Infertility

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FEMALE AND MALE
INFERTILITY
Professor Adeyemi O. Adekunle
Department of Obstetrics and Gynaecology
College of Medicine, University of Ibadan
University College Hospital,
Ibadan, Nigeria.
Adekunle A.O.

1

FEMALE AND MALE INFERTILITY
ENABLING OBJECTIVES


Define the various terms associated with
infertility;



List the causes of infertility;



Discuss the diagnosis and routine clinical
examination of the infertile couple;



Discuss the investigations and treatment for
the infertile couple;



List the various forms of Assisted Reproductive
Techniques
Adekunle A.O.

2

Introduction


Infertility is the involuntary failure of a couple
to conceive after 12 months of unprotected
regular coital exposure.



It constitutes 50% of gynaecological
consultations in developing world.



Infertility is associated with emotional and
social distress.



Sterility is a synonymous term.



Fecundity – denotes the probability of
conception.
Adekunle A.O.

3

TYPES AND PREVALENCE
TYPES
 Primary Infertility – no previous conception;


Secondary Infertility – previous conception
(whatever the outcome).

PREVALENCE
 10 – 15% of married couples of reproductive
age.


Infertility is a disorder of couples and both
partners must be evaluated.
Adekunle A.O.

4

Contributions of Partners to Infertility
and Probability of Conception





SOURCE OF THE PROBLEM
Sole cause in the male
Sole cause in the female
Combined cause
No recognizable cause

- 30% - 40%
- 30% - 40%
- 15% - 30%
- 5% - 10%

CHANCES OF PREGNANCY (Normal Couples)
 60% of couples conceive in 6 months
 80% - 85% in 1 year
 90% in 18 months, and
 10% - 15% -- infertile.
Adekunle A.O.

5

ISSUES ASSOCIATED WITH
INFERTILITY IN NIGERIA


Regarded as a social stigma;



Causes marital instability and social neglect;



Results in exploitation and economic
deprivation of female partners;



Causes emotional stress and unhappiness/
psychological consequences;



Male ego.
The longer the couple has been trying to
conceive without success, the greater the
decline in conception rate.
Adekunle A.O.

6

CAUSES OF INFERTILITY - Female










GENERAL
Dietary disturbances
Severe anaemias
Anxiety, fear, etc
(hypothalamus)
ENDOCRINE
Pituitary failure
Adrenal hypoplasia
Polycystic disease
Thyroid disturbances
Ovarian failure














DEVELOPMENTAL
Uterine absence
Uterine anomalies
Hypoplasia
Gonadal dysgenesis
GENITAL DISEASE
Pelvic inflammation
STIs
Tubal obstructions
Myomas and polyps
Vaginitis, Cervicitis
Endometriosis,
Tuberculosis
7
Adekunle A.O.

CAUSES OF INFERTILITY - Male











GENERAL
Fatigue
Alcohol
Excessive smoking
Fear
Excessive coitus
Impotence
ENDOCRINE
Pituitary failure
Adrenal hyperplasia
Thyroid deficiency












DEVELOPMENTAL
Undescended testis
Testicular germinal
aplasia
Klinefelter’s syndrome
Thyroid deficiency
GENITAL DISEASE
Mumps orchitis
Sexually Transmitted
Infections (STIs)
Prostatitis
Adekunle A.O.

8

CAUSES OF INFERTILITY –
Female and Male


Marital maladjustments



Sex problems



Ignorance – (timing, douching)



Low fertility index



Immunological incompatibility

Adekunle A.O.

9

FUNCTIONAL CLASSIFICATION OF
INFERTILITY










TIME
Time of intercourse
Frequency of intercourse
SEMEN
Semen profile
Other components of
ejaculate
OVA
Ovulation
Implantation
Adequacy of corpus luteum

INCUBATOR
 Endometrial dysfunction










TRANSPORT
Male – coital
Female Transport
Failure
Cervical, Uterine
and Tubal
OTHER PROBLEMS
Generalised
endocrine
disorders
Systemic diseases
(e.g. Diabetes
Mellitus)

Adekunle A.O.

