INFERTILITY
Dr.K.Saji. MD(Hom)
What I am going to tell you
Infertility in general Male & Female infertility
Theory Lab investigations Management : General & Therapeutic Clinical Cases
Infertility
Definition The inability of a couple to achieve
conception after a year or more of regular, unprotected coital exposure.
Failure to have a baby because of repeated abortion also is a form of infertility.
Duration - Exceptions
Incidence in India
15-20 % 80-85 %
Types
Primary Secondary
Male and Female factors
30%
30%
30%
10%
Male
Female
Both
Un-explained
Male
Female
Both
Conditions that warrant seeing a doctor
Female Frequent menses ( 3 weeks or less ) Amenorrhoea longer than 3 months Irregular menses History of pelvic infection Two or more abortions Women over the age of 35
Male History of prostate infection Un-descended testes
Male Infertility
Male factors
Defects ofSpermatogenesisEfferent duct systemSperm depositionSeminal fluid
Defective Spermatogenesis
Congenital : Un-descended testes
Thermal factor : Varicocele
Infections : Mumps, Systemic
General factors : Habits, Nutrition
Endocrinal : DM, Thyroid, Pituitary
Genetic :Klinefelter’s (47xxy),Reifenstein’s (46xy)
Iatrogenic : Radiation, Drugs
Immunological : ASA
Defects of Efferent ducts
Congenital absence of vas
Obstruction which may be due to Infection : Tubercular, Gonococcal Accidental : During Surgeory
Defects in sperm deposition
Impotency Defective ejaculation
Premature Retrograde Absence
Hypospadius
Defects of Seminal fluid
High or low volume High viscosity Low fructose High prostaglandin
Varicocele
Varicocele is the commonest cause of
low sperm count with poor motility
Incidence of Varicocele : 15 % of the general male population 40 % of men evaluated for primary infertility & 50 % of men evaluated for secondary infertility
Grades of Varicocele
Grade III or Large On inspection one can see the 'bag of worms‘
Grade II or Moderate On palpation without coughing one can feel the
'bag of worms‘ Grade I or Small
Only on coughing can one feel the 'bag of worms‘ Subclinical Varicocele
Detected only by color doppler
Causes of varicocele
Suggested theories Left testicular vein enters the left renal
vein perpendicularly Long (8 - 10 cm) left testicular vein
(aided by gravity) Compression of left renal vein between
aorta and superior mesenteric artery ('nut cracker' effect)
Absence or incompetent valves in testicular vein
Adverse effects of a varicocele
Suggested theories Hyperthermia Pooling of warm venous blood
leads to impaired spermatogenesis (Heat Injury).
Toxins Increased concentration of metabolic waste products (Nitric oxide / reactive oxygen free radicals). Abnormal concentration of adrenal and renal substances.
Hypoxia Decreased availability of oxygen and nutrients.
Hormonal Impairment of testosterone production and concentration.
Theory of Cremasteric Compartment Complex
The encircling cremasteric muscle creates a tight compartment around the structure of the spermatic cord.
This leads to venous stasis and secondary venous dilatation and tortuosity.
According to this theory, it is 'venous stasis' and not 'venous reflux' that leads to the effects of varicocele.
MAIN SPERMAL ANOMALIES
Aspermia Azoospermia Oligospermia Aesthenospermia Teratospermia Necrospermia Polyspermia Globozoospermia Haematospermia
LAB INVESTIGATIONS - MALE
Semen Analysis Color Doppler Study of Scrotum Hormone Assay
FSH,LH,Testosterone,TSH Sex Chromatin Study Testicular biopsy
SEMEN ANALYSIS
Abstinence : 3-7 Days Collection : Coitus Interruptus Specimen Submission Delay :
Less than 30 minutes Volume : 2-6 ml. Liquifaction : Within 60 minutes
