Definition

sterility : it is means women’s inability to become pregnant. due to known condition, such as congenital anomalies. It could be absolute or relative

a. absolute :Pregnancy is absolutely impossible because of the lack of a

fundamental part of the genital tract as uterus or fallopian tubes

b. Relatives:Women fail to conceive in the presence of all essential physical

requirements. Due to organic disease or physiological disorder

As 1.hypospadias

2.Epispadias

3. Retrogrades ejaculation

Diagnostic procedures

Male : semen analysis is the most important diagnostic procedure for male and should be done before any further investigation on the couple.

- Average value are assessed on three samples produce over several week as quality is variable

- as a rule there should be 2-3 days abstinence before production of specimens . Then the specimen should be examined in the laboratory within one hour

The normal value of the seminal fluid :

1. volume :2-6 ml

2. PH: 7.2-7.8

3. Sperm count > 20 million sperm \ml

4. Morphology 60% normal

5. Motility 70% progressive motility at ejaculation , 60% are motile after 2 hours

6. liquefaction within 30 mint

7. viscosity moderate thin

**Oligospermia: the low sperm count in seminal fluid , count > 20 million \ ml

** Azoospremia : the absence of the living spermatozoa in the seminal fluid . This may due to defective transport( blocked or missing vasadefentia .

* Agglutination: it should not occur if it occur it indicate

1. Infection

2. Anti sperm antibodies especially if the man has testicular trauma

Definition : is an " inability of couples to become pregnant (regardless of cause) after 1 year of unprotected sexual intercourse (using no birth control methods)", and \or

inability of women to maintain pregnancy to term.

Types of infertility

:There are four types of infertility

1. Primary infertility: The couples have been no previous conceptions

2. Secondary infertility: the couples have been previous pregnancy, but the couples unable to conceive at present.

3. Sub fertility: Is lessened ability to conceive, affected by many factors such as: age, smoking and occupation.

*The infertile couple:

a couple is said to be infertile if :

1. pregnancy without result after one year of normal marital without contraceptives

2. women conceive but aborts repeatedly

3. women bear one or two children , then aborted repeatedly or fail to conceive there after

Requirement of normal pregnancy and delivery of a viable fetus

1. Normal health reproductive organs

2. Discharge of a healthy ovum from the ovary

3. The ovum find its way into fallopian within a few hours

4. Insemination occurs and the spermatozoa migrate to the tubes

5. Fertilization of ovum in ampulla's

6. Fertilized ovum implanted and develops in a favorable site in the endometrial

7. Maturation proceeds normally until delivery

Etiology of female infertility

A- Infertility due to (ovulation) problems: an ovulation

Due to:

1. significant weight gain; will lead to increase estrogen secretion and hormonal imbalance which will leads to polycystic ovary syndrome, endometrial hyperplasia, uterine leiomyomas and endometrial cancer

2- Extreme weight loss: will result in amenorrhea or an ovulation

3- Premature menopause

4- Polycystic ovarian syndrome: women do not ovulate regularly and have ovaries that contain multiple small cystic structures

5. Prolonged use of oral contraceptive pills

6. endocrine disorder or dysfunction of (hypothalamus, pituitary, thyroid, adrenal)

7- Systematic diseases like (renal failure, diabetes, sever anemia).

8-ovarian disorders (hormonal, tumor, endometriosis).

9-Eating disorder.

Treatment

Clomiphene citrate tablets to induce ovulation, it blocks the estrogen receptors in the pituitary gland .

B-Tubal factor infertility: It caused by

1- Completely blocked fallopian tubes.

2- No tubal blockage but tubal scarring or other tubal damage.

3.Pelvic infection, such as pelvic inflammatory disease (PID) that caused by gonorrhea or Chlamydia raised from the cervix up to the uterus and tubes.

4- Endometriosis

Testing for tubal infertility:

@Hysterosalpingogram: This is an x-ray examination in which contrast material (dye) is injected through the cervix to the uterine cavity.

-If the fallopian tubes are open the dye flows into the tubes and then spills out to the abdominal cavity.

Treatment of tubal factor infertility

The treatment for tubal factor infertility is usually either tubal surgery to repair some of the damage or in vitro fertilization (IVF).

C- Uterine problems causing infertility:

1 -Uterine Fibroids (leiomyoma).2 -Intrauterine adhesions - scar tissue within the

uterine cavity. This can interfere with conception, or can increase the risk of a miscarriage.

3. Congenital uterine malformations 4. Uterine Polyps. 5. Thin endometrial lining - this is uncommon

Investigated by (Hysteroscopy)

Treatment: According to the cause.

