 The Infertile Couple

 INFERTILITY –DEFINITION, CAUSES, DIAGNOSTIC PROCEDURES

 Infertility

 Inability to conceive a child or sustain a pregnancy to childbirth

 Pregnancy has not occurred after at least 1 year of engaging in unprotected sexual
intercourse

 Affects 14% of couples desiring children

 Definition of terms

 Primary infertility – no previous conception

 Secondary infertility – previous viable pregnancy but couple is unable to conceive at present

 Sterility – inability to conceive because of a known condition, such as the absence of the uterus.

 Subfertility – lessened ability to conceive

 Male Infertility Factors

 Disturbance in spermatogenesis (sperm cell production)

 Obstruction in the seminiferous tubules, ducts or vessels

 Qualitative or quantitative changes in the seminal fluid preventing sperm motility

 Development of autoimmunity that immobilizes sperm

 Problems of ejaculation or deposition

 Inadequate sperm count

 Sperm count is the number of sperm in a single ejaculation or in a milliliter of semen.

 Minimum considered normal – 20m/ml or 50m/ejaculation

 At least 50% is motile, 30%normal in shape & form

 Cont.

 Spermatozoa must be produced & maintained at a temperature slightly lower than body
temperature.

 This is the reason why the testes is suspended in the scrotum, away from the body surface.
 Conditions affecting the sperm count

 CRYPTORCHIDISM – undescended testes

 VARICOCELE – varicosity of the spermatic vein

 Trauma to the testes

 Surgery

 endocrine imbalance

 drug use & excessive alcohol intake

 CRYPTORCHIDISM

 VARICOCELE

 Obstruction or impaired sperm motility

 May occur at any point

 Adhesions & occlusions produced by

– mumps orchitis

– epididymitis

– tubal infections (gonorrhea)

 Other conditions affecting motility

 Congenital stricture of spermatic duct

 BPH

 Autoimmunization after vasectomy

 Penile anomalies like HYPOSPADIA (urethral opening on the ventral surface of the penis) or
EPISPADIAS (dorsal surface)

 Extreme obesity in male affecting penetration & deposition

 BPH

 HYPOSPADIA/ EPISPADIAS

 Ejaculation Problems

 Psychological problems
 Debilitating disease such as Parkinson’s disease or CVA

 Medications (anti-HPN drugs)

 ERECTILE DYSFUNCTION

Primary – never achieve erection & ejaculation

Secondary – has experienced ejaculation in the past but now has difficulty

Sildenafil (Viagra) – drug of choice

 Viagra

 Female Infertility Factors

 ANOVULATION

– most common cause of infertility in women

– May result from hormonal imbalance.

 Ovarian tumors may produce such d/t feedback stimulation on the pituitary.

 Stress affects by ↓ hypothalamic secretion of GnRH, eventually ↓ LH & FSH

 PCOS – ovaries fail to respond to FSH

 Tubal transport problems

 Scarring of the fallopian tube often caused by PID or salphingitis

 PID – infection of the pelvic organs ; may lead to pelvic peritonitis

 PID usuallt begins with cervical infection that spreads by surface invasion along the
endometrium and then out to the FT & ovaries.

 salphingitis

 Uterine problems

 Tumors

 Congenitally deformed uterine cavity

 Endometriosis

– Implantation of uterine endometrium, or nodules that have spread from the interior of
the uterus to locations outside
 
Endometriosis

 Cervical problems

 cervical mucus

 Polyp obstructing the cervical os

 Cervical polyps

 Vaginal problems

 Infection that may affect the vaginal pH may limit or destroy the motility of the sperm

 Fertility Assessment

Health history

 General health

 Nutrition

 Alcohol, drug or tobacco use

 Congenital health problems

 Current illnesses

 Menstrual history

 Contraceptive use

 Pregnancies or abortions

 Physical assessment

 Secondary sex characteristics

 Genital abnormalities

 Breast and thyroid examination

 Fertility Assessment

Fertility Testing

 Semen Analysis

 After 2-4 days of sexual abstinence

  ejaculates by masturbation into a clean, dry specimen jar

 examined within 1 hour

 Number, appearance & motility is noted

 Test may be repeated after 2-3 months

 The semen analysis should include basic parameters such as sperm number, motility, and
morphology (shape).

