24 Infertility

Infertility
• Infertility is a unique medical condition-------it

involves a couple, rather than a single individual
• Defined as inability of a couple to conceive after 12
months of regular intercourse (after six months in
women 35 years and older) and without use of
contraception
• Some clinicians use the term subfertility to describe
this failure to conceive unless the couple has been
proven to be sterile.
• Primary vs. Secondary infertility
• Primary infertility, in which no previous
pregnancies have occurred, and
• secondary infertility, in which a prior
pregnancy, although not necessarily a live
birth, has occurred.
• Fecundability is the probability of achieving
pregnancy within a single menstrual cycle
• Fecundity is the probability of achieving a live birth
within a single cycle.
• Sterility implies an intrinsic inability to achieve
pregnancy
• So, what is the difference between sterility and
infertility?
What is the Normal chance of
Pregnancy?
• 25% of couples will conceive within 1 month
• 50% of couples will conceive within 6 months
• 75% of couples will conceive within 9 months
• 80% of couples will conceive within 1 year
Factors Affecting Successful
Conception
• Satisfactory sexual and ejaculatory function,
• Appropriate timing, and
• A Complex set of interactions between the male
and the female reproductive tracts
Prevalence of Infertility
• Affects 15% of couples in US
• More prevalent in developing countries; why do you
think?
Etiology
• Female factor, male factor, combined factor,
unexplained
• Survey by WHO on infertility(8500 couples), in
developed countries, female factor infertility was
reported in 37% of infertile couples, male factor
infertility in 8%, and both male and female factor
infertility in 35%
• Five percent of couples had unexplained infertility
and 15 percent became pregnant during the study
Female factor
• Ovarian/endocrine: anovulation-------30%
• Tubal factors 16%
 tubal occlusion e.g. PID,
 tubal motility d/r e.g. Kartagener’s syndrome
• Cervical factors 4%
 infection( Chlamydia, Ureaplasma),
 cervical surgery, Cone biopsy
 defective sperm-mucus interaction:
immunological/infectious
• Uterine factors 1%: Asherman, TB, submucosal myoma
• Peritoneal factors 5%: adhesions due to Infection,
endometriosis, surgery
Male factors
• Testicular pathologies: gonococal epididmo orchitis, mumps,
cord torsion, trauma, toxins, primary testicular failure
• Anatomical anomalies: e.g. Hypospadia, bilaterally un-
descended testis
• Congenital absence of vas deference
• Varicocele: distended veins of the pampiniform plexus of the
spermatic cord
• Retrograde ejaculation
• Central: Hypothalmic-pituitary-testis axis; e.g. pituitary
adenoma
• Organic or psychogenic impotence
• Unexplained: 14%
Evaluation of infertility
Principles of evaluation
• Both couples should be
evaluated simultaneously
• Couples must be in a position
to have a regular intercourse
• Most important component
of evaluation is Hx
• The recognition, evaluation, and Rx of infertility are
stressful for most couples
• Clinician should not ignore the couple's emotional
state, which may include depression, anger, anxiety,
and marital discord
• It is important to remember that the couple may
have multiple factors contributing to their infertility;
therefore, a complete initial diagnostic evaluation,
including a complete history and physical
examination, should be performed.
Common tests that are useful in most
couples with infertility
1. Semen analysis to assess male factors
2. Menstrual history, assessment of luteinizing
hormone surge in urine prior to ovulation, and/or
luteal phase progesterone level to assess ovulatory
function
3. Hysterosalpingogram or sonohysterogram with a
test of tubal patency such as hysterosalpingo-
contrast-sonography to assess tubal patency and
the uterine cavity.
4. Assessment of ovarian reserve with day 3 serum
follicle-stimulating hormone and estradiol levels,
anti-Müllerian hormone, and/or antral follicle count
5. Thyroid-stimulating hormone
6. Pelvic ultrasound to assess for uterine myomas and
ovarian cysts
7. Laparoscopy to identify endometriosis or other
pelvic pathology
Rx
• Therapy aimed at correcting reversible etiologies
• The couple is also counseled on lifestyle
modifications to improve fertility-----------smoking
cessation, reducing excessive caffeine and alcohol
consumption, and appropriate timing and frequency
of coitus (every one to two days around the
expected time of ovulation)
• Therapeutic interventions for Rx of male and female
infertility may involve
drug therapy, surgery, and/or procedures such as
intrauterine insemination or in vitro fertilization

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Infertility

• Infertility is a unique medical condition-------it

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