This document provides an outline on infertility, including definitions, incidence, classifications, factors responsible for fertility, etiology, investigation, and management. It notes that infertility affects 10-15% of couples in developed countries and 25-30% in Nigeria. Causes are classified as male factors (40%), female factors (40%), combined (10%), or unexplained (5-10%). Investigations include semen analysis, ovulation confirmation, and tubal patency tests. Management includes treating any etiological factors, ovulation induction drugs, surgery, and artificial reproductive techniques like IVF and ICSI.

1. INFERTILITY
DR. IBEANU

2. OUTLINE
DEFINITION
INCIDENCE
CLASSIFICATION
FACTORS FOR FERTILITY
ETIOLOGY
INVESTIGATION
MANAGEMENT

3. DEFINITION
 Failure of a couple of reproductive age that live together to
conceive despite:
 Regular (2/3times a week with spaced intervals(alternate days))
 Unprotected coitus
 Peniovaginal intercourse
 Leading to ejaculation
 Absence of contraception
 Time

4. INCIDENCE
 In developed countries, infertility affects about 10% - !5% of married
couples.
 In Nigeria, the incidence varies from 25% – 30%. Despite growing concern
about overpopulation and under nutrition in Africa, It is estimated that
about 30% - 40% of women in sub-Saharan Africa, would complete their
reproductive years without a child.

5. CLASSIFICATION
Primary: Denotes couples who have never conceived
Secondary: Indicates previous pregnancy but failure to conceive
subsequently

6. FACTORS RESPONSIBLE FOR FERTILITY
 Healthy Spermatozoa
 Ovulation
 Spermatozoa should fertilize the oocyte at the ampulla of F.tube
 Embryo should reach the uterine cavity after 3 – 4 days of
fertilization
 Endometrium should be receptive for implantation and corpus
luteum should function adequately

7. ETIOLOGY
 Causes of Infertility includes:
 Male factor (40%)
 Female factor (40%)
 Combined (10%)
 Unexplained factor (5% - 10%)

8. MALE FACTOR
PRE - TESTICULAR
 Endocrine:
 Gonadotropin deficiency
 Thyroid dysfunction
 Hyperprolactinemia
 Psychosexual:
 Erectile dysfunction
 Impotence
 Drugs:
 Antihypertensive
 Antipsychotics
 Genetic:
 47 XXY
 Y chromosome deletions
TESTICULAR
 Immotile cilia (kartagener syndrome)
 Cryptorchidism
 Infection (mumps, orchitis)
 Toxins: drugs, radiation
 Varicocele
 Immunologic
 Sertoli-cell-only syndrome
 Primary testicular failure
 Oligoasthenoteratozoospermia

9. POST - TESTICULAR
 Congenital:
 Absence of Vas deferens (cystic
fibrosis)
 Young's syndrome
 Acquired infections:
 TB
 Gonorrhoea
 Surgical:
 Herniorrhaphy
 Vasectomy
 Others:
 Ejaculatory failure
 Retrograde ejaculation
 Hypospadia
 Bladder neck surgery

10. FEMALE FACTOR
OVARIAN
 Anovulation or oligo-ovulation
 Decreased ovarian reserve
 Luteal phase defect (due to
defective folliculogenesis)
 Luteinised unruptured follicular
syndrome (trapped ovum)
TUBAL & PERITONEAL
FACTORS
 Pelvic infections causing:
 Peritubal adhesions
 Endosalpingeal damage
 Previous tubal surgery or sterilization
 Salpingitis isthmica nodosa
 Tubal endometriosis
 Polyps

11. UTERINE
 Congenital malformation
 Uterine fibroid
 Chronic endometritis
 Endometial damage
CERVICAL
 Chronic cervicitis
 Cervical stenosis
 Immunological factor (antisperm
antibody)
VAGINA
 Congenital (atresia, transverse
vaginal septum, narrow introitus)
 Vaginism

12. COMBINED
 Age (F > 35 years)
 Infrequent sexual intercourse, lack of knowledge of coital technique
& timing of coitus
 Apareunia and dyspareunia
 Anxiety and apprehension
 Use of lubricants which maybe spermicidal
 Immunological factor

13. INVESTIGATION
OBJECTIVES
 To detect the aetiological
factor(s)
 To rectify the abnormality in an
attempt to improve the fertility
 To give assurance with
explanation to the couple if no
abnormality is detected
WHAT TO INVESTIGATE ?
 Semen analysis
 Confirmation of ovulation
 Confirmation of tubal patency

14. MALE
PROPER HISTORY
 Age
 Prev. marriage
 STI
 Prev. surgery
 Occupational hx (exposure to
excessive heat or radiation)
 Sex hx (frequency, erection,
penetration, orgasm, satisfaction)
 Social habits etc
PHYSICAL EXAMINATION
 Inspection and palpation of the
genitalia.
 Size and consistency of testicles
 Testicular volume (measured by
an orchidometer) should be at
least 20 cm3

15. SEMINAL FLUID ANALYSIS
Volume 2 – 5ml
Count > 20 million
Morphology > 30%
Motility > 50%
pH 7.5 - 8
Viability > 75% living
TRANSRECTAL US
 Indications include:
 Azoospermia or severe
oligospermia with normal
testicular volume
 Abnormal DRE
 Ejaculatory duct abnormality
 Genital abnormality
(hypospadias)

16.  OTHERS:
 Testicular biopsy
 Vasogram
 Blood and urine tests
 Hormone profile; serum FSH, LH, testosterone, prolactin & TSH
 Karyotype analysis
 Immunological tests

17. FEMALE
PROPER HISTORY
 General medical history
 Surgical history
 Menstrual history
 Previous Obstetric history
 Contraceptive practice
 Sexual problems
EXAMINATIONS
 General examination
 Systemic examination
 Gynecological examination
 Speculum examination
 Vaginal examination

18.  Basal body temperature
 Abdomino-pelvic US
 Hysterosalpingography (HSG)
 Hormone profile
 Laparoscopy and chromopertubation (NB: precisely diagnose
peritubal adhesions, pelvic endometriosis. Chromopertubation with
methylene blue reveals patency and nature of tubal motility)
 Immunological test
 Post-coital test

19.  Hormone profile:
 S. Progesterone: done 21th day mid cycle. > 25 ng/ml suggests ovulation
 S. LH: Daily estimation of serum LH at midcycle can detect LH surge.
Ovulation occurs about 34-36 hours after beginning of the LH surge. It
coincides about 10 -12 hours after LH peak.
 S. oestradiol: attains the peak rise approximately 24 hours prior to LH surge
and about 24 – 36 hours prior to ovulation

20. MANAGEMENT
 Assurance
 Control risk factors:
 Body weight
 Smoking and alcohol
 Psychosocial
Treat etiological factor

21. SURGICAL: Vaso-vasostomy, varicocelectomy
CONSERVATIVE:
Ovulation induction; clomiphene citrate, Letrozole, hMG (Humegon,
Pergonal)
Antiprolactin agent; bromocriptine
Antibiotics
Steriods

22.  ARTIFICIAL REPRODUCTIVE TECHNIQUE:
 Artificial Insemination
 In vitro fertilization and embryo transfer
 Intracytoplasmic sperm injection

23. THANK YOU
FOR YOUR ATTENTION