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INFERTILITY
DEFINITION:
According World Health Organization:
TheWorld Health Organization defines infertility as
follows:
Infertility is “a disease of the reproductive system defined
by the failure to achieve a clinical pregnancy after 12
months or more of regular unprotected sexual
intercourse (and there is no other reason, such as
breastfeeding or postpartum amenorrhoea).
 OR
Infertility is defined as a failure to conceive within one or
more years of regular unprotected intercourse.

SUB FERTILITY :
It refers to a state in which a couple has tried unsuccessfully to
have a child for a year or more. The term sub fertile means
less fertile than regular couple.
PRIMARY INFERTILITY:
Primary infertility is infertility in a couple who have never had a child.

SECONDARY INFERTILITY:
Secondary infertility is failure to conceive following a previous pregnancy.
Infertility may be caused by infection in the man or woman, but often there is
no obvious underlying cause.
 FACTORS REQUIRED FOR FERTILITY
(MALE & FEMALE):
 Healthy spermatozoa should be deposited high in the vagina at
or near the cervix .
 The spermatozoa should undergo changes (capacitation,
acrosome reaction) and acquire motility(cervical factor).
 Motility :The motile spermatozoa should ascend through the
cervix into the uterine cavity and the fallopian tubes.
 Ovulation –ovum should reach the fimbriated end of the tube
 Patent fallopian tube: Fertilization should occur at the ampulla
of the tube.
 Transportation of fertilized ovum to uterine cavity ; in 3-4 days
the fertilized ovum should reach the uterine cavity for nidation.
RISK FACTORS FOR INFERTILTY:
 Age
 Stress
 Poor diet
 Smoking
 Alcohol
 STDs
 Overweight
 Underweight
 Caffeine intake
 Too much exercise
CAUSES OF INFERTILITY:
 Male factors that causes infertility:

 Defective spermatogenesis:.The causes of defective

spermatogenesis are:
Congenital
Hypospadias.
Thermal factor
Infection.
Gonadotrophin suppression:
 Endocrine factors
 Genetic
 Iatrogenic.
 Immunological factor.
 Obstruction of the efferent ducts.
 Failure to deposist sperm high in the vagina (coital problems):
Erectile dysfunction.
Ejaculation defects such as premature ,retrograde or absence of ejaculation .
Hypospadias.
Errors in seminal fluid :
 Unsually high or low volume of ejaculate(normal volume is 2ml or more).
 Low fructose content.
 High prostaglandin content.
 Undue viscosity.
 Female factors that causes infertility:
• OVARIAN FACTORS :
 An ovulation or oligo –ovulation
 Tubal and peritoneal factors:Tubal and peritoneal factors are
responsible for about 30 to 40% of cases of female infertility.These
include :
 Peritubal adhesions .
 Endosalphingeal damage.
:
 Previous tubal surgery or sterilization
 Salphingitis.
 Tubal or peritoneal endometriosis.
 Polyps within the lumen.
 Tubal spasm.
 UTERINE FACTORS: These include factors that interfere
with reception and nidation of fertilized ovum (unfavorable
endometrium

 CERVICAL FACTORS: Ineffective sperm penetration due

to following factors :
 Chronic cervicitis
 Presenceof antisperm antibodies
 Second degree uterine prolapsed
 Occlusion of cervical canal with polyp
 Scanty vaginal mucus
 VAGINAL FACTORS (IMPLICATED):
 Atresia
 Septum
 Narrow introitus

COMBINED FACTORS :These include presence of factors both in

female and male factors causing infertility:
 Age of wife beyond 35years and advancing age in men.
 Infrequent intercourse (less than 4 – 5 /week)during fertile period
(around ovulation).
 Apareunia (failure of emission of semen /ejaculation )and dyspareunia.
 Anxiety and apprehensions
 Use of lubricants during intercourse which may be spermicidal
 Immunological factors (antisperm antibodies).

INVESTIGATION:

INVESTIGATIONS FOR MALE:

 History collection
 Physical examination
 Testicular volume
 Routine investigation
 Semen analysis
 Serum FSH, testosterone ,prolactin, and TSH.
 Fructose content in the seminal fluid.
 Testicular biopsy
 Transrectal ultrasound(TRUS).
 Vasogram
 Karyotype analysis.
 Immunological tests.
 Presence of plenty of pus cells.
 INVESTIGATIONS FOR FEMALE:
 History
 Physical examination
Diagnostic test –
 Basal body temperature BBT
 Cervical mucous study
 Hormone estimation
 Endometrial biopsy
 Sonography
 Laparoscopy
 Insufflations test (Rubin’s test)
 Hysterosalphingography (HSG)
 Laparoscopic chromotubation
 Sonosalphingography
 MANAGEMENT OF INFERTILITY:

