Subfertility, or difficulty conceiving, affects 15% of couples. It is defined as failure to conceive after one year of unprotected intercourse. There are several potential causes of subfertility, including problems with ovulation, sperm production/function, tubal damage, cervical factors, or sexual function. A thorough history, examination, and testing of both partners is needed to identify the underlying cause so appropriate treatment can be initiated.

1. Subfertility
Subfertility
Dr.Mudathir
Dr.Mudathir Omer Abdelmaboud
Omer Abdelmaboud
Lecturer
Lecturer-
-Obstetrics & Gynaecology
Obstetrics & Gynaecology
15/09/2009
15/09/2009

2. Definition
Definition:
:
-
-failure to conceive after a year of regular
failure to conceive after a year of regular
unprotected intercourse.
unprotected intercourse.
-
-15% of couples
15% of couples
-
-Primary
Primary→
→ female never conceived.
female never conceived.
-
-secondary
secondary→
→ previously conceived
previously conceived.
.
Basic requirements:
Basic requirements:
-
-Ovulation.
Ovulation.
-
-Adequate sperm production & release.
Adequate sperm production & release.
-
-Sperm must reach egg.
Sperm must reach egg.
-
-Fertilized egg must implant.
Fertilized egg must implant.

3. Hypothalamic
Hypothalamic-
-pituitary
pituitary-
-ovarian axis
ovarian axis

4. Menstrual cycle
Menstrual cycle

5. History
History

 Remember
Remember –
– male & female partners
male & female partners

 General medical
General medical –
– chronic illness, cancer, (mumps,
chronic illness, cancer, (mumps,
epididymitis, undescended testes)
epididymitis, undescended testes)

 Surgical
Surgical

 Gynaecology
Gynaecology-
- PID?, adhesions?, Menstrual
PID?, adhesions?, Menstrual hx
hx

 Obstetric ?TOP
Obstetric ?TOP

 Meds ? taking folic acid
Meds ? taking folic acid

 Social
Social

 Smoking/C2H5OH/illicit drugs
Smoking/C2H5OH/illicit drugs

 Rubella status
Rubella status

6. Examination
Examination
Female
Female:
:

 BMI
BMI-
- check height &
check height &
weight
weight

 Underweight/overweight
Underweight/overweight

 General medical
General medical
examination
examination

 Exopthalmos
Exopthalmos, anaemia,
, anaemia,
goitre,
goitre, hirsutism
hirsutism

 Pelvic examination
Pelvic examination

 Cervical smear
Cervical smear
Male:
Male:

 General medical
General medical
examination, height (?
examination, height (?
Kleinfelters
Kleinfelters syndrome
syndrome
47XXY)
47XXY)

 Inguinal scars
Inguinal scars

 Size/site of testes
Size/site of testes

 Varicocoele/epididymal
Varicocoele/epididymal
cysts
cysts

7. Causes
Causes
Anovulation(30%) PCOS, hypothalamic
Anovulation(30%) PCOS, hypothalamic hypogonadism
hypogonadism,
,
hyperprolactinemia
hyperprolactinemia
thyroid dysfunction, ovarian fa
thyroid dysfunction, ovarian failure
ilure
Male factor(25%) idiopathic,
Male factor(25%) idiopathic, varicocele
varicocele, antibodies,
, antibodies,
drugs/chemical exposure
drugs/chemical exposure
No fertilization Tubal damage
No fertilization Tubal damage →
→infection, surgery,
infection, surgery,
endometriosis(25%)
endometriosis(25%)
cervical factor
cervical factor
sexual factor
sexual factor
Unexplained (%30)
Unexplained (%30)

8. 30%
25%
20%
5%
5%
30%
Anovulation
Male problem
Tubal Problem
Coital problem
Cervical problem
Unexplained
3

9. Investigations
Investigations

 Female:
Female:

 Confirm ovulation
Confirm ovulation→
→
Day 21 Progesterone
Day 21 Progesterone
> 30nmol/l.
> 30nmol/l.