Other factors:

Age: infertility increase with age because it affects on the quality, numbers, shape and regularity of the eggs. *Smoking*Occupation

A "good"

egg from a 32 year

old woman

low quality, oocyte from a woman over 40Egg is irregularly shaped and dark

@@Investigation for infertility females:• Personal &family history with a thorough

physical examination.• Pelvic exam.• Clomiphene citrate challenge test (CCCT).• Tests to predicate ovulation predictions.• Blood test that measure various hormone.• Hysterosalpinogram(HSG) for tube potency • Hysteroscopy • Post coital test• Endometrial biopsy.• 10-Laparoscopy or culdoscopy.

Tests done to predicate ovulation:

1-Basal body temperature (BBT):

body temperature is drops before ovulation, then raised just after ovulation & remain elevated for at least 3 days.

2. Cervical mucous : it is become thinner , clear, copious and watery at the time of ovulation. it also show

Frenning pattern when dried on a slide

3. Ovulation prediction kit :most accurate methods. The test detects an increased

level of luteinizing hormone (LH) present in an early morning urine sample 1 to 2 days before ovulation.

4. Ultrasound scanning (USS): to detect a ripening graafian follicle and thickening of the endometrial

5.Hormonal assays: Blood tests that measure the levels of various hormones, such as luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), estradiol, and progesterone, aid greatly in determining the cause of infertility

Treatment of female infertility:

1. Correction of coital Difficulties2. Improve vaginal and\or cervical secretion through: a. treatment of infected cervical erosion b. improve deficient or viscous cervical secretion by

administration of estrogen in the first 10 days of cycle

3. Correction of cervical sperm hostility:In some cases a large number of sperms are seen

dead in post-coital test within 6 hrs from intercourse, inspite of that cervical secretion is normal and the number of sperm are adequate . In this cases maybe antibody against the sperm .

Treatment is to advise the couple to used a condom .for 3-6 months as antibodies will gradually disappear

4. Correction of any lesion in the uterine body a. remove of uterine polyps b. myomectomy for fibroids c. correction of R.V.F 5. Correction of the lesion of the tube a. salbingotomy :open abdominal end b. salbingolysis: clear peritubal adhesion c. tubal implantation: when the isthmus is blocked

the tube is cut and implanted into the uterus rarely performed now because the results are very

poor

6. Stimulation of ovulation:

Before start the treatment you must do hormonal assay to assess the prolactine, estrogen, FSH,LH, and progesterone

A. If prolactine level is high this will lead to decrease level of estrogen , and progesterone and prevent ovulation. After exclusion of pituitary tumor, high level prolactine is treated by parlodel

B. If an ovulation occurring due to FSH, and LH she is treated by clomid as the following

1. 59 mg\day start from the 3rd day of menstrual cycle

2. treatment is given for 3 month . Ovulation should occur around day 12-16 and intercourse advice each other day from 10-18 day

• If failed increase the dose up to 120mg \day for another 3 month , but at this time clomid is combined with human chorionic gonadotropin (HCG)2000IU.IM\ daily from 10-18 in cycle

• If failed stop clomid , and given menopausal gonadotropin (HMG) pergonal 1 ampoule( 75 IU)\ day from day one in the cycle until mature follicle is detected on the USS. Then given HCG

Artificial Reproductive Technology

Clinical and laboratory techniques that Clinical and laboratory techniques that are used to enhance fertilityare used to enhance fertility

1. Artificial insemination

Indications:Indications:

1. Oligospermia

2.2. Cervical factor infertility: poor mucus, hostile Cervical factor infertility: poor mucus, hostile secretions or immunological. secretions or immunological.

3.3. Mechanical problem Mechanical problem

4.4. Unexplained infertility Unexplained infertility

Technique:

1- Stimulated cycles

2. semen sample will be processed by the lab in order to separate the sperm from the seminal fluid. A catheter is used to inject of 0.3 - 0.5c.c the processed sperm directly into the uterus. The IUI procedure is short and involves minimal discomfort

2.In vitro fertilization & Embryo transfer ( IVF & ET ):

Indications:

1. Tubal factor

2. Oligospermia

3.3. Cervical factor infertilityCervical factor infertility

4. Endometriosis (failed medical & surgical treatment).

Stages of IVF & ET:Pretreatment screening and proper Pretreatment screening and proper

counseling of the couple about results counseling of the couple about results before doing it.before doing it.