10

MANAGEMENT





History
Clinical Examination
Investigations
Treatment
PRINCIPLES OF MANAGEMENT





Deal with the infertile couple together
No one is “at fault” or “to blame”
Carry out investigations and treatment
consistently in proper sequence.
Adekunle A.O.

11

RATIONALE FOR SEEING COUPLE AS
A UNIT


To determine presence of single or multiple
defects;



Engender cooperation between couples on
one hand or couple and gynaecologist on the
other;



Assess level of motivation and emotional
stress of partners;



Improve liaison with other specialists to be
involved e.g., urologist.
Adekunle A.O.

12

History Taking – Female Factors













Age, Current problems.
In utero DES exposurestenosis/cervical
abnormalities
History of pubertal
development (menarche
etc)
Present menstrual cycle
characteristics (length,
duration)
Contraceptive history;
Frequency of
intercourse, timing,
correct acts,
dyspareunia
Galactorrhoea
Hirsutism















Prievious pregnancies,
outcomes
Previous surgeries,
especially pelvic
Previous infectionsSTIs, PID, Abortions
Past treatments/current
treatments
History of abnormal pap
smear, treatment;
Drugs and medication
Hereditary disease.
General health (Diet,
weight stability,
exercise patterns,
review of systems).
13
Adekunle A.O.

History Taking – Ovulatory Factors


Excessive weight loss/weight gain (20%
below or above body weight);



Excessive exercise;



Extreme emotional stress:




death of loved ones;
relocation of home;
Holding too many jobs/responsibilities.



History of heat /cold intolerance, change in
mood - Thyroid disease;



Acne /oily skin - suggests androgen excess;



Exclude galactorrhoea
Adekunle A.O.

14

History Taking – Peritoneal Factors


History of appendicitis /appendix rupture;



Abdominal pelvic operations;



Treatment for P.I.D. (especially chlamydia,
gonoccocal infections);



Previous IUCD insertion;



Premenstrual spotting, dysmenorrhoea,
dyspareunia – Endometriosis.
Adekunle A.O.

15

History Taking – Cervical Factors


Factors that decrease quantity or quality of
cervical mucus may decrease sperm
viability:









Previous operation on the cervix – D & C,
conization, previous abortions;
Prenatal exposure to DES (stenosis &
abnormalities)
Chronic cervicitis,
Douching and use of vaginal lubricants.

Cervical incompetence.
Adekunle A.O.

16

History Taking – Uterine Factors


Previous abortions,



Previous D & C;



Prenatal exposure to DES -- T-shaped
uterus;



Uterine syneachiae;



Fibroids;



Polyps
Adekunle A.O.

17

History Taking – Male Factors


Occupation –excess heat, radiation, toxic
chemicals,? Sedentary jobs;



In utero DES exposure (microphallus,
epidydymal cysts, hypertrophy of the
prostatic utricle);



Congenital abnormalities (History of
undescended testes);
(Presence of unilateral undescended testes
leads to impaired spermatogenesis)



Prior paternity;
Adekunle A.O.

18

History Taking – Male Factors (Contd.)












Frequency of intercourse
Sexual function (difficulty in achieving or
maintaining erection)
Exposure to toxins (environmental)
Previous surgery (Testicular operations/
Bladder neck/ Prostate operation; Testicular
cancer)
Previous infections, treatment (e.g. STIs,
mumps orchitis)
Drugs and medications (e.g.,sulphasalazine,
cimetidine, nitrofurantoin)
General health (diet, exercise, review of
systems)
Adekunle A.O.

19

Examination of the Infertile Couple Female


Look for signs of endocrine or other
systemic diseases;



Examine:
 Heart, lungs, check the BP
 Breasts – abnormal masses, Check for
galactorrhoea
 Abdomen
 Pelvis



Perform postcoital test (PCT)
Adekunle A.O.

