Infertility, Male and Female Approach and Management

1. Infertility
Dr Wafa Allauddin Sheikh
Consultant Family Medicine
Trainer at Post Graduate Academy
Al Madinah Al Munawarah
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2. learning out come
Definition
Primary and secondary infertility
How to approach to male and female infertility based on Real case scenario
History , Examination and Management
Role of family physician
Summery and conclusion
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3. The WHO has defined male and female infertility
“A disease of the reproductive system defined by
the failure to achieve a clinical pregnancy after 12
months or more of regular unprotected sexual
intercourse.” (ICD 11).
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4. Primary Infertility World Health Organization (WHO), when a
woman has never conceived .
Secondary Infertility is the incapability to conceive in a couple
who have had at least one successful conception in the past .
(after trying unsuccessfully to conceive for six months to a year.)
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5. 5
2010
Primary infertility
2%of women
around the
world(NHS)
)
50 million couples worldwide experience infertility
.
Primary Infertility World Health Organization
(WHO), when a woman has never conceived .

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2010
Approximately
secondary
infertility10.5% of
women around the
world(NHS)
)
Secondary Infertility is the incapability to conceive in a couple
who have had at least one successful conception in the past .

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8. The current fertility rate for Saudi Arabia in 2021 is 2.241 births per woman, a
1.45% decline from 2020. The fertility rate for Saudi Arabia in 2020 was 2.274
births per woman, a 1.43% decline from 2019.
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11. Because 85% of couples conceive spontaneously within 12 months if
having intercourse regularly, it is important to identify those who will
benefit from infertility evaluation .(American Academy Family Physician)
In the absence of exigent history or physical findings, evaluation may be
initiated at 12 months in women ≤35 years of age
and at 6 months in women aged ≥35 years.
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12. In women >40 years of age, more immediate evaluation and
treatment may be warranted .
• Oligomenorrhea or amenorrhea
• Known or suspected uterine, tubal, or peritoneal disease
• Stage III or stage IV endometriosis and
• Known or suspected male infertility
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13. Male Infertility
• Male infertility can also be classified based upon the medical interventions that
can potentially assist conception.
• Untreatable male sterility is seen in 12% - primary seminiferous tubular failure,
Sertoli cell-only syndrome, bilateral orchiectomy.
• Treatable causes of male infertility are found in 18% - obstructive azoospermia,
ejaculatory duct, and prostatic midline cysts, gonadotropin deficiency, sexual
function disorders, sperm autoimmunity, varicoceles, and reversible toxin effects.
• Untreatable male infertility is found in 70% - oligozoospermia,
asthenozoospermia, teratozoospermia, and normospermia with functional
defects. Assisted reproductive techniques will be necessary for reproduction.
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14. Clinical case ….
38 years old Ali came with severe stress and
anxiety to the FM Clinic when you ask about his
bio data and social life he immediately burst out
and said he is not happy ?
How to take a good detailed history ?
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18. Comprehensive history male Infertility
• The evaluation starts with a complete and comprehensive sexual and medical history,
including reproductive history, family history,
• Significant trauma to the pelvis, testicles or head,
• Sexual history Ejaculatory dysfunction , sexual dysfunction
• Occupation (Heat exposure and radiation )
• Intake of alcohol, smoking, recreational drugs, medications, steroid abuse, previous
chemo/radiotherapy,
• Pubertal development, testicular descent, surgical history involving the scrotum and
inguinal regions, exposure to toxic chemicals such as pesticides, loss of body hair,
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19. Comprehensive history of Male Infertility
• Prior biological children produced, maternal exposure to DES, anosmia (associated with
Kallman syndrome), breast enlargement and galactorrhea, precocious puberty (at 9
years of age or earlier), etc. An undescended testicle, whether unilateral or bilateral
• Sickle cell disease can , Chronic renal failure has been associated with hypogonadism,
while liver failure sometimes causes gynecomastia (from increased estrogen levels),
testicular atrophy, and reduced secondary sex characteristics.
