DR/ ADEL FAROUK M.D.

ASSISTANT PROFFESOR of
Obstetrics & Gynecology
Cairo University
Infertility
nfertility
 INFERTILITY
(STERILITY)
Definition: Inability to conceive after one
year of continuous marital life without use of
contraception.
Primary infertility: Conception has never
occurred.
Secondary infertility: Failure of conception
after a period of previous fertility.
 INFERTILITY (STERILITY)
Infertility and sterility may be used as synonyms.
Others define infertility as inability to conceive due to
curable condition while sterility is inability to conceive
due to incurable condition e.g. congenital absence of
uterus.
Some believe that infertility is inability to produce a
viable offspring i.e. including cases of habitual
abortion
Some believe that secondary infertility (sterility) should
be considered to occur after a longer period than
primary infertility (e.g. one year for primary infertility
and 2 years for secondary infertility), as there may be
a period of lactational amenorrhea and anovulation
after the previous childbirth.
 INFERTILITY (STERILITY)
Incidence: It is about 10-15% of couples are
infertile i.e. one in every seven marriages.
The chance for conception per cycle per
couples around 20% and approximately 60%
of the healthy women up to the age of 25
years conceive after 6 months of unprotected
intercourse and 85% conceive after 12
months. The age of the female partner is the
most important factor in infertility (by the age
of 35 years or above the fertility is halved
and it declines sharply after the age of 37.
 Male causes: (30-40% of cases)
Physiology: The male should be able to
deposit into the posterior fornix of the vagina
adequate amount of normal seminal fluid
containing an adequate number of healthy
spermatozoa. Failure to do this rule causes
infertility.
Male causes may be due to:
1- Faults in spermatogenesis:
2- Faults in the seminal fluid.
3- Failure of transport of sperms.
4- Failure of deposition of semen in the vagina
Male causes of infertility
 Male causes of infertility
1- Faults in spermatogenesis: This may be due to:
Undescended testes.
Varicocele, hot baths, steam baths and tight and nylon
underwear (high temperature impairs spermatogenesis).
Previous infection with mumps (destruction of
spermatogonia).
Exposure to irradiation (destruction of spermatogonia).
Excessive smoking (hypoxia of the spermatogenic
tubules).
Chromosomal factor (Klineflter’s syndrome xxy males with
tall stature, gynecomastia and testicular atrophy).
Intake of certain drugs such as anti-epileptic,
antihypertensive agents some antibiotics and
chemotherapeutics
 Male causes of infertility
In cases of defective spermatogenesis, semen
analysis may show
Azoospermia (complete absence of spermatozoa).
Oligozoospermia (oligospermia): low sperm count.
Asthenozoospermia (asthenospermia) decreased
motility.
Necrozoospermia (necrospermia) dead sperms.
Teratospermia: Excessive abnormal spermatozoa
 Male causes of infertility
2- Faults in the seminal fluid: Seminal fluid with
poor fructose or prostaglandins content or with high
viscosity can cause infertility.
3- Failure of transport of sperms:
Bilateral obstruction of the vas deferens: may be
due to Gonorrheal infection or T.B
Bilateral surgical occlusion (a complication of
inguinal hernia operation).
4- Failure of deposition of semen in the vagina:
Impotence, premature ejaculation, retrograde
ejaculation or hypospadius (penile or scrotal).
II- Female causes (40- 60%)
 (1) Ovarian (ovulatory) causes (15-20%)
(anovulation, luteal phase defect, L.U.F syndrome)
 (2) Tubal causes (20-30%) (salpingitis is the most
important cause)
 (3) Uterine causes (2-4%)
 (4) Cervical causes: (5-10%)
 (5) Vaginal causes
 (6) General causes
 (7) Peritoneal causes
 Female causes
• (1) Ovarian (ovulatory) causes: (15-20%)
• Persistent anovulation (see later).
• Luteal phase defect (weak or short luteal
phase): May cause habitual abortion or
sterility.
• Lutinized unruptured follicle syndrome
(L.U.F.S)
 Female causes
 (2) Tubal causes: (30-40%)
 Congenital: aplasia or hypoplasia of the fallopian tube.
 Traumatic causes: Tubal ligation or salpingectomy.
 Inflammatory causes: Salpingitis (it is the most common
cause of secondary infertility). Salpingitis may be puerperal,
post abortive, Chlamydia (common) gonococcal or
tuberculous in origin.
Salpingitis causes sterility by: Destruction of the cilia and loss
of the pick up mechanism.
 Neoplastic causes: Bilateral cornual or broad ligamentary
fibroids.
 Endometriosis: It causes pelvic and peritubal adhesions.
 Disturbed physiology: Poor cilial currents, disturbed ovum
pick up mechanism and biochemical changes of the tubal
fluid.
 Female causes
• (3) Uterine causes: (2-4%)
• Congenital causes: - Uterine aplasia, hypoplasia,
septate or subseptate uterus.
• Traumatic causes: Heavy curettage and intra-uterine
synechia.
• Inflammatory causes: Tuberculous endometritis.
• Neoplastic causes: Fibroid polyp or submucous
fibroid.
• Disturbed physiology: Congestion as in cases of
prolapse or retroversion.
 Female causes
(4) Cervical causes: (5-10% )
Congenital: Severe stenosis of the cervix, congenital
elongation or hypoplasia of the cervix.
Traumatic: Extensive cauterization, amputation as in
Fothergill’s operation.
Inflammatory causes: Cervical erosion, chronic cervicitis
(hostile cervical mucus).
Neoplastic causes: Cervical polyp, cervical fibroid or
cancer.
Disturbed physiology: Very thick mucus containing pus
(Hostile cervical mucus), the presence of sperm antibodies
(sperm agglutinins) that can kill sperms.
Cervical displacement as in prolapse or retroversion.
Increased viscosity of the cervical discharge.
Incompetent isthmus leading to habitual abortion.
 Female causes
(5) Vaginal causes:
Congenital: Vaginal aplasia or vaginal septum.
Inflammatory: Vaginitis with increased acidity& hostile vaginal
discharge that can kill the sperms
(6) General causes:
General causes as diabetes, tuberculosis, malnutrition, obesity
or psychological factors. They act through inhibition of
ovulation.
(7) Peritoneal causes:
Endometriosis causing peritubal adhesions interfering with the
ovum pick up mechanism and high level of peritoneal
macrophages with disturbed level of peritoneal prostaglandins
interfering with normal tubal motility
Peritoneal (peritubal) adhesions: which may be due to
peritonitis or previous surgery or others.
 III- Disturbance of sexual
relations
1- Abnormal frequency of intercourse:
 Too frequent intercourse may produce
immature sperms.
 Too infrequent intercourse: may not
coincide with the time of ovulation.
 2- Dyspareunia: Difficult or painful
coitus may indicate pelvic pathology.
 3- Vaginismus: Violent reflex spasm of
levator ani, gluteal muscles and
adductors of the thigh on any attempt
at sexual intercourse.
 4- Effluvium seminis: Excessive escape
of seminal fluid from the vagina after
intercourse.
 IV-Unexplained infertility
No apparent cause. Incidence varies according to different
centers.
It is diagnosed by exclusion when standard investigations
for infertility (semen analysis, tubal patency and laboratory
assessment of ovulation) yield normal results, 60% of
couples with unexplained infertility will conceive within 3
years
The most common suggested causes are: (sperm
dysfunction and diminished fertilization capacity,
hyperprolactinemia, cases of (L.U.F syndrome), damage
of the endosalpinyx, endometrial receptor defect, T.B.
endometritis, immunological factor, endometriosis,
psychological causes and occult infection.
Treatment include 3 cycles of induction of ovulation with
clomiphene citrate with HCG and intrauterine insemination,
if unsuccessful, the next step is in- vitro fertilization (I.V.F)
 Investigations of infertile
couples
Female partner:
History, general and local examination.
History: (Personal history, Past history,
Family history, Menstrual history, Obstetric
history, Sexual history).
General examination
Local examination
 Male partner
History
General examination
Local examination
 Investigations of the male
partner
1- Semen analysis:
It is the first step in evaluation of infertile
couples. Sample is obtained 2-3 days after
the last ejaculation. The specimen is
obtained by masturbation or coitus interrupts
in a clean glass jar (condom should not be
used for collection of semen as it contains
spermicidal compounds) it should be
examined within 1 hour after collection.
 Semen analysis
Normal figures: normal W.H.O reference values 1999 are
put between brackets
Volume: 3-5 cc. (2 ml or more)
Reaction: alkaline (P.H≥ 7.2).
Color: whitish gray.
- Odor: seminifrous odor.
Count: 40-80 millions /cc (minimal of 20 millions /cc and no
more than 250 Millions /cc).
Motility: 80-90% motile within 1 hour of ejaculation, it then
decreases by 10%/ Hour. (50% or more motile [grade a+b] or
25% or more progressive motile sperms [grade a] within 60
minutes of ejaculation).
Vitality: 60% motile after 4 hours.
Abnormal forms: not exceeding 20%.(more than 30% normal
forms)
Pus cells or R.B.C.S: None (less than 1 million/ml).
Normal sperms
Shape of spermatozoa
 Semen Border Patho
Normal
Characteristics line logical
Volume (ml) 2.0-6.0 1.5-2.0 <1.5

