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3 categories:
1. Sperm production
2. Sperm transport
3. Sperm deposition
SPERM PRODUCTION
Lack of production of sperms mainly due to damaged
testis or destruction of it after production.
Therefore not enough sperm to achieve fertilisation in
natural way.
2 categories:
1. Anovulatory/oligo-ovulation
2. Anatomical and
tubo-peritoneal dysfunction
ANOVULATORY/OLIGO-OVULATION
Anovulation : no ovulation
Oligo-ovulation : infrequent or irregular ovulation
Causes are:
1.Polycystic ovarian syndrome(PCOS)-most common cause
2.Hyperprolactinemia-seen in prolactinoma
3.Hypothyroidism
4.Premature ovarian failure-total failure of ovaries in women under
the age of 40 years
5.Luteal phase defect
ANATOMICAL &
TUBO-PERITONEAL DYSFUNCTION
Major reason for causing infertility
The causes are as follows:
1. Uterine factors-congenital/acquired
2. Cervical factors-cervical stenosis, anti sperm Ab
3. Vaginal factors-vaginal infection
4. Endometriosis
5. Salpingitis(PID)-lead to impaired oocyte picked-
up mechanism or to damaged tubal epithelium.
Cervical stenosis
DISORDER OF IMPLANTATION
Defectsrelated to endometrial
development and maintenance.
Female Male
Gynecological History • History of sexual
- menstrual history dysfunction (Erectile
- last menstrual period dysfunction/ premature
Previous pregnancies ejaculation)
(miscarriage, still birth)
• History of mumps or
Contraception history
measles infection
Past histroy of infection ( STD/ PID)
Other problems: • History of lump in scrotal
- Post-coital bleeding area/ surgery to testis
- Symptoms of PCOS
- Thyroid Disorder(hypothyroidism)
- Hyperprolactinaemia(oligomenorrhea,
galactorrhea, acne)
Examination
For male:
Look any abnormalities of penis , testicular location , scrotal abnormality
For female:
Obesity(calculated by BMI)
Examination of breast-look for galactorrhea
Look for thyroid enlargement
Abdominal examination-Rule out any mass per abdomen like leiomyoma or
chocolate cysts.
Speculum examination-look any vaginal discharge.
Bimanual examination -look for retroverted uterus & mobility of uterus
Cervical motion-suggestive of endometriosis/pelvic inflammatory
disease(PID).
INVESTIGATION FOR FEMALE
Free Testosterone levels 1.0–8.5 pg/mL (3.5–29.5 pmol/L) Levels are most often checked to
evaluate signs of higher
testosterone levels (Irregular or
absent menstrual periods, male
type baldness, change in voice)
Tubal Patency Test:
Hysterosalpingogram (HSG)
Itis non-invasive outpatient procedure done in radiology.
Injected radio-opaque contrast into cervix by Leech-Wilkinson’s
canula or Foley’s catheter.
Under fluoroscopy:
Filling of the uterine cavity with the contrast
Any spillage of the dye into peritoneal cavity.
-normal uterine cavity will be triangular
Detect abnormalities in the uterus, such as an
abnormal shape or structure, an injury, polyps, fibroids,
adhesions, or a foreign object in the uterus.
http://www.ivf-
infertility.com/infertility/investigations/female/laparoscopy.php
Laparoscopy showing perihepatic adhesions Laparoscopy showing bicornuate uterus
http://www.ivf-
infertility.com/infertility/investigations/female/laparoscopy.php
Advantages of laparoscopy and dye testing over
HSG
◦ The surrounding pathology in the peritubal region can
be visualised. (e.g: adhesions or endometriotic deposits.)
◦ Treatment of the above conditions can be done in the
same procedure by adhesiolysis and cauterisation of the
endometriotic deposits.
Medical :
Lifestyle modification
– quit smoking and alcohol
- Wear loose undergarments
Antioxidant (ie: Coenzyme Q10) if there is only
asthenozoospermia
Low dose clomiphene citrate for 3 months (if semen analysis is
abnormal-count, morphology and motility)
Sildenafil citrate in case of erectile dysfunction
Surgical
Only done when a blockage has been detected by
testicular biopsy( to correct blockage)
Varicocelectomy done in men with varicocele to
improve sperm count
FEMALE INFERTILITY
Lifestyle modification
Weight loss in obese women
Stress management
3. Metformin
Facilitating ovulation induction in obese PCOS
Acts as insulin sensitizer-reduce insulin
resistance(which is thought to cause PCOS)
Metformin helps prevent miscarriage in PCOS
Surgery
Limited
Laparoscopic cauterization of endometriotic deposits and chocolate
endometriosis.