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Sub fertility causes effects definition etc etc
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- 3. Objectives • Introduction tosubfertility • Differentiate between primay and secondary infertility • Causes of subfertility • Role of hormones during menstrual cycle • Graphical interpretation of changes in hormones
- 4. Infertility Failure to conceivewithin one year of unprotected sexual intercourse or within 6 month in women older than 35 years.
- 5. What is subfertility “Subfertilityis defined as the failure to conceive within 1 year of unprotected regular sexual intercourse” May also refers to the state of women who is unable to carry a pregnancy to full term
- 6. Primary and SecondaryInfertility • Primary: Couples who have had no previous conception. • Secondary: Difficulty conceiving after already having conceived (and either carried the pregnancy to term or had a miscarriage)
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- 8. Causes of femalesubfertility • Ovulation disorders • Tubal damage • Age (>37 decr chances of conception) • No previous pregnancy • Malnutrition leading to obesity,anemia,underweight • Endometriosis • PID • Fibroids
- 9. Cont. • Ovulation disordersincludes • Defect in hypothalamus pituitary or ovarian hormones. • Due to stress ,weight changes ,hypothalamic lesions, hyperthyroidism and hypothyroidism • Amenorrhea or oligomenorrhea • Polycystic ovarian disease • Premature ovarian failure(total failure of ovaries in women under the age of 40) due genetic sex chromosomal abnormalities or aquired by toxins pelvic surgeries irradiation or autoimmune cause
- 10. Cont. • Tubal dysfunction •Tubal damadge by pelvic infection • Endometriosis • pelvic surgeries • Pelvic sepsis following appendicitis or peritonitis • STDs • Disorders of implantation • Defect in endometrial development • Submucosal fibroids
- 11. Cont. • Systemic diseases Renalfailue, hepatic dysfunction. • Drugs Phenothiazine, androgens, OCPs. • Resistant Ovarian Syndrome • Uterine factors Multiple sub mucous fibroids, uterine anomalies, intra uterine adhesions.
- 12. Cont. • Cervical factors Hormonal,Infection. • Immunological factors Sperm antibodies in cervical mucus,fallopian tubes and follicular fluid.
- 13. Male Subfertility • Lowsemen quality and quantity • Immotile sperms • Primary ciliary dyskinesia • Azoospermia • Oligospermia
- 14. Cont. • Disorder ofspermatogenesis Chromosomal abnormalities eg. Microdeletion ofychromosome cryptorchidism, orchitis, traumatorsion, scrotal temp, chemical & physical agentsvaricocele, chronic illness. • Impaired sperm transport Congenital malformation of the epididymis or vas deferens,blockage due to infective lesion or surgical trauma eg vasectomy.
- 15. Cont. • Ejaculatory dysfunction Drug-induced,idiopathic, caused by metabolic & systemic diseases eg. diabetes & multiple sclerosis). • Immunological factors Sperm antibodies: Infective factors Coital problems
- 16. WHO Criteria ForSemen Analysis
- 17. Unexplained Infertility • Idiopathicin a sense that its cause remains unknown after an infertility work-ups. • 15-25% of infertile couples. • Usually self-correcting.
- 18. Hormones Involved InMenstrual cycle
- 19. HYPOTHALAMUS ANTERIOR PITUITARY GnRH OVARIES FSH LH FSHcause the ovarian follicles to mature which is surrounded by granula cells Physiology Of Menstrual cycle Role Of Hormones These granulosa cells multiply and secrete estogen that proliferate and thicken the endometrium The LH released by pituitary has surge in the middle of cycle near day 14 and causes ovulation and decline in estrogen As the ovum is released the granulosa cells accumulate lipids and form corpus luteum Critical phase for fertilization
- 20. Graph Of ChangesIn Hormones In Menstual cycle
- 21. This corpus luteuminitiates the SECRETORY PHASE and releases progesterone This progesterone prepares the endometrium for implantation of ovum as endometrial glands become tortuous and stromal cells swells If ovum is fertilized it is implanted in endometrium If ovum is not fertilized corpus luteum degenerates and ceases the hormones which causes spasm of endometrial vessels and basal layers of endometrium dies and shed away in menstrual phase that lasts for 4-5 days Cont.
