The document covers the management of infertility, defining infertility, its causes, and various treatment options. It outlines the necessary investigations, requirements for both men and women, and methods such as assisted reproduction techniques, hormonal treatments, and counseling. Additionally, it addresses the emotional and psychosocial impact of infertility on couples.

1. MANAGEMENT OF CLIENTS WITH
INFERTILITY PROBLEMS

2. •At the end of the lecture, students are
expected to:
Define infertility
Explain the causes of infertility to both
males and females
Manage a clients with infertility

3. •Infertility absolute state of inability of a couple to
achieve conception within one (1) year or more of
regular and un protected sexual intercourse.
OR
•Infertility is the inability to conceive and carry a
pregnancy to viability after one (1) year of regular
sexual intercourse without contraception
•Sub infertility is a relative state of lowered capacity to
conceive

4. Types of infertility
•Primary infertility : carried to alive birth: is
inability to conceive and carry a pregnancy to
viability with no previous history of pregnancy
•Secondary infertility: It is where there has been
previous pregnancy irrespective of the outcome.

5. Causes of infertility
Men
•Defective spermatogenesis
Dysfunction of: hypothalamus, pituitary
gland, adrenals and thyroids
•Systemic diseases: diabetis mellitus and renal
failure

6. •Testicular disorders & inflammation
Trauma
Environmental ( high temperature)
•congenital (hydrocele, undescended testes)
•occupational (fernacemen, long-distance
truck/ lorry drivers)
•acquired (varicocele, tight clothing)
•Cancer treatment- radiation exposure

7. •Defective transport
Obstruction or absence of seminal ducts :
Infection
Congenital anomalies
Trauma

8. •Impaired secretions from prostate or
seminal vesicles:
 Infections
 Metabolic disorders

9. •Ineffective delivery
psychosexual problems/ stress
drugs
Inadequate sperm production and maturation
Inadequate motility of the sperm

10. •Sexually transmitted diseases
•Failure to depose spermatozoa in the vagina

11. Females
•Vaginal- abnormalities
Infections- causing dyspareunia
Highly acidic vaginal( PH)
Congenital anomaly

12. •Cervical –Hostility environment( insufficient oestrogen
or infection)-mucus hostility
• Incompetent cervix, trauma, infections, antisperm
antibodies in the mucus
•Uterus – abnormalities- hostile environment for
implantation and survival of blastocyst
•Tubal – adhesions, scar tissue due to PID, previous
tubal surgery leading to defective transport

13. •Defective implantation due to : hormonal
imbalance, congenital anomalies, fibroids and
infection
•Ovarian disorders- irregular infrequent
ovulation, hormonal defect, ovarian cysts or
ovarian diseases
•Systemic conditions- diabetis mellitus, renal
failure

14. •Defective ovulation due to endocrine disorders
from dysfunctioning of the: hypothalamus,
pituitary gland, adrenal glands and thyroid
gland
•Coital errors- dyspareunia , frequent
untimming coitus, use of lubricants of which
some are spermicides

15. • Defective ovulation due to Endocrine disorders
thus dysfunction of : hypothalamus,
pituitary,adrenals,thyroid
•Unexplained infertility

16. Investigations- both partners should be involved
History
• History of regular un protected sex for one year and above,
age (too young or too old, occupation, duration of marriage,
bleeding pattern and any previous pregnancy.
• Medical / surgical history , operations, infections, if normal
coitus
• Menstrual history, menstrual cycle, any dysmenorrhea,
duration of bleeding and use of contraceptive

17. •History of drug therapy
•Duration of marriage
•Social history-alcohol intake

18. Examination & investigations
•Physical examination to rule out any physical
abnormalities-attention to the genital , uterus,
size , location, mobility, fixation,
•Vagina
•Males- penis for any abnormalities

19. •Semen analysis (normal values .WHO).
Submitted specimen to reach the laboratory
within 2 hours.
-semen volume >2-5ml
-sperm concentration >20million/ml
-mortality> 50%progressive mortality
- Morphology >30%normal forms
-white blood cells <1 million /ml

20. •Abnormalities is opposite of the above including
necrospermia (dead sperms) and
Azoossparmia( no sperms)
The post coital test- glass slide smear to check
for sperms
Serum progesterone test
Endometrial biopsy
Hysterosalpingingram
Laparoscopy

21. Culdoscopy
Robins test
Asses for patency of the tubes for blockage
D& C in the secretory phase and send specimen
for histology

22. Management of infertility
•There is no universal treatment or cure for infertility.
In general, treatment depends on the specific cause
of infertility for that couple.
• The majority of couples who seek advice, testing
and treatment for infertility do conceive. About 50%
of the women become pregnant with 12 - 18 months
of starting investigation

23. Treat the cause as per history, examination and
investigations
Initial visit: The initial encounter with the infertile
couple is the most important to outline the general
causes of infertility and to discuss the subsequent
evolution.

