Infertility

Content

• Infertility      
• Definition
• Causes
• Evaluation
  of the Infertile couple
• Abnormalities
  of Spermatogenesis
• Evaluation
  of Ovulation
• Diagnosis

Objectives

At the
end of this PDF Notes, students will be able to –

•       Define primary and secondary
infertility

•       Describe the causes of infertility

Infertility

•       The
inability to conceive following unprotected 
sexual intercourse

–      1
year (age < 35) or 6 months (age >35)

–      Affects
15% of reproductive couples

•       6.1
million couples

–      Men
and women equally affected

•       Reproductive
age for women

–      Generally
15-44 years of age

–      Fertility
is approximately halved between 37^th and 45^th year due to
alterations in ovulation

–      20%
of women have their first child after age 30

–      1/3
of couples over 35 have fertility problems

•       Ovulation
decreases

•       Health
of the egg declines

Primary
infertility

–      a
couple that has never conceived

Secondary
infertility

–      infertility
that occurs after previous pregnancy regardless of outcome

Requirements
for Conception 

•       Production
of healthy egg and sperm

•       Unblocked
tubes that allow sperm to reach the egg

•       The
sperms ability to penetrate and fertilize the egg

•       Implantation
of the embryo into the uterus

•       Finally
a healthy pregnancy

Causes for infertility

•       Male

–      ETOH

–      Drugs

–      Tobacco

–      Health
problems

–      Radiation/Chemotherapy

–      Age

–      Enviromental
factors

•       Pesticides

•       Lead

•       Female

–      Age

–      Stress

–      Poor
diet

–      Athletic
training

–      Over/underweight

–      Tobacco

–      ETOH

–      STD’s

–      Health
problems

Causes
of Infertility

•       Anovulation
(10-20%)

•       Anatomic
defects of the female genital tract (30%)

•       Abnormal
spermatogenesis (40%)

•       Unexplained
(10%-20%)

Evaluation
of the Infertile couple

•       History
and Physical exam

•       Semen
analysis

•       Thyroid
and prolactin evaluation

•       Determination
of ovulation

–      Basal
body temperature record

–      Serum
progesterone

–      Ovarian
reserve testing

•       Hysterosalpingogram

Abnormalities of Spermatogenesis

Male Factor

•       40%
of the cause for infertility

•       Sperm
is constantly produced by the germinal epithelium of the testicle

–      Sperm
generation time 73 days

–      Sperm
production is thermoregulated

•       1°
F less than body temperature

•       Both
men and women can produce anti-sperm antibodies which interfere with the
penetration of the cervical mucus

Semen
Analysis (SA)

•       Obtained
by masturbation

•       Provides
immediate information

–      Quantity

–      Quality

–      Density
of the sperm

•       Abstain
from coitus 2 to 3 days

•       Collect
all the ejaculate

•       Analyze
within 1 hour

•       A
normal semen analysis excludes male factor 90% of the time

Normal Values for SA

Volume – 2.0 ml
or more

Sperm Concentration
– 20 million/ml or more

Motility – 50%
forward progression

                 25%
rapid progression

Viscosity – Liquification
in 30-60 min

Morphology – 30%
or more normal forms

pH – 7.2-7.8

WBC – Fewer than
1 million/ml

Causes
for male infertility

•       42%
varicocele

–      repair
if there is a low count or decreased motility

•       22%
idiopathic

•       14%
obstruction

•       20%
other (genetic abnormalities)

Abnormal Semen Analysis

•       Azospermia

–      Klinefelter’s
(1 in 500)

–      Hypogonadotropic-hypogonadism

–      Ductal
obstruction (absence of the Vas deferens)

•       Oligospermia

–      Anatomic
defects

–      Endocrinopathies

–      Genetic
factors

–      Exogenous
(e.g. heat)

•       Abnormal
volume

–      Retrograde
ejaculation

–      Infection

–      Ejaculatory
failure

Evaluation of Ovulation

Menstruation

•       Ovulation
occurs 13-14 times per year

•       Menstrual
cycles on average are Q 28 days with ovulation around day 14

•       Luteal
phase

–      dominated
by the secretion of progesterone

–      released
by the corpus luteum

•       Progesterone
causes

–      Thickening
of the endocervical mucus

–      Increases
the basal body temperature (0.6° F)

•       Involution
of the corpus luteum causes a fall in progesterone and the onset of menses

Ovulation

•       A
history of regular menstruation suggests regular ovulation

•       The
majority of ovulatory women experience

–      fullness
of the breasts

–      decreased
vaginal secretions

–      abdominal
bloating

–      mild
peripheral edema

–       slight weight gain

–       depression

•       Absence
of PMS symptoms may suggest anovulation

Anovulation

Symptoms

•       Irregular
menstrual cycles

•       Amenorrhea

•       Hirsuitism

•       Acne

•       Galactorrhea

•       Increased
vaginal secretions

Evaluation*         

•       Follicle
stimulating hormone

•       Lutenizing
hormone

•       Thyroid
stimulating hormone

•       Prolactin

•       Androstenedione

•       Total
testosterone

•       DHEAS

*Order the appropriate
tests based on the clinical indications

Anatomic
Disorders of the Female Genital Tract
Sperm
Transport, Fertilization, & Implantation

•       The
female genital tract is not just a conduit

–      facilitates
sperm transport

–      cervical
mucus traps the coagulated ejaculate

–      the
fallopian tube picks up the egg

•       Fertilization
must occur in the proximal portion of the tube

–      the
fertilized oocyte cleaves and forms a zygote              

–      enters
the endometrial cavity at 3 to 5 days

•       Implants
into the secretory endometrium for growth and development

Congenital Anatomic Abnormalities