This document discusses infertility, including definitions of infertility and sterility. It describes types of infertility as primary or secondary. Causes of infertility can include problems with the woman's menstrual cycle or the man's hormones. The process of spermatogenesis and sperm morphology are outlined. Tests for evaluating male and female fertility are mentioned. Common causes of infertility and treatment options like IUI, IVF, and ICSI are summarized at a high level.

1. Dr Vikash
JR(Pathology)
IMS,BHU

2. Infertility-Apparent faliure of a couple to conceive
Sterility-Absolute inability to conceive.
If a couple fails to achieve pregnancy after 1 year
of unprotected and regular intercourse , it is an
indication to investigate the couple

3. Type
 Primary- If conception has never occurred.
 Secondary
It may be physiological
Before puberty and after menopause
Over age of 40 year fertility reduced and increase risk
for chromosomally and other malformed foetus.

4.  Woman: abnormal menstrual periods
 Man: hormonal problems (changes in hair
growth or sexual function)
Infertility is rarely absolute so the term sub-fertility
may be more appropriate

6.  Spermatogonia--Mitosis--spermatocytes—
Meiosis I-Haploid Secondary Spermatocytes---
Meiosis II-Spermatid ( 74 days)
 Spermiogenesis: differentiation
of the round spermatid into a
spermatozoon
 This is the process in which
sperm morphology is largely
determined

7.  The human sperm cell is
about 70 μm long
 The nucleus is in the head –
contains the 23
chromosomes
 It is the head which binds to
the egg at fertilization
 Midpiece: the energy for
motility is generated
 Tail: motility – the beat is
initiated just behind the
midpiece, and then
propagated along the tail

8.  At puberty there are 300,000 primordial
follicles
 Dominant follicle produces oestradiol which
leads to LH surge
 Ovulation occurs 24-36 hours later
 The fertilization life span of the ovum is 24-36
hours
 The receptivity of the endometrium is days 16-
19 of a 28 day cycle

15.  Dyspareunia and Vaginal Causes
 Congenital Defect in genital tract-Absent or septate
vagina,Hypoplasia
 Infection- Chlamydia Cervicitis
 Cervical factor-cervical mucous
 Uterine causes-Hypoplasia,Malformed uterus and
incomplete os
 Tubal factor-Salpingitis,Gonorrhoea ir chlamydial
infection
 Ovaries-PCOD,LFD
 Peritoneal causes-Pelvic endometriosis
 Chronically ill health
 Hormonal pitutary dysfuction-
Hyperprolactinoma,Hypothalmic disease

16.  Age
 Tobacco smoking
 Alcohol use
 Being overweight
 Too much exercise
 Caffeine intake

17. Tests for men
 General physical examination
 Semen analysis
 Hormone testing
 Transrectal and scrotal ultrasound
Tests for women
 Ovulation testing
 Hysterosalpingography
 Laparoscopy
 Hormone testing
 Ovarian reserve testing
 Genetic testing
 Pelvic ultrasound

18.  History
 Examination
 Specific test-
Hysterosalpingography(HSG)
Laproscopic chromotubation
Sonosalpingography(SSG)
Hysteroscopy and falloscopy
Ampullary and fimbrial salpingoscopy
Endometrial Biopsy
Fern Test
Ultrasound
Hormonal Test

22. A mixture of seminal plasma and cells
 Seminal plasma contains:
 Prostatic fluid (~30% of the volume)
 Epididymal plasma (~5% of the volume)
 Seminal vesicle fluid (the remainder of the ejaculate)
 The cells are:
 Spermatozoa
 Germ line cells
 Leukocytes of various types
 Bacteria
 Epithelial cells
 Occasional red cells

23. •There are several macroscopic evaluations which
give useful diagnostic information about the
sample:
– Appearance
– Odour
– Liquefaction
– Volume
– Viscosity
– pH

24. •pH is important because sperm die at pH < 6.9
• The pH of liquefied semen is normally determined
using test strips (we use EM Science ColorpHast
type, pH 6.5–10.0)
•We usually measure pH after volume and
viscosity – by touching the “emptied” volumetric
pipette to the test strip
• The normal pH range is 7.2–8.4
• Inflammatory disorders of the accessory glands
can take the pH outside of this range