20

Examination of the Infertile Couple Male


Look for signs of endocrine or other
pathology, e.g. eunochoid features;



Examine:
 heart, lungs (exclude gynaecomastia),
 abdomen,
 penis, testes, (exclude varicocoeles,
hydrocoele and hernia (supine and
standing).



Perform rectal examination
Adekunle A.O.

21

INVESTIGATIONS
AIMS OF INVESTIGATIONS




To offer an explanation of the infertility;
A prognosis, and
A basis for treatment.
GENERAL LABORATORY INVESTIGATIONS (Both
partners)



Blood group, Hb, W.B.C., E.S.R., test for syphilis,



Chest x-ray if any history or suspicion of respiratory
disease or TB.



Urinalysis – glucose, protein, bacteriology.
Adekunle A.O.

22

INVESTIGATIONS: Tests of Ovulation
BASAL BODY TEMPERATURE RECORDING
(BBTR)


A temperature rise in mid-cycle sustained for
about 14 days suggests that ovulation may
have taken place, but it is not an accurate
index of progesterone levels.



The following features may suggest, but are
not diagnostic of abnormal ovulation
patterns:
 monophasic (perhaps an inability to take
the temperature)


slow rise in temperature, or short elevation
of temperature
Adekunle A.O.

23

INVESTIGATIONS: Tests of Ovulation


Serum progesterone
 Mid-luteal phase (day 21- 23 of a 28 day cycle)



Endometrial biopsy
 If no hormone assays are available and to
exclude tuberculosis where the disease is
common.
(Premenstrual phase ---Secretory changesevidence of ovulation).



Ovulation patterns vary between cycles and it
may therefore be necessary to repeat tests on
more than one occasion.
Adekunle A.O.

24

INVESTIGATIONS: Tests of Ovulation


Serum progesterone levels










Is 2 or 3 times as high as those of the rest of the
cycle (15ng/ml compared with 3 to 6ng/ml) if
ovulation has occurred.
If not, FSH rather than LH levels should be checked
for they are more specific of ovulation.
Prolactin levels should be measured to exclude
microadenomata of the pituitary gland; levels > 1000
mu/L are significant and should lead to a CT scan of
the pituitary fossa).

Vaginal cytology and cervical mucus
Laparoscopy
Serial ultrasound folliculography
Adekunle A.O.

25

INVESTIGATIONS: Tests of Tubal
Patency


LAPAROSCOPY
Tubal patency may be tested under direct
vision at laparoscopy.



A solution of methylene blue is injected
through a tightly fitting cannula (Sparksman
or Rubin) in the cervical canal.



The passage of the dye may be observed:


When the tubes are normally patent, the dye
pours out of the fimbriated end of the tube into
the pouch of Douglas.



Tubal obstruction may be recognized as can the
presence of adhesions; hydrosalpinx may be seen
to fill with dye that does not spill.
26
Adekunle A.O.

INVESTIGATIONS: Tests of Tubal
Patency
HYSTEROSALPINGOGRAHY (HSG)


May be done to evaluate blockage of the
tubes and to show the site of obstruction;



It can also demonstrate a congenital
malformation of the cavity of the uterus,
which will not be apparent at laparoscopy.



A radio- opaque aqueous solution is injected
through the cervix to access the uterine
cavity and patency of the fallopian tubes.
Adekunle A.O.

27

INVESTIGATIONS: Tests of Tubal
Patency
HYSTEROSALPINGOGRAHY (Contd.)


Timing: Within the first 10 days of menstruation (but
at least two days after stoppage of menstrual blood
flow) in order to avoid inadvertent exposure of the
early embryo to ionizing radiation.