 Day 3 FSH/LH
Day 3 FSH/LH

 Testosterone, prolactin,
Testosterone, prolactin,
TFTs
TFTs

 Confirm tubal patency
Confirm tubal patency-
-
-
-Laparoscopy & dye
Laparoscopy & dye
-
-Hysterosalpingogram
Hysterosalpingogram

 Rubella status.
Rubella status.

 Male:
Male:

 Semen analysis
Semen analysis

 If abnormal
If abnormal→
→ repeat.
repeat.

 FSH, LH, Prolactin,
FSH, LH, Prolactin,
testosterone
testosterone

 Antisperm
Antisperm antibodies.
antibodies.

 Referral to urologist
Referral to urologist

10. Tests of Tubal patency
Tests of Tubal patency

11. Polycystic ovary syndrome
Polycystic ovary syndrome
PCOS
PCOS

 PCOS
PCOS →
→5% of women
5% of women →
→causes 80%
causes 80% anovulatory
anovulatory
infertility.
infertility.

 PCO 20% of women
PCO 20% of women→
→ regular
regular ovulatory
ovulatory cycles.
cycles.

 ∆
∆ at least 2 out of the 3 criteria:
at least 2 out of the 3 criteria:
1.PCO on scan(
1.PCO on scan( ≥
≥12 follicles ,diameter 2
12 follicles ,diameter 2-
-8 mm) in an
8 mm) in an
enlarged ovary (>10 ml volume).
enlarged ovary (>10 ml volume).
2.Irregular periods(>35 days)
2.Irregular periods(>35 days)
3.Hirsuitism:clinical acne or excess body hair and / or
3.Hirsuitism:clinical acne or excess body hair and / or
biochemical
biochemical ↑
↑serum testosterone
serum testosterone.
.

12. Hirsutism
Hirsutism

13. PCOS
PCOS

14. Aetiology
Aetiology

 Mainly genetic.
Mainly genetic.

 ↑
↑LH and insulin levels (peripheral insulin
LH and insulin levels (peripheral insulin
resistance)
resistance)→
→ ↑
↑Ovarian & adrenal androgens
Ovarian & adrenal androgens
↓
↓hepatic production (SHBG )
hepatic production (SHBG )
↑
↑Androgen free index (AFI)
Androgen free index (AFI)

 Excess small ovarian follicles (PCO picture).
Excess small ovarian follicles (PCO picture).

 Irregular or absent ovulation.
Irregular or absent ovulation.

 ↑
↑Androgens
Androgens →
→acne /excess body hair.
acne /excess body hair.

 BMI
BMI →
→insulin levels
insulin levels →
→androgen levels.
androgen levels.

 Family history of type 2 diabetes.
Family history of type 2 diabetes.

15. Clinical features
Clinical features
PCOS
Obese Acne/ Hirsuitism Oligomenorrhoea

16. Investigations
Investigations

 ↑
↑LH(3:1)
LH(3:1)

 FSH
FSH

 ↑
↑Serum testosterone
Serum testosterone

 Prolactin
Prolactin →
→exclude
exclude prolactinoma
prolactinoma.
.

 TSH
TSH

 USS
USS →
→PCO .
PCO .

 Fasting lipid profile & glucose screen.
Fasting lipid profile & glucose screen.

17. PCOS
PCOS

18. Complications
Complications

 Type 2 diabetes in later life (50%).
Type 2 diabetes in later life (50%).

 Gestational diabetes (30%).
Gestational diabetes (30%).

 Endometrial cancer.
Endometrial cancer.

 Subfertility
Subfertility or recurrent miscarriage.
or recurrent miscarriage.

19. Treatment
Treatment

 Symptomatic:
Symptomatic:

 Weight loss, diet and exercise.
Weight loss, diet and exercise.

 COCP
COCP→
→ regular menses/ treat
regular menses/ treat hirsuitism
hirsuitism.
.