Management of infertility or subfertility would depend upon the

cause identified ,duration and age of the couple especially the
female.
Management of male fertility :
General care
 Improvement of general health:
 Reduction of weight in obese .
 Avoidance of alcohol and heavy smoking
 Avoidance of tight and warm undergarments.
 Avoidance of occupation that may elevate testicular temperature.
 Avoiding medications that interfere with
spermatogenesis such as:
 Cytotoxic drugs , nitrofurantine ,cimetidine ,anticonvulsants
,antidepressants and beta blockers.
 Medications to treat specific cause:
 hCG and hMG for hypogonadism.
 Dopamine agonist (cabergoline) for hyperprolactinemia and
altered testosterone level and to improve libido ,potency and
fertility.
 GnRH therapy for hypogonadism.
 Clomiphene citrate to increase serum levels of FSH ,LH and
testosterone .
 Antibiotics for genital tract infections.
Special treatments for causes identified such as:
 Intrauterine insemination (IUI).
 In vitro fertilization or (IVF).
 Intracytoplasmic sperm injection (ICSI).
 Artificial insemination with donor sperm (AID).
Surgical treatment:
 In men whose testicular biopsy shows normal spermatogenesis
and obstruction is suspected ,Vasoepididymostomy or
Vasovasostomy may help.
 Correction of hydrocele.
MANAGEMENT OF FEMALE
INFERTILITY:
 Treatment for females is also according to the disorders
identified.
Ovulatory dysfunction:
 Induction of ovulation using drugs such as clomiphene citrate
, letrozole ,FSH, hCG and GnRH.
 Correction for biochemical abnormality: metformin for
hyperinsulinemia, dexamethasone forandrogen excess,
bromocriptine for prolactin excess.
 Substitution therapy: Thyroxin for hypothyroidism ,
antdiabetic drugs for diabetes mellitus.
Surgery:
 Laparoscopic ovarian drilling (LOD) or laser vaporization for
polycystic ovarian syndrome (PCOS).
 Surgical removal of virilizing or functioning ovarian or tumor.
 Tubotubal anastomosis for adhesion in tube.
 Cannulation and balloon tuboplasty for block in tube.
 Fimbrioplasty for fimbrial adhesion.
 Adhesiolysis for separation or division of adhesion.
 Salphingostomy to create an opening in tube in a completely
occluded tube.
 MANAGEMENT OF UNEXPLAINED
INFERTILITY

 Unexplained or persistent infertility refers to those who have

undergone complete basic infertility work up and in whom no
abnormality has been detected and still remains infertile.The
reported evidence is about 10 to 20% . About 60 to 80 % of those
couples become pregnant within 3 years without any treatment.
 The recommended treatment for unexplained infertility is
induction of ovulation , intrauterine insemination (IUI),and
superovulation combined with IUI.
 ASSISTED REPRODUCTIVE
TECHNOLOGY(ART):

 ART encompasses all methods used to achieve pregnancy by

artificial means.It involves manipulation of gametes and embryos
outside the body for the treatment of infertility.
 In ART , the process of intercourse is bypassed either by
intrauterine insemination (IUI) or fertilization of the oocytes in the
laboratory environment as in in vitro fertilization (IVF).
 DIFFERENT TECHNIQUES OF ART:

 Intrauterine insemination(IUI)
 In vitro fertilization and embryo transfer (IVF –ET)
 Gamete intrafallopian transfer (GIFT)
 Zygote intrafallopian transfer (ZIFT)
 Intracytoplasmic sperm injection (ICSI)
INTRAUTERINE INSEMINATION:

 Intrauterine insemination (IUI) is a fertility treatment

that involves placing sperm inside a woman’s uterus to
facilitate fertilization. The goal of IUI is to increase the
number of sperm that reach the fallopian tubes and
subsequently increase the chance of fertilization.
 IUI provides the sperm an advantage by giving it a head start,
but still requires a sperm to reach and fertilize the egg on its
own. It is a less invasive and less expensive option compared
to in vitro fertilization.
 IUI may be artificial insemination husband , artificial
insemination donor or insemination with donor egg.
IN VITRO FERTILIZATION AND
EMBRYO TRANSFER (IVF-ET):

 Fertilization of an ovum outside the body is a technique used

when a woman has blocked fallopian tubes or some other
impediment to the union of sperm and ovum in the
reproductive tract.
GAMETE INTRAFALLOPIAN TRANSFER
(GIFT):

 GIFT is an assisted reproductive procedure which involves

removing a woman’s eggs, mixing them with sperm, and
immediately placing them into a fallopian tube.
 ZYGOTE INTRAFALLOPIAN
TRANSFER (ZIFT):
 ZIFT is an assisted reproductive procedure similar to in vitro
fertilization and embryo transfer, the difference being that the
fertilized embryo is transferred into the fallopian tube instead of
the uterus.
 Because the fertilized egg is transferred directly into the tubes,
the procedure is also referred to as tubal embryo transfer (TET).
INTRACYTOPLASMIC SPERM INJECTION
(ICSI):

 This treatment is given for couples where there is a problem

of male infertility. One such example is that of a low sperm
count or oligospermia. Other candidates for this treatment
include abnormally shaped sperm or problems with sperm
mobility.
 It can also help those men who have undergone an
unsuccessful vasectomy reversal procedure.
PREVENTION
 Regular exercise
 Avoid alcohol, tobacco, and narcotics
 Limit caffeine – No more than 250 mg per day
 Limit medications
 Eat a balanced diet
COPING WITH INFERTILITY:

 Consider other options – Adoption, donor sperm or egg •

 Talk about your feelings
– To each other
– Support groups
– Counseling services
 Acupuncture
 Practice relaxation
 Stay in touch with loved ones
CONCLUSION
 Infertility is a significant medical and social problem affecting
couple worldwide.
 It is a sensitive issue that should be handled with great care
with continuous professional counselling.
 Most young couples will conceive naturally within 2 years.
Evaluation of both partners for causes is essential.
 Treatment depends on the cause, and varies from medical
treatment to surgery to ART.