SEMEN ANALYSIS
Count : 40-250 million/ml Motility Active : 20-30 % Total : > 60 % Vitality : > 65 % Morphology : > 60 % Normal
Cells Fructose : 150-600 mg/ml
LAB ERRORS
Count Total Count
OLIGOSPERMIA
• Sperm densities of less than 20 million/ml or a total count of less than 50 million
Motility : Grading
Fast Progressive Swim forward fast, in a straight line
Slow progressive Swim forward slowly or in a curved line
Non progressive Move their tails but do not move forward
Immotile
AZOOSPERMIA
CENTRIFUGE SPECIMEN
SPERM ABSENT SPERM PRESENT
W/O for OLIGOSPERMIAR/O ABSENT VAS
VAS ABSENT
CBAVD
VAS PRESENT
HORMONE STUDIES
NORMAL FSH –
NORMAL SIZED TESTESFSH > 2x-3x NORMAL, LH,T – NORMAL
SMALL TESTES
FSH, LH ELEVATED
T NORMAL OR LOW
FSH,LH LOW
TESTES BIOPSY
SPERMATOGENESIS
NO SPERMATOGENESIS
VASOGRAM & SAMPLE VAS FLUID &
DEFINITIVE REPAIR
R/O ANY CORRECTABLE ABNORMALITIES
GERM CELL FAILURE TESTICULAR FAILURE
FULL ENDOCRINE EVALUATION
HYPOGONADOTROPIC HYPOGONADISM
OLIGOSPERMIA
HORMONE STUDY SEMEN FRUCTOSE
LOW
• CAVD
• Partial Duct Obstruction
TSH T FSH
HIGH
Hypothyroidism
LOW
Daily Injection Of HCG
5000 units X 4 doses
UNRESPONSIVE RESPONSIVE
Klinefelter’s Syndrome
Sex Chromatin Study
Hypogonadotropic Hypogonadism
HIGH NORMAL OR LOWTesticular Failure
Pus cells ++ No Infection
Prostatic Massage
Smear + Culture
TESTICULAR BIOPSY
NORMAL SPERMATOGENESIS
HYPO SPERMATOGENESIS
Obstruction to Efferent ducts
Vasogram
Damage of Tubular Epithelium
Rubrics : Semen Analysis
Volume : Ejaculation,copious,excessive
Ejaculation scanty,short,feeble Pus Cells : Ejaculation,purulent Blood Cells : Ejaculation, bloody Viscocity : Ejaculation,thick,sticky
Ejaculation,failing during sex,though the orgasm is present
RUBRICS OF RELATED PATHOLOGY
Atrophy,testes Cysts, genitalia.( Sil,Thuj ) Hydrocele, scrotum Injuries to,genitalia Kryptorchism ( Aur, Psor, Syph, Thyr, Tub ) Small, testes ( Bar-c,Iod,Puls,Sil,Spong,Tub) Varicocele, spermatic cord
RUBRIC - MALE INFERTILITY
COMPLETE REPERTORY
Male, Sterility : agn am-c arg bor calc cann-s caust cer
cic con cordy-a croc dam dulc dysp erb eur ferr graph holm hyos lant merc nat-c nat-m neod onc-t phos plat pras ruta sam sul-ac sulfa sulph 1terb 1thul x-ray ytte
Complete Repertory arg – argentum metallicum - Scholten cer - cerium mettallicum cordy-a _ cordyline australis - Marlow dysp – dysprosium metallicum erb – erbium metallicum eur – europium metallicum gad – gadolinium metallicum holm – holmium metallicum lant – lanthanum metallicum neod – neodymium metallicum onc-t –onchorynchus tschawythscha - Sherr pras – praseodymium metallicum sam – samarium metallicum terb – terbium metallicum thul – thulium metallicum ytte - ytterbium metallicum
Male, Sterility : 35 medicines
Agn, Alet, Aur.m, Bar.m, Bers.l, Borx, Caul, Cissu.c, Con, Dam, Erios.co, Fil, Form, Goss, Grew.oc, Gunn.p, Helon, Iod, Lapp, Mill, Nat.c, Nat.m, Nat.p, Phos, Pyren.sc, Roye.l, Rub.c, Sabal., Sol.so, Sul.ac, Ther, Trium.r, Vern.co, Wies, X-ray.
SYNTHESIS
Synthesis
Cissu-c – Cissus cuniefolia Erios-co – Eriosema cordatum Fil – Filix mas Grew-oc – Grewia occidentalis Pyren-sc – Pyrenacantha scandens Roye.l – Royena lucida Rub-c – Rubea cordifolia Sol-so – Solanum sodomoeum Trium-r – Triumfetta rhomboidea Vern-co – Vernonia corymbosa
SYNTHESIS
These medicines are taken from three authors
Dr. J.H.ClarkeDr.A.T.BryantDr.Jhar, and Dr.Stephenson
SYNTHESIS Dr.J.H.Clarke ( c2 ) : From ` A Clinical
Repertory to the Dictionary of Materia Medica'.
Agn, Alet, Aur.m, Bar.m, Borx, Caul, Con, Dam, Fil, Form, Goss, Helon, Iod, Lapp, Mill, Nat.c, Nat.m, Nat.p, Phos, Sabal, Sul.ac, Ther, Wies..