Sperm
concentration 20-250 10-20 <10
(M/ml)

Motility (0.5-2 h
>50 35-49 <35
after ejaculate)
Vitality (% live) > or = 75 50-74 <50
Semen analysis
 Other investigations
2- Testicular biopsy: In cases of azoospermia to
differentiate between bilateral obstruction of the vas
(obstructive azoospermia) and testicular lesions
(functional azoospermia).
3- Chromosomal studies: If chromosomal anomalies
are suspected as Kleinfelter’s syndrome.
4- Biochemical studies of semen: e.g. fructose,
prostaglandins may be done if desired.
5- Hormonal assays: e.g. serum F.S.H., L.H.,
testosterone and prolactin may be needed.
6- Culture and sensitivity of pus cells in the semen.
7- Sperm fertilizing capacity. vasography or
absence of α glucosideoxidase enzyme (denoting
obstruction).
 Treatment of the male
 1- Medical measures: factor
Reassurance, explanation, and good
diet and may be one of the following:
 Multivitamins, folic acid, vitamin B12 & E and vitamin C
(antioxidant therapy), hormonal treatment (effective in cases of
hypogonadotropic hypogonadism) the use of these hormones
for 12 months may restore testicular volume and
spermatogenesis. It can be used for oligospermia; selection of
drugs is according to the cause.
- Gonadotropins.
- Clomiphene citrat
- Testosterone.
- Thyroid preparations.
 2- Surgical measures: May be used for varicocele (ligation),
obstruction of the vas (vasoepidiymostomy), penile deformities
& un-descended testes (before puberty), improvement of fertility
after these surgeries is not confirmed
 Treatment of the male
factor
 3- Artificial insemination using the husband’s
semen (A.I.H.) (I.U.I) with ovarian stimulation
gives high conception rates gives high conception
rate comared to no treatment.
 4- Assisted reproduction technology (ART):
such as intracytoplasmic sperm injection (ICSI)
achieves better results than other treatment. Cases
with azoospermia can be treated by sperm
aspiration then (ICSI) after proper chromosomal
studies
ICISI
 Injection of the
sperm in the
cytoplasm of the
mature ovum.