Infertility

1. Infertility

2. Infertility • The inability to conceive following unprotected sexual intercourse • 1 year (age < 35) or 6 months (age >35) Normally a fertile couple has approximately a 20 % chance of conception in each ovulatory cycle

3. Infertility • Primary infertility • a couple that has never conceived • Secondary infertility • infertility that occurs after previous pregnancy regardless of outcome

4. Requirements for Conception normally developed reproductive tract in both the male and female partner normal functioning of an intact hypothalamic-pituitary-gonadal axis supports gametogenesis (the formation of sperm and ova). timing of intercourse Unblocked tubes that allow sperm to reach the egg The sperms ability to penetrate and fertilize the egg Implantation of the embryo into the hormone-prepared endometrium Finally a healthy pregnancy

5. Infertility. Statistic • A female factor (ovulatory dysfunction, pelvic factor) is in approximately 50% • A male factor (sperm and semen abnormalities) is in approximately 35% • Unexplained factors and causes (e.g., coital techniques) related to both partners are in approximately 15%

6. Causes for infertility

7. Cause of Female Infertility • CONGENITAL OR DEVELOPMENTAL FACTORS • Abnormal external genitals • Absence of internal reproductive structures • HORMONAL FACTORS • Anovulation-primary • Pituitary or hypothalamic hormone disorder Adrenal gland disorder • Congenital adrenal hyperplasia • Anovulation-secondary • Disruption of hypothalamic-pituitary-ovarian axis Early menopause • Amenorrhea after discontinuing OCP Increased prolactin levels • TUBAL/PERITONEAL FACTORS • Absence of fimbriated end of tube Tubal motility reduced • Absence of a tube Inflammation within the tube Tubal adhesions • UTERINE FACTORS • Developmental anomalies • Endometrial and myometrial tumors • Asherman syndrome (uterine adhesions or scar tissue)

8. Cause of Female Infertility CONGENITAL OR DEVELOPMENTAL FACTORS

9. Cause of Female Infertility CONGENITAL OR DEVELOPMENTAL FACTORS

10. Cause of Female Infertility CONGENITAL OR DEVELOPMENTAL FACTORS

11. Cause of Female Infertility CONGENITAL OR DEVELOPMENTAL FACTORS

12. Cause of Female Infertility TUBAL/PERITONEAL FACTORS • Chlamidial infection • Pelvic infections (ruptures appendix, STIs)

13. Cause of Female Infertility UTERINE FACTORS Uterine fibroids

14. Cause of Female Infertility UTERINE FACTORS Endometrial tumor

15. Cause of Female Infertility UTERINE FACTORS Asherman syndrome

16. Cause of Female Infertility VAGINAL-CERVICAL FACTORS • Vaginal-cervical infection • Sperm antibody

17. Cause of Male Infertility • STRUCTURAL OR HORMONAL DISORDERS Undescended testes Hypospadias Testicular damage Varicocele Low testosterone levels caused by mumps • OTHER FACTORS Endocrine disorders Genetic disorders Psychologic disorders Sexually transmitted infections Exposure of scrotum to high temperatures Exposure to workplace hazards such as radiation or toxic substances • SUBSTANCE ABUSE • Changes in sperm (Smoking, heroin, marijuana, amyl nitrate, butyl ni­trate, ethyl chloride, methaqualone, Monoamine oxidase) • Decrease in sperm (Hypopituitarism, Debilitating or chronic disease, Trauma, Gonadotropic inadequacy, Decrease in libido Heroin, methadone, selective serotonin reuptake in­hibitors, and barbiturates) • Impotence (Alcohol, Antihypertensive medications) • OBSTRUCTIVE LESIONS OF THE EPIDIDYMIS AND VAS DEFERENS • NUTRITIONAL DEFICIENCIES

18. Cause of Male Infertility STRUCTURAL OR HORMONAL DISORDERS

19. 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

20. Assessment of woman • 1.Age • 2. Duration of infertility (length of contraceptive and noncontraceptive exposure) • 3. Obstetric • A. number of pregnancies, miscaridges and abortion • B. Length of time required to initiate each pregnancy • C. Complication of pregnancy • D. Duration of lactation • 4. Gynecologic: detailed menstrual history • 5. Previous tests and therapy of infertility • 6. Medical: general (chronic&hereditary disease), medication, family problem, sexual development, galactorrhea • 7. Surgical: abdominal or pelvic surgery