SYNTHESIS
These medicines are mentioned under the rubric sterility in Clinical repertory . But whether it is male or female is not specified.
The medicines seems more deviated to the female side on reference
SYNTHESIS
In Synthesis these medicines are seen added to the rubric -sterility in both the chapters, Male and Female.
So, medicines under the rubric are to be further studied clinically to arrive at a conclusion whether they are to be considered as valuable and reliable for the treatment of male sterility.
RUBRIC
SYNTHETIC REPERTORY : Male Sterility : Sulfa, X-ray.
REPERTORY TO THE HERING’S GUIDING SYMPTOMS OF OUR MATERIA MEDICA. : Dr.K.B.KNERR.
Male sexual Organs : Testicles : Sterility : Ferr.
RUBRIC
Dr.K.N.MATHUR : DIABETES MELLITUS,ITS DIAGNOSIS AND TREATMENT .
In the therapeutic part : Concomitants of
Diabetes -
Sterility : Aur.m.n, Aur.m, Borx, Con, Graph, Helon, Iod, Med, Nat.c, Nat.m, Phos, Thyr.
( No specification- whether Male or Female )
RUBRIC
Dr.BERKELEY SQUIRE : A REPERTORY OF NOSODES AND SARCODES.
Male Genital : Aspermatogenesis, Oligospermia : Lepr.
Male Genital, Male Sterility , Impotence : Ambr, Bac.7, Cortico, Lac.d, Lepr, Med, Psor, RNA, Syco, Thal, X-ray.
RUBRIC
Dr.C.M.BOGER : SYNOPTIC KEY.
Sexual Impulse :
Sterility : Aur, Bor, Merc, Nat.m, Phos.
( No specification- whether Male or Female )
RUBRIC
Dr.RAUE.C.G. :
SPECIAL PATHOLOGY AND DIAGNOSTICS WITH THERAPEUTIC HINTS.
Under the section Impotence and Sterility, the medicines mentioned are :
Agar, Agn, Baryt, Calad, Eup.pur, Gels, Hamam, Helon, ,Lyco, Nat.m, Nit.ac, Phos, Phytol, Selen, Stilling.
RUBRIC
CLARKE.J.H. :
A CLINICAL REPERTORY :
Sterility : Agn, Alet, Ar.lp, Aur.m, Bar.m, Bor, Caul, Con, Fil, ( For ), Gos, Hlon, Iod, Mil, nat.c, Nat.m, Nat.p, Pho, Sbl, Su.x, ( Ther ), Tur, Wis.
RUBRIC
RAI BAHADUR Dr. BISHAMBAR DAS : SELECT YOUR REMEDY :
Azoospermism : ( Absence or diseased condition of spermatozoa in the semen )
Chininum sulph, Conium, Damiana, Iodium, Strychninum.
RUBRIC
KAMAL KANSAL Dr. :
HAND BOOK OF HOMOEOPATHIC MOTHER TINCTURES :
Sterility, males : Turnera.
RUBRIC
Dr.O.A.JULIAN:
DICTIONARY OF
HOMOEOPATHIC MATERIA MEDICA.
Clinical Repertroy part by P Freche and M Haffen
Sterility : Arg.m, Cobalt.nitr, Foll, Mandr of, Nep, Rauw serp, Sulfanil, Thyr.
RUBRIC
Dr.SAYEED AHMAD : STERILITY IN FEMALE AND MALE :
Chin sulph, Con.mac, Damiana, Iodium, Strychninum.
RUBRIC
Dr.J.N.SHINGHAL : QUICK BEDSIDE PRESCRIBER :
Sterility male : Agnus, Bufo, Nat.m, Phosphorus, Sel
EVALUATION OF MEDICINES
Among this medicines., Agn, Arg.m, Bac.7, Bufo, Chin.s,
Cobalt.nitr, Con , Dam , Ferr , Iod, Lepr, Nat-m, Phos , Rauw.serp, Sel, Strych, Sulfa , X-Ray. could be taken as confirmed medicines as they are mentioned under the heading male sterility or a synonymous term.
EVALUATION OF MEDICINES
All the additions from J.H.Clarke’s Repertory, which are found to be of female part on reference to the Materia Medica, may be removed from the list. They are :
Alet, Bar.m, Bor, Caul, Fil, Goss, Helon, Nat.c, Sul.ac, and Wies.
EVALUATION OF MEDICINES
Those medicines which are found under the `clinical’ section of Clarke but not under female may be included as medicines for male sterility, but with less marks.
They are : Aur.m, Lapp, Mill, Nat.p., Sabal.
