen analyses show
either oligospermia or azoospermia.

Causes of Male infertility - Gonadotoxins
Radiation :
Sertoli and germ cells are extremely radiosensitive.
Drugs:

MALE
FACTORS
Pre-
Testicular
Hypothalamic
LH deficiency, FSH
deficiency
Pituitary
disease
Testicular
(47,XXY)
SCD)
-Cryptorchidism
-Varicocele
-Idiopathic
Post-
testicular
-Cystic fibrosis

Post-testicular Causes of Male infertility
The post testicular portion of the reproductive tract
includes the epididymis, vas deferens, seminal
vesicles, and associated ejaculatory apparatus

1. Cystic fibrosis -
98% of men with CF having missing parts of the
epididymis. In addition, the vas deferens, seminal
vesicles, and ejaculatory ducts are usually
atrophic, or completely absent

2014/07/23 64
• In CF the vas deferens almost always fails to develop properly

2. Bacterial infections
Bacterial infections (E coli in men age >
35) or Chlamydia trachomatis in young
men) may involve the epididymis, with
scarring and obstruction.

3. Retrograde ejaculation:
•This is caused by an open bladder neck during
ejaculation.
•Retrograde ejaculation may be due to causes
such as diabetes, bladder neck surgery, TURP,
colon or rectal surgery, multiple sclerosis, or
spinal cord injury.
•Diagnosis is made by observing 10-15 sperm
per high-power field (HPF) in the post
ejaculatory urine.

MALE
FACTORS
Pre-
Testicular
Hypothalamic
LH deficiency, FSH
deficiency
Pituitary
disease
Testicular
(47,XXY)
SCD)
-Cryptorchidism
-Varicocele
-Idiopathic
Post-
testicular
-Cystic fibrosis

Causing disorders of motility: Infections

FEMALE FACTORS

Female
Factors
Ovulatory
Outflow tract
abnormality
Others
conditions
Idiopathic
(10-15%)

2014/07/23 71
1. Hypothalamic dysfunction
GnRH (hypothalamic amenorrhea)
2. Pituitary Insufficiency
Prolactinoma, hypopituitarism
Ovulatory dysfunction (15 – 20%)
hypothalamus
pituitary
ovary
Dr Taiwo Aremu

2014/07/23 73
hypothalamus
pituitary
ovary
Dr Taiwo Aremu

2014/07/23 74
3. Ovarian factor
Premature ovarian failure
PCOS
luteinized unruptured follicle syndrome
hypothalamus
pituitary
ovary
Dr Taiwo Aremu

4. Luteal phase defect
 results in low production of progesterone
 may lead to early miscarriage
5. Systemic disease
thyroid or adrenal dysfunction (Cushing),
renal/hepatic failures
6. ƒCongenital:
Turner’s syndrome (gonadal dysgenesis) or
gonadotropin deficiency
7. Stress, poor nutrition, excessive exercise.2014/07/23 75Dr Taiwo Aremu

2014/07/23 76
Outflow tract abnormality
(Pelvic factors)
1. Tubal factors (20-30%):
 PID (Pelvic inflammatory disease)
 adhesions (previous surgery, peritonitis,
endometriosis)
 ligation/occlusion (e.g. previous ectopic
pregnancy)
Dr Taiwo Aremu

2014/07/23 77
Outflow tract abnormality
(Pelvic factors)
ƒ1. Tubal factors (20-30%):
 PID (Pelvic inflammatory disease)
leading to blocked or damaged fallopian tubes
may interfere with fertilization and transport of egg
 adhesions (previous surgery, peritonitis,
endometriosis)
 ligation/occlusion (e.g. previous ectopic
pregnancy)
Dr Taiwo Aremu

2. Uterine factors (<5%):
 congenital anomalies (e.g. prenatal DES
exposure), bicornuate uterus, uterine septum

Congenital Anatomic Abnormalities

 intrauterine adhesions (e.g. Asherman’s
syndrome)
 infection (endometritis, pelvic TB)
 fibroids/polyps (particularly intrauterine)
 endometrial ablation

3. Cervical factors (5%):
 hostile or acidic cervical mucus
 anti-sperm antibodies
 structural defects
 Infections
4. Extra-genital tracr factors
 Infection, abnormal structures

Others
• Parasitic infestation (schistomiasis)

2014/07/23 84
Both Male and Female Factors
1. Psychological factors
mental stress , anxiety
sexual behavior may reflect couple’s desire not to have
children
2. Immunologic factors
Iso-immunity- antisperm antibody
auto-immunity-AZP (antizona pellucida antibody)
Immunological incompatibility (may cause sperm
agglutination)
3. Unknown
Dr Taiwo Aremu