 Cyproterone
Cyproterone acetate.
acetate.

 Meformin
Meformin.
.

 Elfornithine
Elfornithine.
.

 Infertility:
Infertility:
1/Ovulation induction
1/Ovulation induction:
:

 A)Clomiphene
A)Clomiphene citrate
citrate →
→anti
anti-
-oestrogen
oestrogen.
.

 Limited to 6/12 (D2
Limited to 6/12 (D2-
-D6)
D6)

 70% ovulation rate / 40% birth rate/ 10% multiple pregnancy.
70% ovulation rate / 40% birth rate/ 10% multiple pregnancy.

 B/
B/Metformin
Metformin

 ↓
↓birth rates compared to
birth rates compared to clomiphene
clomiphene.
.

 Effective in
Effective in clomiphene
clomiphene -
-resistant women
resistant women.
.

 Treat
Treat hirsuitism
hirsuitism/no risk of multiple pregnancy
/no risk of multiple pregnancy.
.

 ↓
↓Early miscarriage and GDM
Early miscarriage and GDM

20. C)
C) Gonadotrophins
Gonadotrophins:
:

 Recombinant or purified urinary FSH
Recombinant or purified urinary FSH ±
±LH
LH

 Used if
Used if clomiphene
clomiphene failed.
failed.

 Needs scan monitoring for follicular development.
Needs scan monitoring for follicular development.

 ↑
↑Multiple pregnancy.
Multiple pregnancy.

 Ovarian
Ovarian hyperstimulation
hyperstimulation syndrome
syndrome.
.

 2/Lapraoscopic Ovarian diathermy
2/Lapraoscopic Ovarian diathermy:
:
-
-As effective as
As effective as gonadotrophins
gonadotrophins.
.
-
-Lower multiple pregnancy rate.
Lower multiple pregnancy rate.
-
-using
using monopolar
monopolar diathermy.
diathermy.
-
-Test tubal patency and treat endometriosis.
Test tubal patency and treat endometriosis.
-
-Regular ovulation for years..
Regular ovulation for years..

21. Laparoscopic Ovarian Drilling
Laparoscopic Ovarian Drilling

22. Premature Ovarian Failure
Premature Ovarian Failure

 Menopause
Menopause occuring
occuring < age 40.
< age 40.

 Radiotherapy/Chemotherapy.
Radiotherapy/Chemotherapy.

 Autoantibodies
Autoantibodies.
.

 Turners syndrome.
Turners syndrome.

23. Pituitary Causes of
Pituitary Causes of
Subfertility
Subfertility

24. Hyperprolactinaemia
Hyperprolactinaemia

 Prolactin
Prolactin ↔
↔ posterior lobe of pituitary.
posterior lobe of pituitary.

 ↓
↓GnRH
GnRH release.
release.

 Anovulation
Anovulation.
.

25. Hyperprolactinaemia
Hyperprolactinaemia
Causes
Causes

 Physiological:
Physiological:

 Stress
Stress

 Exercise
Exercise

 Pregnancy/Lactation
Pregnancy/Lactation

 Pharmacological:
Pharmacological:
-
-Phenothiazines
Phenothiazines
-
-Methyldopa
Methyldopa
-
-Opiates
Opiates

 Pathological:
Pathological:

 1
1º
º Pituitary neoplasm
Pituitary neoplasm

 Macroprolactinoma
Macroprolactinoma

 Microprolactinoma
Microprolactinoma

 Hypothyroidism ( TSH) stimulates pituitary
Hypothyroidism ( TSH) stimulates pituitary

26. Hyperprolactinaemia
Hyperprolactinaemia
Presentation:
Presentation:

 Primary/secondary
Primary/secondary
amenorrhoea
amenorrhoea

 I
I0
0 Infertility
Infertility

 Gallactorrhoea
Gallactorrhoea

 Visual disturbance
Visual disturbance

 Frontal headache
Frontal headache
∆
∆

 Serum
Serum prolactin
prolactin.
.