• Tuberculosis, prostatitis, epididymitis, and STIs (especially gonorrhea) can cause vasal
scarring and obstructive azoospermia, while mycoplasma infections tend to reduce
sperm motility.
• The use of sexual lubricants that are toxic to sperm (such as water-based, water-soluble
personal lubricant, saliva, and others) should be eliminated.
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20. Ali’s Case history …..
Ali age is 36 engineer , stressful job ,Married 10 years have 2 children last child 5 years old
Sexual history : Coital once in a week , loss of libido
Childhood history Normal no infection or trauma
No history of any chronic illness in childhood or adult
No family history of any chronic or autoimmune disease
No history of any surgical procedure
No drug history
History of smoking 1-2 packet /day No history of alcohol or drug abuse (cocaine , hashis)
Increase intake of tea and coffee
Life style : Fast food and no exercise
Social financial issues no good performance might loss his job
Psychological history : Mood sad and depressed and anxious and on the top No children
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21. Physical Examination of Male Infertility
General physical examination BMI
Thyroid exam ( swelling , bruit)
Signs of Hypogonadism in childhood causes delayed puberty, while in adults, it causes
decreased libido, erectile dysfunction, decreased body hair, infertility, and loss of secondary
sexual characteristics.
Examination of the penis for hypospadias, phimosis, and Peyronie plaques.
Testicular size (4cm) and volume ,Any clinical abnormalities of the testicles should be
identified, such as epididymal lesions, spermatoceles, and large varicoceles.
Bilateral absence of the vas deferens on physical examination (CFTR gene mutations)
Sign of Cushing disease the presence of a buffalo hump along with a round (moon) face, thin
skin with multiple bruises and stretch marks while patchy, diffuse hyperpigmentation might
suggest iron overload syndrome.
Psychosocial assessment
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22. Physical Examination of Male Infertility Ali case continue…..
Ali had good attitude and behavior but nervous and anxious
BP 110/70 mmhg
Weight and Height BMI 26
Thyroid exam ( swelling , bruit) Normal Abdominal exam Normal
Signs of Hypogonadism No signs
Examination of the penis Normal
Testicular size (4cm) Normal
No Bilateral absence of the vas deferens (CFTR gene mutations)
No Sign of Cushing disease & iron overload syndrome.
MMSE Anxious and nervous (stress level assessment and psychological assessment should be
done )
GAD score 13 moderate severe anxiety
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23. Male Infertility Investigation
Single most important investigation
Semen analysis – this assesses the sperm count, motility,
morphology, vitality, concentration and volume.
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24. Male Infertility Investigation
Chlamydia screen
Hormone analysis – testosterone, FSH, LH and prolactin
Ultrasound – to investigate any potential structural abnormality
Viral screen – HIV, Hepatitis B and Hepatitis C screening should be offered to those
undergoing IVF treatment.
Testicular biopsy – to both define any histological diagnosis and potentially extract any
sperm
Genetic testing …..
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25. Case management (Evidence based)
Ali with sharing understanding agree with the plan of management to bring her
wife in the next visit
Non pharmacological :
Healthy life style diet and exercise
CBT and stress relaxation therapy for anxiety in stress and if not Improving may
be advice for SSRI (Citalopram)
Refer to the smoking cessation clinic
Advice to decrease the intake of tea and coffee
And finally Ali refer for semen analysis
Follow up after one month .
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27. Case follow up …..
After month Ali came happy he admit as he promise he brought her
wife Sara
He start healthy life style and following with dietitian and Smoking
cessation clinic his mood is improved but still having anxiety so
Our plan to continue the CBT
Today he brought the result of his semen analysis he was nervous and
anxious .
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28. Semen analysis report of Ali
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29. Semen analysis report of Ali
• Sperm concentration: 15 million per mL (12 – 16) [Usual normal value is > 20 million per
mL.] If low, check for varicocele and consider a hormonal analysis.
• Total sperm count: 39 million per ejaculate (33 – 46 million)
• Sperm Morphology (normal) forms: > 4% [Usual normal value > 30%]
• Motility: 40% (38 – 42%) [Usual normal value is 60%](If low, check for varicocele and
consider antisperm antibodies test.)