- 23. History • Specific historyquestions from women? • Details of menarche menstrual cycle menstrual freq. • If irregular ask for symptoms of PCOS , thyroid , hyperprolactaenemia • Specific questions from men? • Fathered any previous pregnancies • any history of mumps, measles, testicular trauma •
- 24. Examination • Males :Assess testicular size ,mass and consistency • Absence of vasdeferens, varicocele , surgical scars • Females: Full general and pelvic examination
- 25. Investigations • Check forhypothalamo pituitary ovarian dysfunction • Tubal patency by hysterosalpingogram, hysterocontrastsonography or operative laparoscopy • HSG and HyCoSy are used as screening test • Semen analysis Testosterone level FSH and LH Levels for diag of hypogonadism Karyotyping for Y chromosomes deletion
- 26. Management • Ovulation Induction(OI)– Clomiphene or FSH • Intrauterine insemination – In unexplained subfertility and endometriosis • Donor insemination – in tubal pathology • IVF Medical
- 27. Surgical Management • Operativelaparoscopy – in endometriosis or ovarian cyst • Myomectomy – hysteroscopy, laparoscopy ,laparotomy in fibroid uterus • Tubal surgery in blocked fallopian tubes • Laparoscopic ovarian drilling in PCOS unresponsive to treatment
- 28. Male Infertility InvestigationAlgorithm 1 Initial Assessment Couple assessment 2 History & PE Reproductive history 3 Semen Analysis Primary screening tool Normal Semen Analysis? Female Investigation Unexplained Infertility Abnormal Semen Analysis? Repeat SA 4 Hormonal Evaluation FSH, Testosterone 5 Specialist Referral Urologist/Andrologist 6 Genetic Testing Karyotype, Y-chromosome 7 Imaging Scrotal ultrasound Presenter: Roll no 586 and 587
- 29. Advanced Male InfertilityTesting Hormonal Evaluation When to consider: Infertile males with impaired libido, erectile dysfunction, oligozoospermia/azoospermia Males with atrophic testes or evidence of hormonal abnormality Key tests: • FSH levels • Testosterone levels • Semen volume, pH, and FSH for azoospermic males Genetic Testing When to consider: Karyotype: Primary infertility with azoospermia or sperm <5 million/mL with elevated FSH Y-chromosome microdeletion: Primary infertility with azoospermia or sperm 1 million/mL ≤ CFTR mutation testing: Males with vasal agenasis or idiopathic obstructive azoospermia Note: Sperm DNA fragmentation not recommended for initial evaluation Specialized Imaging When to consider: Scrotal ultrasound: If varicocele suspected TRUS/Pelvic MRI: If semen analysis suggests ejaculatory duct obstruction Renal ultrasound: For patients with vasal agenasis to evaluate renal abnormalities Clinical pearl: Genetic testing is particularly important when azoospermia is present. Karyotype analysis helps differentiate between chromosomal abnormalities and testicular failure.
- 30. Summary and ClinicalApplications Subfertility Classification Primary: Never conceived despite 12+ months unprotected intercourse Secondary: Unable to conceive again after previous pregnancy Causes of Subfertility Male Factor (30-50%): Sperm production/function issues Female Factor (35-50%): Ovulatory, tubal, or uterine disorders Combined (9%): Both male and female factors Unexplained (25-30%): No identifiable cause Hormonal Control Follicular Phase: FSH, estrogen rise; LH low Ovulation: LH surge triggers egg release Luteal Phase: Progesterone/estrogen rise Male Infertility Investigation Initial: Semen analysis, hormonal evaluation Advanced: Genetic testing, imaging
- 31. Clinical Applications: Clinical Applications: TargetedTreatment: Structured approach enables specific interventions based on identified causes Improved Outcomes: Systematic evaluation increases chances of successful reproduction A systematic approach to subfertility investigation enables targeted treatment strategies and improved reproductive outcomes for infertile couples