21. 1. Follicular development, ovulation, and luteal develop­ment are supportive of pregnancy: • a. Basal body temperature (presumptive evidence ofovulatory cycles) is biphasic, with temperature eleva­tion that persists for 12 to 14 days before menstruation • b. Cervical mucus characteristics change appropriatelyduring phases of menstrual cycle • c. Laparoscopic visualization of pelvic organs verifiesfollicular and luteal development • 2. The luteal phase is supportive of pregnancy: • a. Levels of plasma progesterone are adequate • b. Findings from endometrial biopsy samples are con­sistent with day of cycle • 3. Cervical factors are receptive to sperm during expectedtime of ovulation: • a. Cervical os is open • b. Cervical mucus is clear, watery, abundant, and slip­pery and demonstrates good spinnbarkeit and ar­borization (fern pattern) • c. Cervical examination does not reveal lesions or in­fections • d. Postcoital test findings are satisfactory (adequatenumber of live, motile, normal sperm present in cer­vical mucus) • e. No immunity to sperm demonstrated • 4. The uterus and uterine tubes are supportive of preg­nancy: • a. Uterine and tubal patency are documented by • Spillage of dye into peritoneal cavity • Outlines of uterine and tubal cavities of adequatesize and shape, with no abnormalities • b. Laparoscopic examination verifies normal develop­ment of internal genitals and absence of adhe­sions, infections, endometriosis, and other lesions • 5. The male partner's reproductive structures are normal: • a. No evidence of developmental anomalies of penis,testicular atrophy, or varicocele (varicose veins onthe spermatic vein in the groin) • b. No evidence of infection in prostate, seminal vesi­cles, and urethra • c. Testes are more than 4 cm in largest diameter • 6. Semen is supportive of pregnancy: • a. Sperm (number per milliliter) are adequate in ejacu­late • b. Most sperm show normal morphology • c. Most sperm are motile, forward moving • d. No autoimmunity exists • e. Seminal fluid is normal

22. Abnormalities of Spermatogenesis

23. Normal Sperm made in seminiferous tubules Travel to epididymis to mature

24. Normal Sperm exit through vas deferens Semen produced in prostate gland, seminal glands, cowpers glands Sperm only 5% of ejaculation Sperm can live 5-7 days

25. Semen Analysis (SA) • Obtained by masturbation • Provides immediate information • Quantity • Quality • Density of the sperm • Morphology • Motility • 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

26. Normal Values for SA Volume Sperm Concentration Motility Viscosity Morphology pH WBC • 2.0 ml or more • 20 million/ml or more • 50% forward progression 25% rapid progression • Liquification in 30-60 min • 30% or more normal forms • 7.2-7.8 • Fewer than 1 million/ml

27. Causes for Abnormal SA Abnormal Count • No sperm • Klinefelter’s syndrome • Sertoli only syndrome • Ductal obstruction • Hypogonadotropic-hypogonadism • Few sperm • Genetic disorder • Endocrinopathies • Varicocele • Exogenous (e.g., Heat)

28. Continues: causes for abnormal SA • Abnormal Morphology • Varicocele • Stress • Infection (mumps) • Abnormal Motility • Immunologic factors • Infection • Defect in sperm structure • Poor liquefaction • Varicocele • Abnormal Volume • No ejaculate • Ductal obstruction • Retrograde ejaculation • Ejaculatory failure • Hypogonadism • Low Volume • Obstruction of ducts • Absence of vas deferens • Absence of seminal vesicle • Partial retrograde ejaculation • Infection

29. Causes for male infertility • 42% varicocele • repair if there is a low count or decreased motility • 22% idiopathic • 14% obstruction • 20% other (genetic abnormalities)

30. Abnormal Semen Analysis • Azoospermia • 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

31. Evaluation of Abnormal SA • Repeat semen analysis in 30 days • Physical examination • Testicular size • Varicocele • Laboratory tests • Testosterone level • FSH (spermatogenesis- Sertoli cells) • LH (testosterone- Leydig cells) • Referral to urology

32. Evaluation of Ovulation

33. Female Reproductive System Ovaries Two organs that produce eggs Size of almond 30,000-40,000 eggs Eggs can live for 12-24 hours

34. 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

36. Ovulation • mild peripheral edema • slight weight gain • depression • A history of regular menstruation suggests regular ovulation • The majority of ovulatory women experience • fullness of the breasts • decreased vaginal secretions • abdominal bloating • Absence of PMS symptoms may suggest anovulation

38. Diagnostic studies to confirm Ovulation • Basal body temperature • Inexpensive • Accurate • Endometrial biopsy • Expensive • Static information • Serum progesterone • After ovulation rises • Can be measured • Urinary ovulation-detection kits • Measures changes in urinary LH • Predicts ovulation but does not confirm it

39. Basal Body Temperature • Excellent screening tool for ovulation • Biphasic shift occurs in 90% of ovulating women • Temperature • drops at the time of menses • rises two days after the lutenizing hormone (LH) surge • Ovum released one day prior to the first rise • Temperature elevation of more than 16 days suggests pregnancy

41. Serum Progesterone • Progesterone starts rising with the LH surge • drawn between day 21-24 • Mid-luteal phase • >10 ng/ml suggests ovulation

42. Salivary Estrogen: TCI Ovulation Tester- 92% accurate

43. Add Saliva Sample

46. Non-Ovulatory Saliva Pattern

47. High Estrogen/ Ovulatory Saliva Pattern

48. Anovulation

49. Anovulation Symptoms Evaluation* • Order the appropriate tests based on the clinical indications Irregular menstrual cycles Amenorrhea Hirsuitism Acne Galactorrhea Increased vaginal secretions Follicle stimulating hormone Lutenizing hormone Thyroid stimulating hormone Prolactin Androstenedione Total testosterone

50. Anatomic Disorders of the Female Genital Tract