Free spillage of dye from both tubes confirms
patency.
Loculated spill may indicate peritubal adhesions and
A club-shaped, dilated appearance on X-rays may
suggest hydrosalpinges.
Filling defects in the uterine cavity are due to
submucous fibroids, polyps or adhesions.






Adekunle A.O.

28

INVESTIGATIONS: Other Tests of Tubal
Patency
CARBON DIOXIDE INSUFFLATION


Is rarely done now because of the dangers of
gas embolism.
HYSTEROCONTRASTSONOGRAHY (HyCoSy)



A modern, ultrasound-based investigation
using a negative (normal saline) and positive
(Echovist) contrast medium to outline the
uterine cavity and fallopian tubes.



It is a simple test to asses the uterine cavity
and tubal potency and it avoids exposure to
x-rays.
Adekunle A.O.

29

INVESTIGATIONS: Other Tests in the
Female




ULTRASOUND
TAS - Global view of the uterus, adnexa and lower
abdomen.
TVS - More detailed evaluation of the uterus &
adnexa.



Evaluates thickness of the endometrium
Favorable endometrium (periovulatory) =7-11mm

OTHER RADIOLOGICAL EXAMINATIONS






Skull x-ray (cone view of the sella turcica).
CT scan/MRI
HYSTEROSCOPY
Submucuos uterine leiomyoma
Intrauterine adhesions or Uterine septum.
TUBOSCOPY AND FALLOSCOPY
Adekunle A.O.

30

INVESTIGATIONS: Male Fertility Tests
SEMEN ANALYSIS (WHO Reference values)








Volume: 2 - 5ml
Liquefaction time: within 30minutes
Concentration: 20 million/ml (20 - 250 million/ml)
Motility: > 50% Progressive motility
Morphology: > 50% normal forms
White blood cells: < 1 million / ml
pH = 7.2-7.8
Process: - Masturbation after 2-3 days of sexual
abstinence and examined within 2 hours of collection.



(A second specimen is examined if the first shows sub
optimal results).

Adekunle A.O.

31

INVESTIGATIONS: Male Fertility Tests
SEMEN VARIABLES (Nomenclature)













Normozoospermia: Normal ejaculates as defined
by the reference values.
Oligozoospermia: Sperm Concentration less than
the reference value.
Asthenozoospermia: Less than the reference
value for motility.
Teratozoospermia: Less than the reference value
for morphology
Oligoasthenoteratozoospermia: Signifies
disturbance of all three variables. (Combination
of only two prefixes may also be used.
)
Azoospermia: No spermatozoa in the ejaculate.
Aspermia: No ejaculate.

Adekunle A.O.

32

INVESTIGATIONS: Male Fertility Tests
ADVANCED SEMEN ANALYSIS


Photomicrography,



Video micrography



These tests are:
 Objective, accurate, and reproducible .



They measure;





Linear velocity
Curvilinear velocity
Cross beat velocity
Lateral head displacement
Adekunle A.O.

33

INVESTIGATIONS: Male Fertility Tests
POSTCOITAL TEST (SIMS-HUNNER TEST)
 Performed in the mid-cycle and within 6-10 hours after
intercourse. The couple should abstain from
intercourse for 3 days. It is possible to assess the
cervical mucus, sperm motility and morphology.











Normal (positive): more than 5 sperms with progressive motion
per HPF
Inconclusive: 1-5 sperms with good motility.
Abnormal (negative): no sperm or all immobile/ non-progressive
or sperm agglutination

OTHER MALE TESTS
HORMONAL ASSAY----LH, FSH, TSH, Prolactin,
Testosterone
TESTICULAR BIOPSY is unnecessary as it may
compromise future therapy like ICSI except if testicular
CIS is suspected.
VASOGRAPHY

Adekunle A.O.

34

TREATMENT –Female Infertility
ANOVULATION


Clomiphene citrate.



Tamoxifen



Cyclofenil



Gonadotrophins



Pergonal ( hMG)
Adekunle A.O.

