Subfertility

INFERTILITYDR. IBEANU

OUTLINE DEFINITION INCIDENCE CLASSIFICATION FACTORS FOR FERTILITY ETIOLOGY INVESTIGATION MANAGEMENT

DEFINITION

Failure of a couple of reproductive age that live together to conceive despite:

Regular (2/3times a week with spaced intervals(alternate days))

Unprotected coitus

Peniovaginal intercourse

Leading to ejaculation

Absence of contraception

Time

INCIDENCE

In developed countries, infertility affects about 10% - !5% of married couples.

In Nigeria, the incidence varies from 25% – 30%. Despite growing concern about overpopulation and under nutrition in Africa, It is estimated that about 30% - 40% of women in sub-Saharan Africa, would complete their reproductive years without a child.

CLASSIFICATION

Primary: Denotes couples who have never conceived

Secondary: Indicates previous pregnancy but failure to conceive subsequently

FACTORS RESPONSIBLE FOR FERTILITY

Healthy Spermatozoa

Ovulation

Spermatozoa should fertilize the oocyte at the ampulla of F.tube

Embryo should reach the uterine cavity after 3 – 4 days of fertilization

Endometrium should be receptive for implantation and corpus luteum should function adequately

ETIOLOGY

Causes of Infertility includes:

Male factor (40%)

Female factor (40%)

Combined (10%)

Unexplained factor (5% - 10%)

MALE FACTOR

PRE - TESTICULAR

Endocrine:

Gonadotropin deficiency

Thyroid dysfunction

Hyperprolactinemia

Psychosexual:

Erectile dysfunction

Impotence

Drugs:

Antihypertensive

Antipsychotics

Genetic:

47 XXY

Y chromosome deletions

TESTICULAR

Immotile cilia (kartagener syndrome)

Cryptorchidism

Infection (mumps, orchitis)

Toxins: drugs, radiation

Varicocele

Immunologic

Sertoli-cell-only syndrome

Primary testicular failure

Oligoasthenoteratozoospermia

POST - TESTICULAR

Congenital:

Absence of Vas deferens (cystic fibrosis)

Young's syndrome

Acquired infections:

TB

Gonorrhoea

Surgical:

Herniorrhaphy

Vasectomy

Others:

Ejaculatory failure

Retrograde ejaculation

Hypospadia

Bladder neck surgery

FEMALE FACTOR

OVARIAN

Anovulation or oligo-ovulation

Decreased ovarian reserve

Luteal phase defect (due to defective folliculogenesis)

Luteinised unruptured follicular syndrome (trapped ovum)

TUBAL & PERITONEAL FACTORS

Pelvic infections causing:

Peritubal adhesions

Endosalpingeal damage

Previous tubal surgery or sterilization

Salpingitis isthmica nodosa

Tubal endometriosis

Polyps

UTERINE

Congenital malformation

Uterine fibroid

Chronic endometritis

Endometial damage

CERVICAL

Chronic cervicitis

Cervical stenosis

Immunological factor (antisperm antibody)

VAGINA

Congenital (atresia, transverse vaginal septum, narrow introitus)

Vaginism

COMBINED

Age (F > 35 years)

Infrequent sexual intercourse, lack of knowledge of coital technique & timing of coitus

Apareunia and dyspareunia

Anxiety and apprehension

Use of lubricants which maybe spermicidal

Immunological factor

INVESTIGATION

OBJECTIVES

To detect the aetiological factor(s)

To rectify the abnormality in an attempt to improve the fertility

To give assurance with explanation to the couple if no abnormality is detected

WHAT TO INVESTIGATE ?

Semen analysis

Confirmation of ovulation

Confirmation of tubal patency

MALE

PROPER HISTORY

Age

Prev. marriage

STI

Prev. surgery

Occupational hx (exposure to excessive heat or radiation)

Sex hx (frequency, erection, penetration, orgasm, satisfaction)

Social habits etc

PHYSICAL EXAMINATION

Inspection and palpation of the genitalia.

Size and consistency of testicles

Testicular volume (measured by an orchidometer) should be at least 20 cm3

SEMINAL FLUID ANALYSIS

Volume 2 – 5ml

Count > 20 million

Morphology > 30%

Motility > 50%

pH 7.5 - 8

Viability > 75% living

TRANSRECTAL US

Indications include:

Azoospermia or severe oligospermia with normal testicular volume

Abnormal DRE

Ejaculatory duct abnormality

Genital abnormality (hypospadias)

OTHERS:

Testicular biopsy

Vasogram

Blood and urine tests

Hormone profile; serum FSH, LH, testosterone, prolactin & TSH

Karyotype analysis

Immunological tests

FEMALE

PROPER HISTORY

General medical history

Surgical history

Menstrual history

Previous Obstetric history

Contraceptive practice

Sexual problems

EXAMINATIONS

General examination

Systemic examination

Gynecological examination

Speculum examination

Vaginal examination

Basal body temperature

Abdomino-pelvic US

Hysterosalpingography (HSG)

Hormone profile

Laparoscopy and chromopertubation (NB: precisely diagnose peritubal adhesions, pelvic endometriosis. Chromopertubation with methylene blue reveals patency and nature of tubal motility)

Immunological test

Post-coital test

Hormone profile:

S. Progesterone: done 21th day mid cycle. > 25 ng/ml suggests ovulation

S. LH: Daily estimation of serum LH at midcycle can detect LH surge. Ovulation occurs about 34-36 hours after beginning of the LH surge. It coincides about 10 -12 hours after LH peak.

S. oestradiol: attains the peak rise approximately 24 hours prior to LH surge and about 24 – 36 hours prior to ovulation

MANAGEMENT

Assurance

Control risk factors:

Body weight

Smoking and alcohol

Psychosocial

Treat etiological factor

SURGICAL: Vaso-vasostomy, varicocelectomy

CONSERVATIVE:

Ovulation induction; clomiphene citrate, Letrozole, hMG (Humegon, Pergonal)

Antiprolactin agent; bromocriptine

Antibiotics

Steriods

ARTIFICIAL REPRODUCTIVE TECHNIQUE:

Artificial Insemination

In vitro fertilization and embryo transfer

Intracytoplasmic sperm injection

THANK YOU

FOR YOUR ATTENTION