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 37th and 45th 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
Unexplained infertility
• 10%
of infertile couples will have a completely normal workup
• Pregnancy
rates in unexplained infertility
– no
treatment 1.3-4.1%
– clomid
and intrauterine insemination 8.3%
– gonadotropins
and intrauterine insemination 17.1%
Summary
• Infertility
is the inability to conceive following unprotected sexual intercourse
• Infertility
should be evaluated after one year of unprotected intercourse
• Primary
infertility – a couple that has never conceived
• Secondary
infertility – infertility that occurs after previous pregnancy regardless of
outcome
• History
and Physical examination usually will help to identify the etiology.