 The technician looks at how well the sperm are moving and counts the total percentage of
motile sperm moving.

 sperm

 Sperm penetration Assay & antisperm Antibody testing

 To determine whether a man’s sperm, once it reaches the ovum will effectively penetrate.

 SPERM FUNCTION TESTS SPERM PENETRATION ASSAY/ HAMSTER EGG TEST

 In this test, the husband's sperm is mixed with hamster eggs to see whether they penetrate the
eggs. Healthy sperms penetrate most, specially processed hamster ova from which the zona has
been removed, and produce a significant degree of polyspermy per egg.

 Human zona binding assay:

 In this test, the husband's sperm is mixed with pieces of human egg shells (zona pellucidas) to
see how many will bind to the shells.

 There are a lot less false positives and false negative results as compared to the hamster egg
test.

VARICOCELE ASSESSMENT

 Varicocele is the collection of dilated veins in the spermatic cord.

 Exact cause for infertility is not known but it may be associated with ipsilateral testicular
volume, elevated scrotal temperature and pain, impaired sperm quality- WHO 1992.

 In 31% cases only treatment of varicocele has resulted in improved sperm count.

 SPERM ANTIBODY TESTING

 Semen is known to be highly antigenic and sperm antibodies are a known cause of infertility.

 Agglutination is the sticking together of sperm in variable patterns.

  cont

 It is caused by anti-sperm antibodies which are usually IgA or IgG.

 Further tests like immunobead or mixed anti globulin reaction (MAR) test can be done for the
detection of these antibodies in semen

 HORMONAL ASSESSMENT IN MEN

 A raised FSH level reflects failure of spermatogenesis.

 Low levels of FSH and LH are diagnostic of hypo-gonadotrophic hypogonadism.

 Normal FSH levels with normal testes but azoospermia suggest obstruction

 Raised LH level with low testosterone levels indicate Leydig cell dysfunction.

 Ovulation monitoring

 BBT

 Ovulation by test strip

 Assesses upsurge of LH that occurs before ovulation

 Ferning

 When the cervical mucus dries on a microscope slide, it should take on the appearance of ferns.

 This assures that the mucus has been exposed to adequate levels of estrogen without any
exposure to progesterone.

 Amount - Cervical mucus production normally increases dramatically just prior to ovulation.

 Clarity - It should be very clear, almost watery.

 Cellularity - There should be relatively few cells present, other than sperm.

 Spinnbarkeit –

This is the stretchiness

of the cervical mucus.

It should be almost

elastic and may stretch

10 cms or more.

POST-COITAL TEST

 Give information how the cervical mucus and sperm interact, to determine whether the mucus
in the cervix is "hostile" to sperm.

 The test must be done within one to two days before or after ovulation.

 A couple should abstain from intercourse for 2 days before ovulation, then have intercourse 2-8
hours prior to the hospital visit for the post-coital test.

 Tubal Patency

 Sonohysterography

 Ultrasound to inspect uterus

 inspect the uterus for abnormalities

 septal deviation or mass.

 Hysterosalpingography

 Radiologic exam of fallopian tubes

 radiopaque medium most commonly used to assess tubal patency

 Advanced Surgical Procedures

 Uterine Endometrial Biopsy

 Used as a test for ovulation or to reveal an endometrial problem such as luteal phase defect.

 Endometrium resembles a corkscrew – ovulation has occurred

 done 2 or 3 days before the expected menstrual flow

 Contraindications

 Suspected pregnancy

 Presence of infection

 Caution that spotting may occur

 Hysteroscopy

 Visual inspection of the uterus through the insertion of a hysteroscope, a thin, hollow tube,
through the cervix.
  Helpful when uterine adhesions are discovered previously

 It uses a hysteroscope, which is a thin telescope that is inserted through the cervix into the
uterus.


HYSTEROSCOPY

 This procedure allows to determine whether there are any abnormalities such as fibroid tumors,
polyps, scar tissue, a uterine septum, or some other uterine problem

 HYSTEROCONTRAST SONOGRAPHY HyCoSy

 A combination of air and saline or contrast medium (Echovist-200) is introduced into the uterus
transcervically.

