Infertility

Chapter10

Definition• Strictly defined as the inability to

conceive after one year of unprotected regular sexual intercourse

• More workable definition: is any involuntary inability to conceive at the time desired

• The definition expanded to include couples who conceive but repeatedly lose a pregnancy before the fetus is old enough to survive

Definitions

• Primary infertility• Couples have never conceived

• Secondary infertility• Couple may have conceived before

but are unable to conceive again

Factors contributing to Infertility

• Factors in man• 1. Abnormalities of the sperm;• Twenty million sperm /milliliter of

semen is considered minimum number adequate for fertilization

• Abnormal structure or motility may reduce motility regardless of number

• Some sperm look normal but unable to penetrate ovum

Factors impair function and # of sperm include

• Abnormal hormonal stimulation of sperm production

• Acute or chronic illness such as mumps,RF• Infection of genital tract• Anatomic abnormalities e.g. Varicocele or

obstruction of ducts that carry sperm to penis

• Exposure to toxins(lead,pesicides)

• Therapeutic treatment (radiation ,antineoplastic)

• Excessive alcohol intake• Use of illicit drug such as cocaine• Elevated scrotal temperature that may

result for example from febrile illness, sauna , hot tub or prolonged sitting

• Immunologic Factors by man or woman against sperm (autoantibodies)

2 .Abnormal Erections

• Reduce man ability to deposit sperm,bearing seminal fluid in woman’s upper vagina near her cervix

• Can be caused by physical and psychologic factors for example: CNS dysfunction caused by drugs, psychiatric disturbance or chronic illness.spinal cord disorders, peripheral vascular disease and drugs such as antihypertensive also reduce erections

3 .Abnormal Ejaculation• Prevent deposition of sperm in the

ideal place to achieve pregnancy

• Retrograde ejaculation such as with DM or nuerologic disorders Anatomic abnormalities such as hypospadias, Excessive alcohol

• Premature ejaculation related to psychologic disorders (Anxiety)

4 .Abnormalities of Seminal Fluids

• Seminal fluid that is abnormal in amount,consistency or chemical composition suggest obstruction,inflammation or infection

• The PH of seminal fluids is slightly alkaline to protect sperm from acidic secretion of vagina

• Adequate frouctose,citric acid and other nutrients must be present to provide energy for the sperm to move

• Seminal fluid that remain thick impede sperm motility into cervix

Factors in the woman

• 1. Disorders of ovulation• Ovulation can be disrupted by 1. Dysfunction of hypothalamus or pituitary

gland that alter secretion of GNRH,FSH,LH 2. Failure of ovaries to respond to FSH and

LH stimulation • These two factors can be caused by many

factors such as cranial tumors ,stress , obesity..etc

• A few woman has a premature ovarian failure (early menopause)

• Polycystic ovary Syndrome also affect fertility

• Other factors include: Cancer chemptherapeutic agents, Excessive alcohol intake and cigarette smoking

2.Abnormalities of fallopian tube1. Tubal obstruction: scarring,adhesions,

result from infection such as STD

2. Endometriosis

3. Congenital anomalies of the tube

4. Poor movement (motility of the distal end of the tube prevent ovum pickup and abnormal cilia actions prevent ovum transport)

3 .Abnormalities of Cervix• Low estrogen level prevent

development of appropriate cervical mucus

• Polyps or scaring from previous surgery may obstruct cervix

• Surgical destruction of the mucus secreting gland and infection

Repeated pregnancy loss

• 1. Abnormalities of fetal chromosome• 2. abnormalities of cervix or uterus may

include -Congenital malformation and stenosis -Prenatelly exposure to DES

(Diethylstilbestrol is a synthetic nonsteroidal estrogen): lead to uterine malformation or incopmetent cervix)

-

Cervical or uterine abnormalities occurs after surgery

-Uterine myomas or fibroid (may lead preterm birth)

• 3. Endocrine abnormalities -inadequate progesterone secretion by

corpus luteum -hypothyroidism and hyperthyroidism -poorly controlled diabetes• 4. Immunologic factors -rejection embryo -SLE (Systemic lupus

erythematosus)related to thrombosis

• 5. Environmental agent

-DES

-Ionizing radiation,alcohol

-suspected toxins such as smoking ,mercury, lead, anesthetic gas, pesticides…..etc

• 6. Infections

Evaluation of Infertility

• Preconception Counseling• Couples may be offered a

preconception counseling to help them evaluate their risk of birth defects and reduce their risk of bearing child with serious birth defect

• History and Physical Examination• General health history and extensive

reproductive history which includes

Reproductive History

• Woman's age at menarche and menstrual characteristics

• Pattern of intercourse in relation to woman’s menstrual cycle

• Contraceptive history• Previous pregnancies and their

outcomes• Previous surgeries ,infection and serious

illness or injuries• Previous fertility of the man or the

woman with other partner

Continued R. history

• Length of time the couples has had unprotected intercourse

• Exposure to potential toxins • Family history of multiple pregnancy

losses ,birth defects ,mental retardation• Any home tests the couples has

used ,such as ovulation predictor kits or BBT

Physical Examinations

• Thorough physical examination of each partner may identify problems such as endocrine disorders ,infection or other chronic disease

• Specific examination of reproductive organs may reveal structural defects ,infection ,or other conditions

• Chromosomal analysis may be done for couple experiencing repeated pregnancy loss

Diagnostic Tests• Tests generally proceeds from simple to

complex, and test is individualized according to each couple condition

• Example of some tests done:• 1.Basal body temperature 2.Hormone

evaluation(estrogene,progestrone,LH,Fsh, and thyroid functions)

• 3.US, Hystrosalpingograghy,endometrial biobsy,semen analysis,testicular biopsy

• See box 10-3 page 206 for diagnostic tests

hysteroscopy

hysterosalpingogram

Therapies to Facilitate Pregnancy

• Many Factors must be considered when identify therapy for treatment include couple’s history ,medical conditions, financial resources, age and time constrains,a and religious and cultural values

• 1. Medications• May be used for example to improve semen

quality, reduce endometriosis, induce ovulation…..etc

• See box 10-5 page 208 for types of medications

2. Ovulation induction• Used for woman who does not ovulate or who

ovulate erratically• Also given to provide multiple ova if a woman

plans to have intrauterine insemination,IVF,GIFT…

• Clomide (Clomiphene citrate) is drug often used to stimulate follicles development

• Complications• -Increase risk of multiple births (triplets or

more)• -Ovarian hyperstimulating Syndrome

syndrome(marked ovarian enlargement)

3. Surgical procedures

• Endoscopic procedures may be used to correct obstructions

• Laparotomy may be needed to relieve pelvic adhesions and obstructions if not corrected by laparoscopy

• Laser surgical techniques may be used to reduce adhesions

• Correction of Varicocele by ligating or embolizing dilated vein, may improve sperm quality and quantity

• Other measures may also used

5 .Therapeutic Insemination

• Intrauterine inseminations(IUI) ,allows sperm to bypass cervical mucus and reduce immunologic incompatibility by injecting prepared sperm directly into uterus

• Surrogate parenting and Egg donation( religiously not acceptable in our countries)

5 .Advanced Reproductive Techniques

• 1. Invitro Fertilization(IVF)

• 2. GIFT: Gamete Intrafallopian Tube Transfer

• 3. Zygote Intrafallopian tube transfer