Subfertility (Infertility)

SubfertilityBy: Abdullah Mohammad

2014-001

Fertility is the natural capability of producing offspring.

Women who are fertile experience a natural period of fertility before and during ovulation, and they are naturally infertile during the rest of the menstrual cycle.

Depends on factors:◦ Nutrition◦ Sexual behavior◦ Culture◦ Endocrinology◦ Timing◦ Emotions

Fertility

What is Subfertility?

Subfertility is defined as the failure to conceive within 1 year of unprotected regular sexual intercourse.

May also refer to the state of a woman who is unable to carry a pregnancy to full term.

What is Subfertility?

Primary◦ Couples who have had NO previous conception.

Secondary◦ Difficulty conceiving after already having

conceived (and either carried the pregnancy to term or had a miscarriage).

Primary and Secondary Subfertility

In these cases abnormalities are likely to be present but not detected by current methods.

Egg is not released at the optimum time for fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails.

It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization.

Unexplained Subfertility

For a woman to conceive, certain things have to happen:

◦ Intercourse must take place around the time when an egg is released from her ovary.

◦ The systems that produce eggs and sperm have to be working at optimum levels.

◦ And her hormones must be balanced.

Conception

Factors affecting fertility in women. Ovulation Disorders Tubal Damage Age (>37 years)

◦ Reduce chance of a spontaneous conception. Low coital frequency or inappropriate time of

intercourse to ovulation. No previous pregnancy Smoking Malnutrition

◦ Obesity◦ Underweight

Endometriosis, Fibroids, PID (Pelvic Inflammatory Disease).

Arise due to defects in the hypothalamus, the pituitary or the ovary.

Factors that disrupt the release of GnRH:◦ Stress and psychological disturbances. ◦ Weight change. ◦ Systemic Diseases and lesions of the

hypothalamus. ◦ Hyper and Hypothyroidism.

Lead to Anovulation and Ammennorrhea

Ovulation Disorders

Most commonest cause of anovulatory infertility.

Symptoms: ◦ Menstrual Cycle Disturbances. ◦ Obesity◦ Hirsutism◦ Acne and INFERTILITY!

Diagnosis: ◦ Low Sex Hormone binding Globulins. ◦ Ultrasound Appearance of an enlarged ovary with

multiple sub capsular follicles and a dense stroma.

Polycystic Ovarian Disease

Total failure of the ovaries in women under the age of 40 years.

Characterized by: ◦ Amenorrhoea.◦ Raised FSH.◦ Decreased Estradiol.

Linked to genetic causes. ◦ Sex Chromosome abnormality.

Acquired from damage by viruses and toxins.

Pelvic Surgery, irradiation or autoimmune.

Premature Ovarian Failure.

Impaired oocyte pick-up mechanisms by the fimbriae or damaged tubal epithelium.

Tubal Damage following: ◦ Pelvic Infection.◦ Endometriosis.◦ Pelvic Surgery

Pelvic sepsis following appendicitis or peritonitis.

STD’s – Leading to tubal damage. ◦ Chlamydia trachomatis◦ Gonocci

Tubal Dysfunction

Defects related to endometrial development and maintenance.

Submucous Fibroids - benign or non-cancerous tumors found in the muscular wall of the uterus distorting the endometrial cavity.

Disorders of Implantation

The main cause of male subfertility is low semen quality. ◦ Semen quality is a measure of the ability

of semen to accomplish fertilization. Thus, it is a measure of fertility in a man. It is the sperm in the semen that are of importance, and therefore semen quality involves both sperm quantity and quality.

Subfertility associated with viable, but immotile sperm may be caused by Primary Ciliary Dyskinesia.

Male Subfertility

Semen Analysis

Volume 2-5 ml

Liquefaction time Within 30 minutes

Sperm Concentration 20 Million/ml

Sperm Motility >50% progressive motility

Sperm Morphology >30% normal forms

White Blood Cells <1 million/ml

WHO criteria for Semen Analysis

WHO classification of Semen Variables

Normozoospermia Normal ejaculate

Oligozoospermia Sperm concentration fewer than 20x106/ml.

Asthenozoospermia Less than the normal value for motility.

Teratozoospermia Fewer than 30% spermatozoa with normal morphology

Oligoasthenoterato-zoospermiaSignifies disturbance of all three variables.

Azoospermia No spermatozoa in the ejaculate

Aspermia No ejaculate

Full medical and surgical history taken from both the male and female partner:

◦ Drug History?◦ Family History and Lifestyle:

Use of Alcohol, smoking, and recreational drugs?◦ Coital frequency or any difficulties with coitus?◦ Past operation?◦ STDs, Past or Present?

History

Gynecological History?◦ Details of Menarche, Menstrual Cycle, and

Menstrual Frequency.

Women with Irregular Menstruation?◦ Symptoms of PCOS? ◦ Thyroid Disorder? ◦ Hyperprolactinaemia?

Specific History Questions for Women?

Fathered any previous pregnancies?

History of mumps or measles?

History of testicular trauma, surgery to testis?

Specific History Questions for Men?

Examination of both partners is essential to ensure normal reproductive organs.

Males:◦ Assess testicular size, consistency, masses,

absence of vasdeferens, varicocele, evidence of surgical scars.

◦ Small Testes: Primary testicular failure

Female:◦ Full general and pelvic examination.

Examination

Check for HPO dysfunction◦ Follicular FSH, LH, estradiol

Tubal patency ◦ Hysterosalpingogram, Hysterocontrastsonography

or an operative laparoscopy and dye test◦ HSG and HyCoSy are used as screening tests and

if blockage is suggested, patient is counselled for an operative laparoscopy for diagnosis and surgical correction if possible.

Investigations

Semen Analysis◦ Low sperm count or azoospermia-Check

Testosterone levels; low levels suggest production impairment

◦ LH/FSH – Hypogonadotrophic gonadism is treated with FSH and hCG injections

◦ CF screening – Congenital bilateral Absence of Vas Deferens

◦ Karyotyping – Y chromosome deletion (AZF region); can be surgically corrected.

Ovulation Induction (OI) – Clomiphene or FSH◦ Anovulation- PCOS, idiopathic

Intrauterine insemination- with or without stimulation with FSH◦ Unexplained subfertility, Anovulation unresponsive to OI,

Minimal to mild endometriosis Donor Insemination – with or without stimulation with

FSH IVF

◦ Patients with tubal pathology, patients who unresponsive to above treatment

Donor Egg with IVF◦ Previous surgery/chemo with decreased ovarian function,

women whose egg quality is poor

Management-Medical

Adhesions, Endometriosis, Ovarian Cyst Operative laparoscopy to treat disease and restore

anatomy Fibroid Uterus

◦ Myomectomy-Hysteroscopy, laparoscopy, laparotomy, fibroid embolization

Blocked Fallopian Tubes amenable to repair◦ Tubal Surgery

PCOS unresponsive to medical treatment◦ Laparoscopic Ovarian Drilling

Surgical

Thank You!