25. • The characteristics assessed are:
– Motility
– Sperm aggregation (random clumping) – “some” is normal, but
large clumps (each with hundreds of sperm) is abnormal
– Spermagglutination (between specific sites) – could suggest the
presence of antisperm antibodies.
– Round cells: should be <1 per 40× field (~ 1 million/ml). If more
abundant, a leukocyte test should be run
– Epithelial cells: usually present in small numbers
– Erythrocytes: should not be present
– Debris: particles smaller than sperm head, may be plentiful
– Bacteria and protozoa: presence indicates infection

26. •% motile = the proportion of sperm with tail
movement
• Progression rating = the grade of progression
shown by the majority of the sperm: this can be
from 0 (all immotile) to 4 (all with rapid
progression); or from a (rapid progression) to d
(all immotile)
• Differential motility count = proportion of sperm
in each of 4 motility classes (rapid progressive;
slow progressive; non-progressive; immotile

27. • Differential motility
classification is based on the
distance swum over time:
– Rapid progressive: > 25 μm/s
– Slow progressive: 5 – 25 μm/s
– Non-progressive: < 5 μm/s
– Immotile: no flagellar
movement

28.  Morphology is even more important than motility
and concentration
 Because of the small size of the human sperm
head, must use an air-dried smear which has been
stained
 The Papanicolaou method is best
 Prepared samples are assessed using a 100× oil-immersion
objective under bright field optics
 The WHO recommends that 200 spermatozoa are
counted per sample (and says that 2 × 200 is better)
 Fields for counting must be selected at random
 When counting, remember about the normal
distribution

29. Variations of normal head shape
Small / large head Tapering heads
Pyriform heads Vacuolated
head
Asymmetric
insertion
Distended
midpiece
Thin
midpiece
Cytoplasmic
droplet
Coiled
tail
Short
tail
Duplicate
tail
Hairpin
tail
Bent
tail
Terminal droplet
Conjoined
form
Non-inserted
tail
Constricted Reduced
acrosome
Dense
staining
Amorphous forms

30.  The Teratozoospermic Index is an expression of the
average number of abnormalities per abnormal sperm
 Each sperm cell is assessed for an abnormality in the
head, neck/midpiece, or tail, and for a cytoplasmic
droplet
 If it does not have any of these abnormalities, it is
“normal”
 If it does have an abnormality, it is “abnormal”, and we
score each abnormality. So, if a cell has an abnormal
head and tail, it is counted as 1 cell, and 2 abnormalities
 Then, (total # abnormalities) / (total # sperm) = TZI
 A TZI > 1.80 has been associated with poor sperm
fertilizing ability in vivo and in vitro

31.  Acid phosphatase: marker for prostatic function
 Citric acid: can indicate prostatic function – low
levels may indicate dysfunction or a prostatic duct
obstruction
 Zinc: marker for prostatic function – colorimetric
assay (WHO)
 Fructose: marker for seminal vesicle function, and
is a substrate for sperm metabolism –
spectrophotometric assay (WHO)
 -Glucosidase: secreted exclusively by the
epididymis and so is a marker for epididymal
function – spectrophotometric assay (WHO)

32.  Aspermia-No semen
 Azoospermia-No sperm in semen
 Oligospermia-Low sperm count
 Asthenospermia-Dimnished Motility
 Necrospermia-Dead sperm
 Teratospermia-Abnormal Morphology

34.  If a partner is sterile (i.e. no gametes), then the couple
would need donor gametes to achieve a pregnancy
 If one or both partners are sub-fertile, then the treatment
options are:
 no treatment, or ovulation induction
 intra-uterine insemination (+ ovulation induction)
 in vitro fertilization (includes ICSI)

35.  IUI is the least invasive of all t/t - involves the selective
washing of semen to isolate the motile spermatozoa
(can’t put whole semen into the uterus)
 Up to 15 million motile spermatozoa are inseminated
 Advantages:
 relatively inexpensive – simple procedures
 minimal use of FSH
 can be used in consecutive cycles
 can usually start treatment virtually immediately
 Disadvantages:
 lower success rate per cycle than other treatment

36.  There are many types of IVF
 For virtually all types, the woman is treated with
“fertility drugs” to stimulate the development of a
group of eggs (the average is around 10 – but the range
can be enormous)
 Just prior to ovulation, the oocytes are retrieved
 That afternoon, they are inseminated with prepared
sperm
 Inseminated eggs checked the next day for fertilization
 The fertilized eggs are kept in culture for up to 5-6 days
 Embryo transfer / possibly cryopreservation

38.  One sperm is injected
directly into an egg
 Only mature eggs
injected
 After the insemination,
the rest of the lab
procedures are the
same as for “standard”
IVF