• Vitality: 58% live (55 – 63%) If low, check for varicocele and consider antisperm
antibodies test.
• Progressive motility: 32% (31 – 34%)
• Total motility: > 40% (Usual normal value is > 60) If low, check for varicocele and
consider antisperm antibodies test.
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30. Potential abnormalities on semen analysis include:
Oligospermia – < 15 million sperm per ml
Teratospermia – < 4% normal morphology
Asthenospermia – < 32% sperm motility
Azoospermia – no sperm found within the ejaculate1,3
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31. Prognosis……….
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• When left untreated, some infertile couples still manage to produce a
pregnancy.
• Studies have shown that 23% of untreated infertile couples conceive
after 2 years which goes up to 33% after 4 years.
• Even in men with severe oligozoospermia (<2 million sperm/mL),
7.6% of these untreated male infertility patients are able to produce a
pregnancy within two years.[81]

32. Algorithm for the approach
to the Male Infertility
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Checklist for the approach
to the Male Infertility

34. In Conclusion Male Infertility
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35. As the Ali promise he will do investigation and keep continue follow-up and bring her wife Sara . How do you proceed with Sara ?
How do you proceed to get further from Sara ?
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36. Sara describe her story that ……..
Sara 30 years old married 10 years , house wife ,
2 children last delivery 5 years ago , all NSVD , no history of abortion ,
her frequency of intercourse has decrease, her menstrual cycle is irregular since 1 year . No
history of OCP and she did not any hormonal therapy to conceive , last menstruation was 1
and half month ago her pregnancy test is negative .
She is conscious about her weight which is increasing gradually from the last year 10 kg
weight ,
she has acne , and few hair on her face .
She is stressed all the time due to her family and friends always commenting and criticizing
her infertility so for this reason she likes to stay alone at the same time having so much
conflict with his husband ? Planning for second maaraige and blaming him for all issue to him .
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39. History female infertility ……
A comprehensive medical history, relevant to the potential etiologies of
infertility, should be obtained from the patient and partner :
Duration of infertility and results of any previous evaluation and
treatment
Menstrual history (including age at menarche, cycle interval, length, and
characteristics; presence of molimina ,signs of ovulation including
positive ovulation tests, cervical mucus changes, or biphasic basal body
temperatures
Pregnancy history (gravidity, parity, time to pregnancy, fertility
treatments, pregnancy outcome, delivery route, and associated
complications).
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40. History female infertility continue ……
•Previous methods of contraception
•Sexual history : Coital frequency and timing , Sexual dysfunction
•Gynecologic history (eg, PID, STI, endometriosis, leiomyomas)
•History of chronic illness :Review of organ systems, including history of
thyroid disease, galactorrhea, hirsutism, pelvic or abdominal pain, and
dyspareunia .
•Previous abnormal cervical cancer screening tests and any subsequent
treatment
•Surgical history :Past surgery focused on abdominal and pelvic procedures
•Previous hospitalizations, serious illnesses, or injuries.
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41. History female infertility continue ……
• Drug history : Current medications and supplements, with an
emphasis on identifying allergies and potential teratogens
nicotine products, alcohol, and recreational or illicit drugs
• Family history of birth defects, developmental delay, early
menopause, or reproductive problems .
• Occupation history : and exposure to known environmental
hazards and toxins .
• Psychological history : Depression , Anxiety , Stress
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42. Important points need to be focus in history (Female Infertility)
Amenorrhea or oligomenorrhea; low body mass index (Hypothalamic amenorrhea)
Amenorrhea or oligomenorrhea; menopausal symptoms; family history of early menopause; single
ovary; chemotherapy or radiation therapy; previous ovarian surgery; history of autoimmune disease
(Ovarian failure/insufficiency)
Irregular menses; hirsutism; obesity (polycystic ovary syndrome); galactorrhea (hyperprolactinemia); fatigue;
hair loss (hypothyroidism) (Ovulatory Disorder)
History of pelvic infections or endometriosis (Tubal Blockage)
Dyspareunia; dysmenorrhea; history of anatomic developmental abnormalities; family history of uterine
fibroids; abnormal palpation and inspection (Uterine abnormalities)
History of abdominal or pelvic surgery; history consistent with endometriosis (Endometriosis or pelvic
adhesions)
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43. Physical Examination of Female infertility
General physical exam : Weight, body mass index, blood pressure,
and pulse .