EVALUATION OF MEDICINES
Among the additions from Raue’s Pathology, as the medicines are given under the combined heading – impotence and sterility, we should find out which ofthem actually cover the condition - sterility.
On studying the symptomatology,among them,
Baryt, Calad, Lyco, Nit.ac, Eup.pur, Gelsem, Helon, and Phyt covers only impotency.
Some symptoms which may be related to infertility are found under Agar (scanty emission) & Hamam ( Varicocele ).Stillingia is found not to cover impotence and sterility.
EVALUATION OF MEDICINES
Medicines mentioned in Synoptic Key are for female sterility only.
Those medicines under the rubric Impotence in Berkeley squire’s Repertory could be taken as medicines for sterility because, Male sterility is cross referred to this rubric and more over separate rubrics erection absent and incomplete is found in the male chapter with a different group of medicines.
From the list, Syc.co can be avoided as no Materia Medica gives the symptom sterility for Syc.co. It is indicated in Impotency. Bac.No.7 is also half correct as the symptom found under it is `loss of sexual function’ and `premature senility’ ( under genitalia )
EVALUATION OF MEDICINES
Those medicines mentioned by Dr.K.N.Mathur (Diabetes Mellitus its Diagnosis & Treatment ) are mainly for infertility in female. The doubtful ones are Aur.m & Con in which sterility is mentioned under the heading `clinical’. The term male sterility was not found under the medicines Medorrhinum and Thyrioidinum.
RUBRIC : MALE INFERTILITY
Agn, ARG.M, Bac.7, Bufo, Chin.s, COBALT.NITR, Con , Dam , FERR, Iod, Lepr, Nat.m, Phos , RAUW.SERP, Sel, Strych, SULFA , X-RAY.
RUBRIC : MALE INFERTILITY
Agar, Aur, Aur.m, Ham ,Lapp, Mill, Nat.p, Sabal, Still, Thyr
( Bers.l, Cissu.c, Cortico, Erios.co, Grew.oc, Gunn.p, Lac.d, Pyren.sc, Rub.c, Sol.so, Trium.r, vern.co. )
RUBRIC : MALE INFERTILITY
Azoospermia :
COBALT. NITR, Chin.s, Con, Dam, Iod, Strych.
Oligospermia :
Lepr., Sulfa.
MANAGEMENT - GENERAL Avoidance of tight undergarments. Avoidance of working in high temperatures. Avoidance sitting long in warm rooms. Avoidance of smoking or tobacco in any form. Avoidance of Alcohol. Stoppage of narcotic habit if any. Avoidance of the intake of cytotoxic drugs. Control of the occupational exposure to toxic substances Avoidance of Nutritional supplements which have an adverse
effect on spermatogenesis.
Cases – Male Infertility
1. Azoospermia
1. Azoospermia
1.Azoospermia
2.Aesthenospermia
2.Aesthenospermia
3.Oligo-aesthenospermia
3.Oligo-aesthenospermia
4.Oligospermia
4.Oligospermia
4.Oligospermia
5.Oligo-aesthenospermia
5.Oligo-aesthenospermia
6.Severe Oligospermia
6.Severe Oligospermia
6.Severe Oligospermia
7.Oligo-aesthenospermia
7.Oligo-aesthenospermia
8.Oligo-aesthenospermia
8.Oligo-aesthenospermia
8.Oligo-aesthenospermia
9.Aesthenospermia
9.Aesthenospermia
10.Oligo-aesthenospermia
10.Oligo-aesthenospermia
Female Infertility
Causes
Ovarian Factors Tubal factors Peritoneal factors Uterine factors Cervical factors Vaginal factors
Ovarian factors
An-ovulation Infrequent ovulation Corpus luteum insufficiency Lutinisation of un-ruptured follicle
Anovulation or Infrequent ovulation
Hypothalamic or cortical factors Drugs : reserpine Stress
Pituitary Tumor, Vascular disturbance
Gonadal factors Dysgenesis, premature ovarian failure, PCO,
Resistant ovarian syndrome Others
Thyroid dysfunction, Substantial weight loss, DM, Adrenal hyperfunction, Endometriosis
PCO
Syndrome with Oligoovulation or anovulation, Excess androgen activity, Polycystic ovaries.
Symptoms
Oligomenorrhea, amenorrhea Hirsutism Hair loss appearing as thinning hair
on the top of the head Acne, oily skin, seborrhea. Obesity Depression
Review
Infertiity Definition Incidence
Male infertility Causes Semen Analysis Sperm anomalies
Female Infertility Causes PCO
Thank you…………………
for your patient listening……
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