pregnant after at least one year of Unprotected Intercourse. 80% to 90% couples conceive within one year of their marriage. Incidence : 10% to 15% of all couple are infertile. Incidence varies among different communities but generally about 15% of couples need some help to achieve pregnancy. Infertility is a common condition affecting one in six couples. About 80 million couples are affected world wide. It is of two types: 1. Primary Infertility 2. Secondary Infertility Pregnancy is a result of complex events which includes ovulation that is release of mature egg from the ovary. Its transport through the fallopian tubes. Availability of healthy sperms that fertilize the egg. The fertilized egg must attaches itself to uterus. So infertility can result from problems that interfere with any of these steps. Infertility is not always women’s problem. Causes of infertility may lie either in male or female or in both. Female Causes ( 40% ), Male causes ( 40% ), 20% is a combination of Male & Female causes. UNEXPLAINED ( 28% ) SPERM PROBLEM ( 21% ) OVULATORY PROBLEM ( 18 % ) TUBAL DAMAGE ( 14 % ) ENDOMETRIOSIS / CERVICAL MUCOUS ( 9 %) COITAL PROBLEM ( 5 % ) OTHER ( 5 % ) OVULATORY: - PCOs, Hypotalamic Amenorrhea, Luteal Phase Deficiency TUBAL / PERITONEAL : - Hydrosalphinx, Tubal Obstruction, Endometriosis, Adhesion UTERINE : -Synechiae, Fibroids, Anomalies CERVICAL -Mucous, Antisperm antibodies OVARIAN RESERVE : -Ovarian Failure Abnormal spermatogenesis Impaired sperm transport Immunological and infective factor Varicoceole Normal spermatogenesis depends upon adequate gonadotrophic stimulation of testes, proper testicular function and patent seminal duct. Orchitis Undescended testes Past history of mumps Chronic renal failure. Chronic liver diseases Malignancies Uncontrol diabetes mellitus Multiple scleroses Exposure to radiations or Chemotherapy Excessive exposure to heat. First step in male investigation is Semen analyses . -. if this is normal then no other test is needed. -. If oligospermia or azoospermia is found then patients are referred to specialist fertility clinic for further investigation. Ejaculate Volume >2ml Sperm Density: >20m/ml Motility >50% Morphology ≥ 15% normal pH 7.5 – 8.5 At least one-half of male problems can be treated. Treatment in collaboration with urologists and endocrinologist is essential. Treatment options are: -Drug Therapy - Surgery - IUI / ART Due to some autoimmune phenomenon. Anti-sperm antibodies maybe present in cervical mucus which neutralize sperms by clumping them together and destroying their membrane. About 12-15% of unexplained infertility in women is linked to ASA. These include Large fibroids distorting uterine cavity Congenital abnormalities in shape of uterus. Leuteal phase insufficiency, due to progestrone deficiency which causes preparation of endometrium for reception of fertilized ovum. Age Stress Poor diet Smoking Alcohol STDs Overweight/ Underweight Caffeine intake Too much exercise PELVIC ULTRASOUND & HYSTEROSALPINGOGRAM Pelvic Ultrasound : A detailed ultrasound is important diagnostic tool. It reveals uterine abnormalities, uterine masses, ovarian size, presence or absence of follicles, diagnosing PCO. LAPAROSCOPY: It is considered as investigation of choice. It has advantage of diagnosing tubal blockage and simultaneously treating the pathology. Treatment should be based on documentation of abnormality leading to infertility. The first thing to offer a couple is counseling and reassurance. Because infertility treatment can be physically uncomfortable, time consuming, costly and without guarantee of success. Improve general health Stop smoking Limiting alcohol consumption Obtaining standard Weight. Both over weight and underweight can cause sub fertility Infections are treated with appropriate antibiotics A delicate balance of Estrogen, Progesterone, FSH, LH is needed for timely growth and release of egg from the ovary. Even slight irregularity in these hormones can cause an ovulation. Drugs used for induction of ovulation are: Clomifen citrate ,HMGS, FSHr, Dopamine Agonists Clomiphene is a synthetic weak estrogen. It competes with endogenous estrogen for estrogen binding sites in the hypothalamus Giving a negative feedback to pitutiary gland which starts producing large amounts of FSH which causes growth and maturity of folical hence ensuring ovulation. HMGS are GlycoProtein Hormones directly stimulates ovary These drugs are prepared from urine of menopausal women. They are used to produce super ovulation in ART and in certain cases where clomiphen citrate fails to produce ovulation. Progesteron support is given from 15 to 25th day. FSH recombinant is more accepatable now because it produce not from human urine and ofcourse it is Halal. It works directly to stimulate folicullogenesis All of stimulation ovulation procedure needs luteal phase support because usually lack of progesterone Bromocriptin is Used when cause of an ovulation is hyperprolactenemia Anti sperm anti bodies are treated with low dose coticosteroids. Predinsolone 40 – 60 mg is used from day 1 to 10 and than 20 mg for next 2 days. This therapy is given for 6 to 9 months. IUI IVF ICSI Infertility should be evaluated for couples after one year of trying pregnant without contraception. History and Physical examination usually will help to identify the etiology. If patients fail the initial therapies then the proper referral should be made to a reproductive specialist. Optionof adoption is also offered to infertile couples when all the treatments are failed