Evaluation

2014/07/23 86
The goals of infertility evaluation
• Determine the probable cause of infertility
• Provide accurate information regarding
prognosis
• Provide counseling/emotional support
• Provide guidance regarding options for
treatment
Dr Taiwo Aremu

2014/07/23 87
The goals of infertility evaluation
• Determine the probable cause of infertility
• Provide accurate information regarding
prognosis
• Provide counseling/emotional support
this may be very important in the traditional African
society where fertility reflects a woman’s status
• Provide guidance regarding options for
treatment
Dr Taiwo Aremu

Evaluation Procedure
 Couple should be
informed about:
 different causes of
infertility
 tests and procedures
required to make a
diagnosis
 various therapeutic
possibilities
 Couple’s interview
should be conducted
together as well as
separately to obtain
confidential information2014/07/23 88Dr Taiwo Aremu

General History (both partners)
• Age
• Duration of marriage (length of infertility)
and type of marriage (monogamous or
polygamous)
• Living together
• Frequency of coitus
• Any pre/post coital practice e.g. lubricant,
douching

General History (Continued)
• Has husband fathered any pregnancy?

• Contraceptive use and for how long

Other History (Female partner)
• Age of menarche
• Menstrual cycle pattern: cycle length,
duration of flow and volume
• Any pre-menstrual symptoms e.g. fatigue,
headache (presence makes ovulation more
likely)
• History of dyspareunia

Other History (Female partner)…
• History of milk discharge from the breast
(prolactinemia)
• History of cold intolerance, weight gain,
decreased appetite, neck swelling
(hypothyroidism)
• History of heat intolerance, weight loss,
neck swelling (hyperthyroidism)
• Visual disturbances (pituitary tumour)

(prolactinemia)
(hypothyroidism)

• History of infection: past history of vaginal
discharge, lower abdominal pain
• History of tubal surgery
• Previous history of D & C, abortions and
where
• History suggestive of puerperal sepsis
• Past history of appendicitis, typhoid
perforation, post abortal infection

where

• Social history: smoking, alcohol
• Exposure to irradiation, cytotoxic
chemotherapy

Other History (Male partner)…
• Occupation (long distance driver, armed
forces)
• Past history of genital infection e.g.
gonorrhoea, mumps orchitis
• History of surgery in the genital tract or
inguinal region
• Exposure to irradiation, chemotherapy,
heat (tight nylon pants, hot bath)

forces)
inguinal region

• Erectile dysfunction
• Does he ejaculate into the vagina during
coitus?

Physical & Systemic Examination
IN FEMALES
Body habitus
• Obesity, hirsutism, acne (PCOS)
• Short with webbed-neck (Turner’s
syndrome)
Galactorrhoea
Thyroid enlargement

IN FEMALES
Body habitus
syndrome)
Galactorrhoea

IN FEMALES
Body habitus
syndrome)

IN FEMALES
Body habitus
syndrome)
Galactorrhoea

IN FEMALES
Body mass index (BMI) > 29
for every BMI unit over 29, chance of
pregnancy fell by 4%
Presence/absence of secondary sexual
characteristics

IN FEMALES
Abdomen: Presence of scar, abdominal
mass
Pelvic: vaginal patency, pelvic masses e.g.
uterine fibroids.

IN MALES
Body habitus: too tall (Klinefelter
syndrome)
Lack of either pubic hair or mascular build
may indicated insufficient testosterone
production.
The normal location of the urethral meatus
should be ensured.

IN MALES
 Presence of testes in the scrotal sac &
Testicular size
 Varicocele,
Rectal examination - prostatitis

INVESTIGATIONS

MALES
1. Semen Analysis
2. Urinalysis
3. Hormonal assessment
4. Vasography
5. Testicular biopsy

1. Semen analysis

1. Semen analysis
2014/07/23 128
Procedure:
Abstain from coitus 2 to 3 days
Obtained by masturbation (into a wide
mouthed sterile glass container)
Collect all the ejaculate
Analyze within 1 hour
Dr Taiwo Aremu

1. Semen analysis
Semen Analysis: WHO reference values
Ejaculate Volume 2 – 5ml
Liquefaction time Within 30mins (20 – 30mins)
PH 7.8 – 8.0
Sperm concentration/Count ≥20 million/mL
Motility > 50% progressive motility
Morphology > 30% normal forms
White Blood Cells (WBC) < 1 million/mL or < 0per hpf
Semen is studied for a number of factors including:

Abnormal semen analysis
• Before it can be said to be abnormal, it
must have been done 3 times with atleast
4weeks interval between collections.
• Oligospermia: count < 20million/mL
• Azoospermia: Absence of spermatozoa in
ejaculate
• Aspermia: No ejaculate

• Asthenozoospermia: < 50% with forward
progression
• Teratozoospermia: < 30% with normal
morphology
• Asthenoteratooligozoospermia:
combination of abnormal motility,
morphology and count
• Volume <1mL, retrograde ejaculation,
microscopic exam of post-ejac urine

 Azoospermia
 Klinefelter (1 in 500)
 Hypogonadotropic-
hypogonadism
 Ductal obstruction
(absence of the Vas
deferens)
 Oligospermia
 Anatomic defects
 Endocrinopathies
 Genetic factors
 Exogenous (e.g. heat)

 Abnormal Morphology
 Varicocele
 Stress
 Infection (mumps)
 Abnormal Motility
 Immunologic factors
 Infection
 Defect in sperm structure
 Poor liquefaction
 Varicocele
 Abnormal Volume
 No ejaculate
 Ductal obstruction
 Retrograde ejaculation
 Ejaculatory failure
 Hypogonadism
 Low Volume
 Obstruction of ducts
 Absence of vas deferens
 Absence of seminal vesicle
 Partial retrograde ejaculation
 Infection

2. Urine analysis: to rule out infection
3. Endocrine tests: to measure concentrations
of hormones testosterone, prolactin, FSH
and LH

2. Urine analysis: to rule out infection
3. Endocrine tests: to measure concentrations
of hormones testosterone, FSH and LH
4. Vasography
5. Testicular biopsy
6. Anti-sperm antibodies
7. Sperm penetration assay: to establish
ability of sperm to penetrate egg
8. Post-coital test (low validity): to establish
ability of sperm to penetrate cervical
mucus2014/07/23 135Dr Taiwo Aremu

FEMALES
1. Cervical factor
- Post Coital Test (to assess ability of
sperm to penetrate and survive in cervical
mucus).

• Carried out in the pre-ovulatory period
• About 6hrs after intercourse
• Microscopically, atleast 6 forwardly mobile spermatozoa
• Spinnbarkeit (atleast 6cm elasticity)
2014/07/23 137

2014/07/23 138
• Microscopically, atleast 6 forwardly mobile spermatozoa

Spinnbarkeit (elasticity) is determined (atleast 6cm is positive – normal)
2014/07/23 139

FEMALES
1. Cervical factor
mucus).
2. Uterine factor
- HSG (patency and absence of anomalies and adhesions)
- Endometrial biopsy (to detect ovulation)
time: pre-menstrual
secretory endometrium in the Luteal phase of menstrual cycle.

2014/07/23 141
Proliferative phase
Luteal phase

FEMALES
1. Cervical factor
mucus).
2. Uterine factor
- HSG (patency and absence of anormalies and adhesions)
- Endometrial biopsy (to detect ovulation)
- Laparoscopy - USS
- Hysteroscopy :to evaluate condition of uterine cavity
(polyps, fibroids)

FEMALES
3. Tubal factor
- HSG

FEMALES
3. Tubal factor
- HSG to determine whether fallopian tubes are blocked

2014/07/23 145
Hysterosalpingography
•The injection of lipiodol or
meglumine diatrizoate
through the cervix under
radiographic control.
•The passage of the dye into
the uterus and out along the
tubes is observed. As well as
determining the exact site of
any tubal blockage.
•The test should be performed
between day 7 and day 12 of a
28 days cycle.
Dr Taiwo Aremu

FEMALES
3. Tubal factor
- HSG to determine whether fallopian tubes are blocked

FEMALES
3. Tubal factor
- HSG

FEMALES
3. Tubal factor
- HSG
- Tubal Insufflation (Rubin’s test)
- Laparoscopy

FEMALES
3. Tubal factor
- HSG
- Laparoscopy
to evaluate for pelvic disease, such as endometriosis, and check
patency of fallopian tubes

FEMALES
3. Tubal factor
- HSG
- Laparoscopy
4. Ovulation factor
- Basal body temperature chart

FEMALES
3. Tubal factor
- HSG
- Laparoscopy
4. Ovulation factor
in the immediate pre-ovulatory period, a slight drop followed by a
rise in temp (biphasic temp pattern) indicates ovulation

FEMALES
3. Tubal factor
- HSG
- Laparoscopy
4. Ovulation factor
- Urinary LH testing
- Transvaginal ultrasonography2014/07/23 154Dr Taiwo Aremu