 CT/MRI brain.
CT/MRI brain.

 Assessment of visual
Assessment of visual
fields (
fields (bitemporal
bitemporal
hemianopia
hemianopia )
)

27. Management
Management

 Dopamine agonists
Dopamine agonists

 Bromocriptine
Bromocriptine

 Cabergoline
Cabergoline

 Surgery
Surgery

28. Sheehan
Sheehan’
’s syndrome
s syndrome

 Pituitary infarction
Pituitary infarction

 Following massive PPH
Following massive PPH

29. Congenital adrenal hyperplasia
Congenital adrenal hyperplasia
(CAH)
(CAH)

 XX but look male( female pseudo
XX but look male( female pseudo
hermaphrodism
hermaphrodism)
)

 Enzyme defect in aldosterone synthesis
Enzyme defect in aldosterone synthesis→
→ ↑
↑
androgens
androgens

 21 hydroxalase deficiency commonest
21 hydroxalase deficiency commonest

 Ambiguous genitalia.
Ambiguous genitalia.

 ↑
↑ 17 hydroxyprogesterone
17 hydroxyprogesterone

30. Physiology of Sperm Production
Physiology of Sperm Production

 Spermatogenesis
Spermatogenesis
complete 70 days.
complete 70 days.

31. WHO criteria for normal semen
WHO criteria for normal semen
analysis
analysis
Volume
Volume >2
>2 mls
mls
Sperm Count
Sperm Count >20 million/ml
>20 million/ml
Progressive motility
Progressive motility >50%
>50%
Morphology
Morphology
Alive
Alive
>40% normal
>40% normal
>50%
>50%

32. Causes
Causes
Abnormal semen analysis
Abnormal semen analysis

 Unknown.
Unknown.

 Smoking/C2H5OH/Drugs.
Smoking/C2H5OH/Drugs.

 Varicocoele
Varicocoele.
.

 Antisperm
Antisperm antibodies.
antibodies.

 Kleinfelters
Kleinfelters syndrome
syndrome-
- 47XXY.
47XXY.

 CF mutation carrier.
CF mutation carrier.

 Drugs
Drugs eg
eg sulphaslazine
sulphaslazine.
.

33. Disorders of Fertilization
Disorders of Fertilization

 Tubal damage
Tubal damage

 Endometriosis
Endometriosis

 Infection (
Infection ( chlamydia
chlamydia)
)

 Surgery( ectopic pregnancy)
Surgery( ectopic pregnancy)

 Cervical problems
Cervical problems

 Antisperm
Antisperm antibodies
antibodies

 Post coital test
Post coital test

 Sexual problems
Sexual problems

34. Assisted conception techniques
Assisted conception techniques

 Superovulation
Superovulation.
.

 Intrauterine insemination ( IUI).
Intrauterine insemination ( IUI).

 In vitro fertilization (IVF).
In vitro fertilization (IVF).

 Intracytoplasmic
Intracytoplasmic sperm injection (ICSI).
sperm injection (ICSI).

35. Treatment
Treatment

 General
General Ensure correct weight/Folic acid
Ensure correct weight/Folic acid

 Anovulation
Anovulation treat underlying cause
treat underlying cause
PCOS :
PCOS :clomid
clomid,
, metformin
metformin,
, gonadotrophine,ovarian
gonadotrophine,ovarian
diathermy
diathermy.
.

 Male factor
Male factor IUI intrauterine insemination.
IUI intrauterine insemination.
IVF invitro fertilization
IVF invitro fertilization ±
± intracytoplasmic
intracytoplasmic sperm
sperm
injection (ICSI)
injection (ICSI)

 Tubal factor
Tubal factor laparoscopic surgery if mild endometriosis.
laparoscopic surgery if mild endometriosis.
IVF if fails or severe endome
IVF if fails or severe endometriosis.
triosis.

 Unexplained
Unexplained IUI/IVF
IUI/IVF