The document provides a comprehensive overview of infertility, outlining its various types, contributing factors, requirements for male and female fertility, and potential causes for infertility in both partners. It details evaluation procedures, including history taking, physical examinations, and specific tests, along with treatment options that range from medications to assisted reproductive technologies. The conclusion emphasizes the need for evaluating both partners as infertility affects them equally and treatment varies based on the underlying causes.

1. INFERTILITY STUDIES
By
Calvin BISONG EBAI
MLS/FHS/UBa

2. 2
PLAN
I. Introduction
II. Types
III. Factors affecting fertility
IV. Requirements for female fertility
V. Requirements for male fertility
VI. Causes of female infertility
VII. Causes of male infertility
VIII. Causes of infertility affecting both partners
IX. Basic work-up for infertility
X. Fertility evaluation procedure
XI. Treatment possibilities
XII. Conclusion

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Introduction
• Significant social and medical problem affecting couples worldwide,
• Average incidence of infertility is about 15% globally,
• Varies in different populations,
• Some causes can be detected and treated, whereas others cannot,
• Unexplained infertility constitutes about 10% of all cases,
• Definition: Inability to conceive after 12 months of having sexual intercourse with average
frequency (2 to 3 times per week), without the use of any form of birth control.

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Types of infertility
• Primary infertility: couple has never produced a pregnancy.
• Secondary infertility: woman has previously been pregnant, regardless of the outcome, and now is unable
to conceive.
• 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.

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Factors affecting fertility:
1. Frequency of Intercourse: coital frequency is positively correlated with pregnancy rates,
probability of conception (within 6 months) 1 time per week 3 times per week 50%.
2. 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 24 hours if not fertilized,
Sperm should be available in the female genital tract at or shortly before ovulation.

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Factors affecting fertility cont’d
3. 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
4. Other infections that may affect fertility include tuberculosis, toxoplasmosis, malaria,
schistosomiasis and leprosy

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Factors affecting fertility cont’d
5. Age of the woman: after 40 the fertility rate decreases by 50% while the risk of miscarriage
increases,
6. Age of the man: increased age affects coital frequency and sexual function,
7. Nutrition for women, weight 10% to15% below normal or obesity may lead to less frequent
ovulation and reduced fertility.

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Factors affecting fertility cont’d
8. Other 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.

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Female and male factors of infertility
• Female and male factors are equally responsible for infertility (30% to 40% each)
• In 20% of cases there is a combination of both factors
• Evaluating both partners is essential.

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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,
• 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.

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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
• 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

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Causes of female infertility
• Pelvic inflammatory disease (PID) leading to blocked or damaged fallopian tubes, may interfere
with fertilization and transport of egg;
• Ovarian dysfunction resulting in absent or diminished egg production;
• Local factors in the uterus and cervix may interfere with implantation and woman’s ability to carry
pregnancy to term;
• Luteal phase defect results in low production of progesterone may lead to early miscarriage;
• Production of anti-sperm antibodies can interfere with fertilization.

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Causes of male infertility
• Conditions that affect quality or quantity of sperm may lead to infertility
• These conditions include:
Varicocele: enlargement of veins within the scrotum,
Primary testicular failure,
Accessory gland infection,
Idiopathic low sperm motility.

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Causes of infertility affecting both partners
• Psychological: sexual behavior may reflect couple’s desire not to have children
• Immunological incompatibility may cause sperm agglutination
• Unknown causes.

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Basic work-up for infertility
• Evaluating both partners is essential,
• Detailed history and physical examination for both,
• Semen analysis,
• Evidence of ovulation,
• Evidence of fallopian tubes patency,
• Postcoital test: still performed by some clinicians, not found valid by some.

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Fertility 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 is conducted together as well as separately to obtain confidential information.