FEMALES
- Endometrial biopsy
- Serum progesterone
on day 21, progesterone > 10nmol/L indicates ovulation
- Vaginal cytology
5. Peritoneal factor
for peritoneal adhesions
- Laparoscopy: endometriosis is a common finding
2014/07/23
156
Dr Taiwo Aremu

2014/07/23 157
6. Thyroid function test
- Hypothyroidism:
TSH↑, T3 (N), T4↓or(N)
- Hyperthyroidism:
TSH↓, T3↑, T4↑
Dr Taiwo Aremu

TREATMENT

General/Conservative management:
– Intercourse every 1-2 days during
periovulatory period (12-16)
– Women advice to lie on her bake at least 15
min after coitus prevent rapid loss of semen
from vagina
– Use non-toxic lubricant
– Postcoital douching , should be avoided.
– Smoking should be reduced or stopped.
– Proper diet and weight reduction
– Eliminate alterations of thermoregulation2014/07/23 159Dr Taiwo Aremu

Treatment possibilities in Males
• Low sperm density(oligospermia) or low
motility(asthenospermia) caused by
hypothalamic-pituitary failure- hMG
• Hyperprolactinemia -Bromocriptine
• Low semen quality coexisting with a
Varicocele - Ligation of the venous plexus
• Infection - Antibiotics

2014/07/23 161
• Low semen volume, count, density
- Intrauterine insemination(IUI)
- In vitro fertilization(IVF)
- Intracytoplasmic sperm injection(ICSI)
• Donor sperm: azoospermia or severe
oligospermia
Dr Taiwo Aremu

2014/07/23 162
Treatment possibilities in Females
Ovulation disorders Ovulation-inducing drugs
Hyperprolactinemia
Prolactin-suppressing
drugs
Uterine and tubal
abnormalities
Surgical procedures
Cervical mucus problems Intrauterine insemination
Endometriosis
Suppressing hormones
or surgical procedure
Dr Taiwo Aremu

Ovulation disorders
• Clomiphene citrate (anti-oestrogen)
dosage is 50mg daily for 5 days beginning on day 5 of
the menstrual cycle.
• Human menopause gonadotropin (hMG)
(FSH &LH) used for whom don't ovulate due to
problems with the pituitary gland, acts directly on the
ovaries to stimulate ovulation.
• Follicle-stimulating hormone (FSH) causes
the ovaries to begin the process of ovulation.

• Gonadotropin-releasing hormone (Gn-RH)
analog used for whom don't ovulate
regularly or ovulate before the egg is ready
(Hypothalamic amenorrhea)
GnRH can be administered in small pulses every 90-120
min by a pump
• Metformin use for PCOS, lower the
levels of testosterone.
• Bromocriptine dopamine agonists,
dosage is 1.25-2.5mg/day
alternative: carbagolide2014/07/23 164Dr Taiwo Aremu

2014/07/23 165
Luteal phase defect
• Progesterone
- the second or third day after
ovulation.
- route: vaginal or intramuscular.
• Clomiphene or HMG
Dr Taiwo Aremu

Cervical disorders
• Cervical infection : antibiotic drug
• Poor mucus quality :
small dose of estrogen from day7 until ovulation
• Low pH:
sodium bicarbonate, gentle douche 30 minutes
before coitus

Uterine and tubal abnormalities
• Fibroids : Myomectomy
• Adhesions: Lysis of adhesions
• Rupture of the fallopian tube: Tuboplasty
• If the fallopian tubes are beyond repair one must
consider in vitro fertilization
OTHERS
 Nutrition
 Exercise

OTHERS
• Hypothyroidism: Levothyroxine (LT4)
50-75mcg daily
• Hyperthyroidism:
- Symptom relief: ORS, β-blockers
- Antithyroid drug: carbimazole 20-60mg daily
methimazole
- Radioactive iodine
- Thyroidectomy

Unexplained infertility

Unexplained infertility
ovulation, normal semen analyses, and a
normal HSG.
• The most efficient management is Clomiphene
citrate and performance of intrauterine
insemination (IUI)
• If IUI is not successful, then IVF can be useful

Assisted Reproductive Technology
(ART)

2014/07/23 172
Assisted Reproductive Technologies (ART)
Non-coital methods of conception
Types
1. Intrauterine insemination ( IUI)
2. In vitro fertilization and embryo transfer
(IVF-ET)
3. Intracytoplasmic sperm injection (ICSI)
4. Gamete intrafallopian transfer (GIFT)
5. Zygote Intrafallopian Transfer (ZIFT)
Dr Taiwo Aremu