 The flow of the medium seen in some unanaesthetised women is more through the uterus and
tubes, and its spill in the pelvis with water soluble than with oily or non-ionic media is monitores
by ultrasound.

 Complications like immediate pain, vomiting, shock and hypotension can occur.

 FALLOPOSCOPY

 The falloposcopy is a visual examination of the inside of the fallopian tubes.

 This involves the insertion of a tiny catheter through the cervical canal and into the uterus to the
fallopian tubes.

 It is then, an even smaller fiber optic endoscope is threaded through the catheter, into the
fallopian tube.

 Laparoscopy

 Introduction of a thin, hollow, lighted tube through a small incision in the abdomen, just under
the umbilicus

 examine the position and state of the FT & ovaries.

 follicular phase of a menstrual period and is done under GA

 The surgeon makes a very small incision below the belly button and inserts an instrument called
a laparoscope

Laparoscopy picture

of a hydrosalpinx,
fallopian tube that is

blocked and dilated

withfluid. This is

evidence of PID

 Infertility Management

 Correction of underlying problem

 Increasing sperm count and motility by abstinence of 7-10 days to ↑ count

 Reducing the presence of infection

 Hormone therapy – Clomiphene Citrate

 Surgery - Myomectomy

 Assisted Reproductive Techniques

 Artificial insemination

 Instillation of sperm into the female reproductive tract to aid conception.

 CRYOPRESERVED (frozen)

 1 day after ovulation, sperm is injected

 Artificial insemination

 In vitro fertilization

 One or more mature oocytes are removed from a woman’s ovary by laparoscopy & fertilized by
exposure to sperm under laboratory conditions outside the woman’s body.

 40 hrs. after fertilization, ova is inserted into the woman’s uterus where 1 would implant & grow
ideally.

 Used by couples who has not conceived

 Man with oligospermia

 Unexplained infertility

 Donor ovum maybe used

 Before the procedure, GnRH is given.

 10th day of menstrual cycle, ovaries are observed. When a mature follicle is seen via sonography,
Hcg is injected causing ovulation 38-42 hours later.

 Gamete intrafallopian transfer

 Ova obtained as in IVF

 Both ova & sperm are instilled within a matter hours using a laparoscopic technique, into an
open end of a patent FT

 Contrainidicated in blocked FT as it may lead to ectopic pregnancy

 Zygote intrafallopian transfer (ZIFT)

 Fertilization in the tube, zygote in the uterus for implantation

 Differs from GIFT as there is no need for at least a functional FT since it is implanted in the
uterus

 Surrogate embryo transfer

 Assisted in women who does not ovulate

 Donated oocyte

 Synchronized menstrual cycle of donor & recipient, gonadotrophic hormones are administered

 INFERTILITY COUNSELLING

 The basic aim of counselling is to ensure that the patient understands the implications of their
treatment choice, the patient receives adequate information and emotional support, and that
they can cope in a healthy way with the consequences of treatment.

 IMPLICATION COUNSELLING

 It is to enable couples to understand the implications of the proposed treatment for themselves,
their family and for any children born as a result.

 This may of particular relevance for couple seeking treatment with donor eggs, donor sperm,
donor embryos or surrogacy.

 Genetic counselling should be offered when there is an increased risk of passing on an inherited
disease to the offspring.

 Psychological counselling should be offered for partners suffering from psychosexual problems.

 SUPPORT COUNSELLING

 To give emotional support and information from the start of the treatment.
 It is primarily the task of the clinical team but unfortunately, tension often erases much of the
information, which has been given, and many patients will not have fully digested what have
been said.

 Infertility counselors need to address these defects and detects any tensions showed by the
patient's poor understanding

 THERAPEUTIC COUNSELLING

 To help couples understand their expectation including the prospects of failure and adjusting to
childlessness, counselling can with time, help people adjusts and accepts the situation.

 Therapeutic counselling also focuses on certain issues such as sexual and menstrual problems

 Role of a Counselor

 The role of counselor is to help infertile couples process their emotions and to arrive at a
situation with which they feel comfortable and with which they can live a normal life.

 It is essential that counselling must be informal and effective and not a hindrance and waste of
time.

 Counselors should have up-to-date knowledge of infertility and assisted reproductive

treatments.