24. •Obtain complete medical, surgical and in addition to
the female partner include: gynecologic and obstetric
history.
•-Important points in history include:
- do they have child? (Together or alone),
- regularity of menstrual cycle,
- adequacy of sexual intercourse.

25. •The couple should have sexual intercourse every
two days during the fertile portions of the
woman's cycle, which is determined.
•risk factors for infertility such as: - history of PID -
use of IUD - history of pelvic surgery - history of
endocrine disorder like pituitary, adrenal and
thyroid function.
• Obtain information regarding genital surgery,
infection, trauma, history of mumps for the male
partner.

26. •Assess emotional impact of infertility on the couple
and counsel accordingly. During this visit, do through
physical examination with particular attention to
height, weight, body habitus, hair distribution, thyroid
gland and pelvic examination.
• If any abnormalities which need further evaluation
are detected on pelvic examination, refer to higher
center.
•But if no abnormalities, were detected on physical
examination including speculum examination, explain
to the client the basic requirements

27. Basic requirements for women
•Woman must be ovulating (look for evidence of
ovulation).
• The tubes that connects the uterus with ovary
should be patent (assessment of patenc) is done by
hysterosalphingo graphy (HSG).
• The lining of the uterus should be healthy and
appropriate for implantation

28. Basic requirements for men
•The man must be able to have adequate erection
and ejaculate sperm.
•The sperm must be fertile and there must be
enough sperm present.
• The tubes which transport; sperm from tests to
penis should be healthy and patent.
• Plan regular return visits for the couple if
appropriate.

29. Drugs
• To induce ovulation ( amenorrhoea,oligomenorrhea and where partner has
adequate sperm) give Clomiphene 500mg at 2nd
day of the cycle,3rd
,4th
and
5th
.Then start coitus up to 26th
-27th
• Bromcriptine can also be administered.2.5 mg to induce ovulation and
suppress prolactin.
• Administer folic acid and b-complex for 3 months in low spermatozoa.
• Administer appropriate antibiotics to treat infections
• Refer to endocrinologists if there is hormonal imbalance for possible
hormonal therapy

30. Assisted reproduction techniques
•Intrauterine insemination ( IUI)
Un explained infertility
Hostile cervical mucus
Antisperm antibodies
• Ensure ovulation takes place before sperm is
inserted high in the vagina

31. •Donor insemination (DI)
•Sperm from an anonymous donor is used and may be
indicated in the following:
Azoospermia
Oligospermia
Vasectomy
Ejaculatory
Chemotherapy or radiotherapy
Transmissible genetic disorder

32. In Vitro fertilization/ embryo transfer (IVF/ET)
• It is a technique where fertilization takes place outside the body
• The suitable oocytes and prepared spermatozoa are
incubated .After successful fertilization, one or two embryos are
transferred in to the woman’s uterus
• Any remaining embryo are frozen for future use

33. Intracytoplasmic sperm injection(ICSI)
•It involves injecting a single spermatozoon in an
ovum
•Sperms are prepared in such a way that the
most motile of these can be selected
•Very useful technique when there are very few
normal sperms available or the fertilising ability
of the sperm is dramatically reduced

34. •Surgery
Removal of some adhesions
Repair of any damaged
organs/tissue(tubal surgery)

35. Counselling
•Counselling: When no obvious cause can be
found for infertility counseling may improve
the couples chance of achieving pregnancy.
•Advice of general health
• Regular exercise
• Avoid excessive drinking alcohol and smoking.

36. •And the couple should also be taught how to
identify the most fertile phase in the menstrual
cycle when sexual intercourse is most likely
result in pregnancy.
•Continue normal sexual habits
•Prevent stress.
•Associate and share with other couples with
similar problems
•Possible adoption

37. Psychosocial aspect of infertility
•Guilty
•Anger
•Depression
•Anxiety
•Inadequacy
•Grief

38. •Loss of control
•Low self esteem
•Relationship difficulties
•Isolation
•Divorce
•Strengthen relationships with other couples who
are infertile

39. Assignment
• Write short notes on the following
• Surrogacy
• Psychosexual aspect of infertility