35

TREATMENT –Female Infertility



TUBAL SURGERY
Microsurgery (Microscopy)
Macro /open surgery (Laparotomy)

Aim: To restore normal anatomy (restore
patency and function) in cases where the
tubes have been damaged by infection.






Salpingolysis: Peritubal adhesions are
divided.
Salpingo-ovariolysis: Removal of
peritubal and periovarian adhesions.
Salpingostomy: Where the fimbrial end is
opened and held open by turning out a
cuff. (Conception rate < 20%).
Adekunle A.O.

36

TREATMENT –Female Infertility
TUBAL SURGERY (Contd.)








Fimbrioplasty: Division of fimbrial adhesions
or repair of fimbrial disease (Conception=
30% - 50%)
Salpingoneostomy: Creation of a new uterine
tubal orifice
Tubal reimplantation: Where the isthmus is
blocked. The medial tubal end is freed and is
re-implanted into the uterine cavity
Re-anastomosis: If the tube is blocked in the
mid segment, the obstructed area is resected
and the open ends re-anastomosed oftenusing microsurgery. (Conception rate 10
-15%).
Adekunle A.O.

37

TREATMENT –Male Infertility











Male fertility depends on sperm quality rather
than numbers.
Hypogonadotropic hypogonadium: Hormonal
treatment (Exogenous hCG +/-GnRH for 12 mths)
Poor sperm motility: Intrauterine insemination +
ovarian stimulation. (AID, AIH)
Infection: Antioxidant therapy (Vitamin E +
Vitamin C) + Antibiotics
Antisperm antibodies: Systemic steroids.
Varicocele: Varicocelectomy
Assisted conception: ICSI
Azoospermia: Sperm aspiration + ICSI
(Chromosomal testing for cystic fibrosis,
karyotyping and Y micro deletions prior to
treatment).
Adekunle A.O.

38

ASSISTED CONCEPTION
TECHNIQUES


First IVF success: Louise Brown on 25/7/78.



Since then, many centres have sprung up all over
the world.

Techniques
 IVF
 DI
 GIFT
 ZIFT
 SUZI
 ICSI
 TESA
 PESA
 MESA

--- In vitro fertilization
--- Donor insemination
--- Gamete intrafallopian transfer
--- Zygote intrafallopian transfer
--- Subzonal insemination
--- Intracytoplamic sperm injection
--- Testicular sperm aspiration
--- Percutanous sperm aspiration
--- Micro-epididymal sperm aspiration.
Adekunle A.O.

39

ASSISTED CONCEPTION
TECHNIQUES
SUCCESS OF IVF/ GIFT




PREGNANCY
1 Embryo 3 embryos -

< 10%
25-30% (single)
5% (twins
1-2% (triplets)

‘TAKE- HOME BABY RATE’: 15-20% for each
Adekunle A.O.

40

ASSISTED CONCEPTION
TECHNIQUES
INDICATIONS FOR IVF


Severe tubal disease



Failed tubal surgery



Endometriosis



Hostile cervix



Unexplained infertility
Adekunle A.O.

41

ASSISTED CONCEPTION
TECHNIQUES
COMPLICATIONS OF IVF


Hyperstimulation syndrome



Pelvic abscess following egg retrieval



Ectopic pregnancy



Anembryonic pregnancy



Spontaneous abortion



Premature delivery



IUGR
Adekunle A.O.

42

OTHER MODES OF TREATMENT


Adoption



Surrogacy



Cloning

Adekunle A.O.

43

FACTORS CONTRIBUTING TO THE
INCREASED DEMAND OF TREATMENT


Increased numbers of women in the
reproductive age group.



A trend towards a later age of child bearing,
with more years of exposure to infections or
toxins as well as age- specific reduction in
fertility.



Availability of new technology and drugs for
treatment of previously hopeless cases.



Greater public awareness of the availability
and scope of such services.
Adekunle A.O.

44

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