1.1. Induction of ovulation & ovum monitoring Induction of ovulation & ovum monitoring by USS. by USS.

2.2. Recovery of oocytes “ oocyte Retrieval ” Recovery of oocytes “ oocyte Retrieval ” by laparoscopy or sonographic guidance by laparoscopy or sonographic guidance when 4 Follicles reach 20mm in size then when 4 Follicles reach 20mm in size then incubation at 37cincubation at 37c for 4-6 hours for 4-6 hours

33 - -IVF processed semen is added to IVF processed semen is added to oocytes till fertilization occurs oocytes till fertilization occurs left for left for 36 - 48 hours (2-4 cell stage)36 - 48 hours (2-4 cell stage)

4. Embryo transfer: 3-4 embryos at 2-4 cell stage (through embryo transfer catheter) near the funds.

5-Monitoring

Ovum retrieval under U/S guidance

3. Gamete Intra fallopian transfer (GIFT)

Ova are picked up as before ,aspirated into a catheter with fresh sperm. Then placed in the distal end of the fallopian tube. Fertilization should then occur in the tube

4. Zygote intra fallopian transfer (ZIFT)

Ova are fertilized outside the body and early stage embryo is the introduced into fallopian tube

Nursing role 1. Encourage feminine and menstrual hygiene to avoid

infection that may lead to infertility 2. Advice women to seek prompt medical care whenever is

infection3. Explain the problem of infertility with emphasis on effects of

stress and psychological factors4. Teach newly married women about physiological of

conception5. Encourage infertile couple to seek proper medical care

6. assist in each of the diagnostic test accordingly

7. explain the exact causes of infertility after diagnosis

8. encourage women to stick to treatment and never lose a hope

9. advice regular check up with treatment

10. prepare the women to accept treatment failure and to go on and never stop

11. listen to women concerns

Causes of Male Infertility:

1-Unknown causes:40% of men with male infertility, the cause their problem is unknown.

2- Hormonal causes of infertility: it is a relatively rare, &cause defective spermatogenesis.

As a result of the dysfunction in the following:

*Hypothalamus

*Pituitary

*Thyroid

*Adrenal

3-Sperm Production ProblemsDisruption of the production of sperm within the testis. This is the common cause

4. Failure of the testes to descend into the scrotum (cryptorchidism).

5- Genetic causes of infertility (Klinefelter Syndrome, Down Syndrome).

6. Infections and sperm production (orchid's). Mumps orchids is the most well known infection of the testis and is caused by an infection with the mumps virus.

7. Heat and testicular function:

The testes are located in the scrotum where the temperature is approximately 1 to 1.5 degrees C below the rest of the body's temperature.

8-varicocele

9- Torsion of the testis

10- Drugs and other substances causing infertility

11.Blockage of sperm transport:Any obstruction of the tubes will lead to keep the sperms away from the testis. The second most common cause affecting about 30 in 100 patients.It is usually due to:*infection * Congenital absence of the vas deferens * Obstructions in region of prostate*trauma

12-Erection and ejaculation problems. caused by: 1.Damage to nerves

2.Spinal cord injury, diabetes or surgery may cause damage to nerves3.obesity4.Psychological problem and stress.

Other factors:

Smoking, occupation, alcohol

@@ NOTE:**spermatozoa survive longest in the alkaline cervical

secretion, & they strode if remain in the acidic cervical secretion.

** They travel by their tail at about 1 cm/hr. proper direction obtain by their tendency to swim (against fluid current, towered the alkaline glycogenic medium of the upper genital tract.

Treatment of the husband:

Medical:

Good diet , vitamins and attention to causative habits as smoking, alcohol and drug addiction

General tonic.

Treatment of diabetes.

Treatment of specific & non specific infection.

Hormonal agents as testosterone to improve spermatogenesis.

Cortisone in cases with circulating antisperm antibodies.

Retrograde ejaculation: ephedrine

Surgical : Varicocelectomy ( by ligation of the testicular

veins)

Vasovasotomy.

Epididymovasotomy.

Prevention of infertility: some but not all of infertility causes are preventable as:

- general advices female marriage and child bearing should be planned earlier rather than in the latter fertile years. An advice to complete family before 35 years female age.

I- Prevention and control of genital infection:1- Sexually transmitted diseases especially gonorrhea,

chlamydia and mycoplasma. 2- Control of non venereal disease as T.B. 3- Immunization of children against Mumps.4- Prevention & treatment of puerperal & postabortive

infections 5- Treatment of appendicitis which lead to pelvic

adhesions.

Avoidance of unnecessary pelvic operations: as

- Repeated cervical cauterization.

- Repeated D & C.

- Laparatomy

Follow the precautions that minimize adhesions during pelvic and abdominal operations .

- Early treatment of diseases that may affect fertility: as

1- Thyroid disorders.

2- Treatment of severe nutritional disorders & obesity.

- Prevention of Male infertility: avoid

- The use of alcohol, Marijuana & heavy metals.

- Radiation to the genital organs which can cause genetic mutations.

- Heat which spermatogenesis.