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Fertility evaluation
• General and Sexual History
 General history
Occupation and background
Use of tobacco, alcohol and drugs
History of abdominal surgery and earlier diseases/infections
 Sexual history
sexual disturbances or dysfunction such as vaginismus, dyspareunia or erectile dysfunction
sexually transmitted infections

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Fertility evaluation cont’d
• Obstetric and Gynecological History
Reproductive history
Gynecological history
Age at menarche,
Menstrual periods: duration and intervals,
Previous contraceptive use,
Previous testing and treatment for infertility.

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Fertility evaluation cont’d
• General and Gynecological Examination
Visual evaluation and pelvic exam for women to rule out: Uterine hypoplasia, cervical lesions,
dyspareunia, endocrinopathy.
Visual evaluation and penile exam for men to rule out:
 Congenital anomalies, hypogonadism, tumors, epididymal cysts,
Cryptorchidism: failure of testes to descend into the scrotum
Hydrocele,
Varicocele.

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Fertility evaluation of female partner
• Evidence of Ovulation
• Ovulation can be established based on:
Urine test: measures the LH in urine to detect if and when ovulation occurred,
Basal body temperature chart: temperature is measured every morning, before woman gets out
of bed, elevation in temperature may indicate ovulation.
Progesterone test: progesterone level in blood is measured on days 21 or 22 of 28-day cycle
Endometrial biopsy: done during premenstrual phase detects if endometrium undergoes
expected changes (consistent with ovulation and production of progesterone).

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Fertility Evaluation of Female Partner cont’d
• Other Tests
Hysterosalpinogram (HSG): to determine whether fallopian tubes are blocked,
Laparoscopy: to evaluate for pelvic disease, such as endometriosis, and check patency of fallopian
tubes,
Hysteroscopy: to evaluate condition of uterine cavity (polyps, fibroids).

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Fertility Evaluation of Male Partner
• Semen Analysis: semen is studied for a number of factors including
Volume (1.5 cc to 5.0 cc),
Number of sperm present (> 15 million/ml of semen),
Sperm motility (> 60%) and forward progression (more than 2 on scale 1 to 4),
Morphology (> 60% normal forms),
Presence of any infection.

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Fertility evaluation of male partner cont’d
• Other Tests
Urine analysis: to rule out infection
Endocrine tests: to measure concentrations of hormones testosterone, FSH and LH
Anti-sperm antibodies
Sperm penetration assay: to establish ability of sperm to penetrate egg
Postcoital test (low validity): to establish ability of sperm to penetrate cervical mucus

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Treatment Possibilities
• Female Infertility 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

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Treatment of female infertility
• Induction of Ovulation:
Involves the use of medication to stimulate development of one or more mature follicles,
Success rates vary considerably and depend on age of the woman, type of medication used and
whether there are other infertility factors present in the couple.
Ovulation Induction Agents induce release of gonadotropins.

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Treatment of female infertility cont’d
• Intrauterine Insemination: a fertility procedure in which sperm are washed, concentrated and
injected directly into a woman’s uterus,
• Increases the number of sperm in the fallopian tubes,
• 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).

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Treatment of female infertility cont’d
• Assisted Reproductive Technology (ART): Noncoital methods of conception
• Includes all fertility treatments in which both eggs and sperm are manipulated.
• Types of ART include:
In Vitro Fertilization (IVF)
Zygote Intrafallopian Transfer (ZIFT)
Gamete Intrafallopian Transfer (GIFT)

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Treatment of female infertility cont’d
• In Vitro Fertilization: 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,
Success rates are about 20% per egg retrieval.

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Treatment of female infertility cont’d
• 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).

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Treatment of female infertility cont’d
• 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
Success rate is about 29% per egg retrieval

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Treatment possibilities:
• Male Infertility
Surgical treatment in some cases (varicocele)
Intrauterine insemination can be performed either with patient’s or donor’s sperm
ART procedures:
GIFT
Donor semen should be free from STDs/HIV

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ART: 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,
• 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

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Conclusion
• 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 ART.
• END!