Thyroid enlargement and presence of any nodules or tenderness
Breast mass, nipple secretions and their character
Signs of androgen excess (acne, hirsutism, obesity, Acanthosis
nigricans) ? POCS
Vaginal or cervical abnormality, lesion/ polyp, or discharge
Pelvic or abdominal tenderness, organ enlargement, or masses
Uterine size, shape, position, and mobility, enlargement(fibroid)
Adnexal masses or tenderness and cul-de-sac masses, tenderness
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44. Physical Examination of Sara for female infertility
Sara General physical exam : BP 110/80 mmgh BMI 34
Thyroid enlargement No swelling & tenderness or nodularity
Breast examination No mass, no nipple secretions
Signs of androgen excess (Sara has acne, hair on face and shoulder
hirsutism, Acanthosis nigricans at neck and ankle )
Vaginal or cervical ,Pelvic or abdominal ,Uterine No adnexal
masses or tenderness (WNL)
What do think about diagnosis ?
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45. Risk factors of PCOS :
Obstructive sleep
Infertility
Metabolic syndrome
Type 2 diabetes mellitus
Heart disease
Mood disorder
Endometrial hyperplasia
American College of Obstetricians and Gynecologists. (2015). Polycystic ovary syndrome. Retrieved May
20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS
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46. Differential Diagnosis of PCOS
Primary ovarian failure
Hyperandrogenism
Thyroid dysfunction
Congenital adrenal hyperplasia
Hyperprolactinemia
Acromegaly
Cushing Syndrome
American College of Obstetricians and Gynecologists. (2015). Polycystic ovary syndrome. Retrieved May
20, 2016, from http://www.acog.org/Patients/FAQs/Polycystic-Ovary-Syndrome-PCOS
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48. Ovulatory function
In most ovulatory cycle women, (99%) normal menstrual cycles are
regular and predictable, generally occur at intervals of 21–35 days,
A serum progesterone measurement should generally be obtained
approximately 1 week before the expected onset of the next menses,
e.g.,(day 21 of a 28-day cycle) to confirm ovulation even if they have
regular menstrual cycles. ).
A progesterone concentration >3 ng/mL provides presumptive and
sufficient evidence of recent ovulation.
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49. Women with prolonged irregular menstrual cycles should be offered
a blood test to measure serum progesterone. need to be conducted
later in the cycle (for example day 28 of a 35-day cycle) and repeated
weekly thereafter until the next menstrual cycle starts. [2004]
Anovulatory women should have further investigation to determine
treatable causes such as thyroid disorders or hyperprolactinemia
based on symptoms.
A high serum FSH level with a low estradiol level can distinguish
ovarian failure from hypothalamic pituitary failure, which typically
reveals a low or normal.
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50. Ovarian factors (ovarian reserve)
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51. Ovarian Reserve (Investigation)
Basal FSH and estradiol should be measured together in the early
follicular phase between menstrual cycle days 2-4 days
• Antimüllerian hormone (AMH) value less than 1 ng/mL
• Antral follicle count less than 5–7 and
• Follicle-stimulating hormone (FSH) greater than 10 IU/L or
• A history of poor response to in vitro fertilization stimulation (fewer than
four oocytes at time of egg retrieval).
Transvaginal ultrasound the follicular phase antral follicle count Less
than 5-7 and ovarian volume .
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52. WHO Classification Ovulatory disorder
WHO categorizes ovulatory disorders into three groups:
Group I is caused by hypothalamic pituitary failure (10%), amenorrhea and
low gonadotropin levels, most commonly from low body weight excessive
exercise.