2014/07/23 173
Intrauterine insemination ( IUI)
Indications:
1. as treatment of male factor infertility;
2. psychological factors;
3. unexplained infertility;
4. genetic defects;
Types:
1. artificial insemination with husband’s sperm (AIH);
2. artificial insemination by donor (AID);
Method:
placement of about 0.3 ml of washed, processed
and concentrated sperm into the intrauterine cavity
by trans-cervical catheterization.Dr Taiwo Aremu

2014/07/23 174
Intrauterine insemination ( IUI) C’tnd…
• The inseminations done approximately 36
to 39 hours after LH surge or the HCG
injection.
 The sperm must be washed to remove
prostaglandin and bacteria. Increases the
number of sperm in the fallopian tubes
Dr Taiwo Aremu

Intrauterine insemination ( IUI) C’tnd…
 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)

2014/07/23 176
cervixs
uterus
sperm oocyte
Intrauterine Insemination
IUI
Sperm preparation
Dr Taiwo Aremu

2014/07/23 177
In vitro fertilization –
embryo transfer
IVF-ET
Dr Taiwo Aremu

In Vitro Fertilization (IVF)
 The first live birth resulting from this technique
occurred in June1978.
 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.

2014/07/23 179
oocytes are aspirated under transvaginal
ultrasonography guidance.

2014/07/23 181
Oocytes collection
Dr Taiwo Aremu

2014/07/23 182
The method of the fertilization is different between IVF and
ICSI
• IVF: the eggs are incubated with sperm
• ICSI: a sperm is injected into the cytoplasm of the
egg
Note:
Dr Taiwo Aremu

Gamete Intrafallopian Transfer (GIFT)
 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)

Zygote Intrafallopian Transfer (ZIFT)
 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

Intracytoplasmic Sperm Injection (ICSI)
 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

Intracytoplasmic Sperm Injection (ICSI)
 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

Psychological Support

2014/07/23 189
Psychological support
• Infertility places a great emotional burden
on the infertile couple.
• The quest for having a child becomes the
driving force of the couples relationship.
• It is important to address the emotional
needs of these patients.
Dr Taiwo Aremu

Case History

Case History(1)
• Mrs JD is a 25yrs old aerobics teacher. She
had irregular periods and a low BMI of 17.
She exercises for 4-5hrs a day. She is
otherwise well and has no significant past
medical or surgical history
• Her husband, Mr MD, works as a computer
programmer. He is well and has no
significant past medical or surgical history.

Case History(2)
• They are both non-smokers and neither of
them drink alcohol.
• Investigation:
Mrs JD: FSH, LH, Thyroid function,
prolactin level, rubella status, pelvic uss
exam
Mr MD: semen analysis

Case History(3)
• Result:
- Mrs JD: rubella immune; pelvic uss
scan normal; FSH 4.3u/L; LH 3.0u/L;
prolactin and thyroid function normal.
- Mr MD: sperm count 53million/mL;
45% motile with good progressive
motility; morphology 65% abnormality

Case History(4)
• Mrs JD was advised to reduce the duration
and frequency of exercise and to gain
weight to a BMI of 19-20. The couple were
reassured that all investigations were
normal. Within 6mnths Mrs JD had
increased her weight and reduced her
exercise.

Case History(5)
• Subsequently, her periods became more
frequent. 3mnths later she conceived
spontaneously and proceeded to deliver a
healthy male infant at term

Summary
 Infertility is a significant social and
medical problem affecting couples
worldwide
 Female and male factors are equally
responsible
 Evaluation of both partners is essential
 Treatment depends on the cause of
infertility and varies from ovulation-
inducing drugs to surgery
to ART2014/07/23 196Dr Taiwo Aremu

References
 WHO (2014). Sexual and Reproductive health;
http://www.who.int/reproductivehealth/topics/infertility/definitions
 Margarete O. Araoye. Epidemiology of infertility: Social problems of the infertile
couple. West African Journal of Medicine (WAJM) Vol. 22 No. 2, April – June, 2003
 WHO (2014). Sexual and Reproductive health: Global prevalence of infertility,
infecundity and childlessness.
http://www.who.int/reproductivehealth/topics/infertility/burden/en/
 Akin Agboola, Textbook of Obstetrics and Gynaecology (2nd edition)
 Ash Monga, Gynaecology by Ten Teachers (18th edition)
I.A.Yakasai & U.A.Umar. A Review of Parasitic Infestation in Pregnancy. Asian
Journal of Natural & Applied Science (AJSC). Vol.2. No.1. March, 2013
 Jenkins, Van Kleunen, Mclnnis, Lewis. Step-up to USMLE Step 2 CK (3rd edition)
 Theodore X. O’Connell & Adam Brochert. USMLE Step 2 Secrets (3rd edition)

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