Group II results from dysfunction of hypothalamic-pituitary-ovarian axis
(85%), polycystic ovary syndrome and hyperprolactinemia.
Group III is caused by ovarian failure (5%). conceive only with oocyte
donation and in vitro fertilization.
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54. Ovulatory Disorder
Ovulatory dysfunction is identified in approximately 15% of all
infertile couples and accounts for up to 40% of infertility in
women
The most common causes of Ovulatory dysfunction include
Polycystic Ovary Syndrome
Obesity, perimenopause,
Weight gain or loss,
Strenuous or excessive exercise,
Thyroid dysfunction
Hyperprolactinemia.
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55. What important investigation should be request
role of family
physician
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56. •
Basic Investigations for PCOS & Infertility
The Royal College of Obstetricians and Gynecologists (RCOG) recommends the following baseline screening tests for women with suspected polycystic ovarian syndrome (PCOS):
Thyroid function tests, serum prolactin levels, and a free androgen index (defined as total testosterone divided by sex hormone binding globulin [SHBG] × 100, to give a calculated free testosterone level).
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57. Hormonal investigation for female Infertility
Screening
Late onset Congenital adrenal hyperplasia
(17 hydroxyprogesterone level low<1000ng/dl)
Cushing syndrome 24-hour urine sample for free
cortisol and creatinine.
Acromegaly( IGF)
Hyperprolactinemia (Prolactin >25 mg/dl)
Basic Test for PCOS
• Androgen (Free testosterone level elevated )
• levels of sex hormone–binding globulin
(SHBG) low with PCOS.
• FSH low (primary ovarian failure)
• LH/FSH 3:1 (PCOS)
• TSH elevated (long standing Primary
hypothyroidism)
• OGTT (140-180)
• Cholesterol >200mg/dl
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58. Investigation of Sara continue…..
Sara came in next visit follow-up with results
HbA1C 6.2
OGTT >150
Lipid profile T. cholesterol and TCG elevated HDL decrease
LH:FSH ratio (18:6)-elevated 3:1
S.17 Hydroxyprogesterone . <3 ng/dl
S.Prolectin mild elevated
Testosterone (free & total ) elevated 4
Thyroid normal
What is your opinion ?
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59. Sara came with Pelvic ultrasound report
Multiple ovarian follicle 12 or more follicles or 25 or more
follicles measuring 2 to 9 mm in diameter or an ovary )
(Rotterdam Diagnostic criteria trade irregular cycle ,
hormonal disbalance and US multiple ovarian follicle )
Diagnosis PCOS and Secondary Infertility
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Polycystic ovary as seen on sonography
Transvaginal ultrasound scan of polycystic ovary

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62. Sara diagnosed with PCOS and Infertility( Management )
Sara was advice to Initial preconception lifestyle advice, which ideally would be given in
primary care:
Encourage regular intercourse – every 2-3 days
Folic acid daily 400 micrograms (take 5mg daily if high risk for neural tube defects e.g.
diabetes, on anti-epileptics etc.)
Assessment of stress level screening of depression and Anxiety ,If need refer to the
Psychologist .(CBT & Stress relaxation therapy )
Metformin 500 mg bid for Pre diabetes sign of insulin resistance and PCOS (ADA 2023)
Stain 10 mg po od (lipid are elevated)
Start with clomiphene 50 mg daily for 5 days on 3-6 cycle .
Follow up after one month
Decrease the risk of infertility ,increases the chance of conception and improving the birth out
come .
erican Society for Reproductive Medicine. (n.d.). Frequently asked questions about infertility.Retrieved May 23, 2016, from https://www.reproductivefacts.org/faqs/frequently-asked-questions-about-inferti
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Teede, H., Deeks, A. & Moran, L. Polycystic ovary syndrome: a complex condition with psychological, reproductive and
metabolic manifestations that impacts on health across the lifespan. BMC Med 8, 41 (2010). https://doi.org/10.1186/1741-
7015-8-41

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65. When to Refer ……..
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