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INFERTILITY

INFERTILITY. Infertility: Introduction. Significant social and medical problem affecting couples worldwide Average incidence of infertility is about 15% globally varies in different populations Some causes can be detected and treated, whereas others cannot

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INFERTILITY

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  1. INFERTILITY

  2. Infertility: Introduction Significant social and medical problem affecting couples worldwide • Average incidence of infertility is about 15% globally • varies in different populations • Some causes can be detected and treated, whereas others cannot • unexplained infertility constitutes about 10% of all cases

  3. Definition of Infertility Inability to conceive after 12 months of having sexual intercourse with average frequency (2 to 3 times per week), without the use of any form of birth control

  4. DEFINITION of Infertility What is Infertility? Infertility is defined two years of unprotected intercourse without pregnancy. (WHO, one year) What is sterility? Absolute inability to conceive

  5. Types of Infertility • Primary infertility • couple has never produced a pregnancy • Secondary infertility • woman has previously been pregnant, regardless of the outcome, and • now is unable to conceive

  6. Conception and Fertility • The chances of conceiving in any given menstrual cycle is less than 20% • Main events necessary for pregnancy to occur are: • ovulation • fertilization • implantation Any condition that interferes with these events may result in infertility

  7. Factors Affecting Fertility:Timing of Intercourse Intercourse just before ovulation maximizes the chance of pregnancy • Sperm survives as long as 5 days in the female genital tract • Ovum life expectancy is about 1 day if not fertilized • Sperm should be available in the female genital tract at or shortly before ovulation

  8. Requirements for Male Fertility • Normal spermatogenesis in order to fertilize egg: • sperm count • motility • biological structure and function • Normal ductal system to carry sperm from the testicles to the penis

  9. Requirements for Female Fertility • Adequate sexual drive and sexual function • Normal immunologic responses to accommodate sperm and conceptus • Adequate nutritional and health status to maintain nutrition and oxygenation of placenta and fetus

  10. Factors Affecting Fertility:STIs and Other Infections • Gonorrhea and chlamydia can cause: • in women: pelvic inflammatory disease (major cause of tubal infertility) and cervicitis • in men: urethritis, epididymitis, accessory gland infection • Mumps, leading to orchitis, may cause secondary testicular atrophy • Other infections that may affect fertility include tuberculosis, toxoplasmosis, malaria, schistosomiasis and leprosy

  11. Factors Affecting Fertility (Continued) • Age of the woman • after 40 the fertility rate decreases by 50% while the risk of miscarriage increases • Age of the man • increased age affects coital frequency and sexual function • Nutrition • for women, weight 10% to15% below normal or obesity may lead to less frequent ovulation and reduced fertility

  12. Factors Affecting Fertility(Continued) • Factors that can contribute to fertility problems include: • toxic agents, such as lead, toxic fumes and pesticides • smoking and alcohol • All these factors may cause: • in women: reduced conceptions and increased risk of fetal wastage • in men: reduced sex drive and sperm count

  13. Infertility: Female and Male Factors • Infertility may be a result of one or more male or female factors • Female and male factors are equally responsible for infertility (30% to 40% each) • in 20% of cases there is a combination of both factors • Evaluating both partners is essential

  14. Causes Causes Percentage Female factors 40-55 % Male factors 25-40 % Both male and female factors 10 % unexplained factors 10 %

  15. Female Factors Ovulatory dysfunction: 1. Hypothalamic dysfunction; 2. Pituitary Insufficiency; 3. Ovarian factor (peripheral defect); 4. Others: thyroid or adrenal dysfunction; Pelvic factorsP: 1. Tubal factors: injury, blockage, adhesion; 2. Uterine factors; 3. Cervical factors; 4. Extra-genital tract factors;

  16. Causes of Female Infertility(Continued) • Local factors in the uterus and cervix • may interfere with implantation and woman’s ability to carry pregnancy to term • Luteal phase defect • results in low production of progesterone • may lead to early miscarriage • Production of anti-sperm antibodies • can interfere with fertilization

  17. Female Factors Hypothalamus Pituitary Follopian tube Uterine ovary oocyte Cervix Extra-genital tract sperm Thyroid Adrenal

  18. Male Factors 1. Abnormal spermatogenesis congenital; chronic diseases; infectious factors; 2. Obstructive; 3. Immunologic factors; 4. Endocrine disorders; 5. Sexual dysfunction;

  19. Causes of Male Infertility • Conditions that affect quality or quantity of sperm may lead to infertility • These conditions include: • varicocele • primary testicular failure • accessory gland infection • idiopathic low sperm motility

  20. Both Male and Female Factors 1. No demonstrable cause; 2. Psychological factors; 3. Immunologicfactors; count for 10%; autoimmune response; auto-antibodies;

  21. Initial Visit • The initial visit is the most important; • The infertility is a problem of couple; • The male partner should be present; • History: both male and female; • The guide to diagnostic and treatment plans;

  22. Basic Work-up for Infertility Evaluating both partners is essential • Detailed history andphysical examination for both • Semen analysis • Evidence of ovulation • Evidence of fallopian tubes patency • Postcoital test • still performed by some clinicians • not found valid by some studies

  23. Fertility Evaluation Procedure • Couple should be informed about: • different causes of infertility • tests and procedures required to make a diagnosis • various therapeutic possibilities • Couple’s interview is conducted together as well as separately to obtain confidential information Richard Lord

  24. Fertility Evaluation:General and Sexual History • General history • occupation and background • use of tobacco, alcohol and drugs • history of abdominal surgery and earlier diseases/infections • Sexual history • sexual disturbances or dysfunction such as vaginismus, dyspareunia or erectile dysfunction • sexually transmitted infections

  25. Fertility Evaluation: Obstetric and Gynecological History • Reproductive history • Gynecological history • Age at menarche • Menstrual periods: duration and intervals • Previous contraceptive use • Previous testing and treatment for infertility

  26. Examinations • Physical examination; • Bimanual examination • Rectal-Vaginal-examination • Laboratory; • Assistant imaging;

  27. Fertility Evaluation: General and Gynecological Examination Visual evaluation and pelvic exam for women to rule out: Visual evaluation and penile exam for men to rule out: Hypogonadism Endocrinopathy Tumors Congenital anomalies Epididymal cysts Uterine hypoplasia Cryptorchidism Cervical lesions Hydrocele Dyspareunia Varicocele

  28. Examinations • Laboratory: semen analysis hormone measurement; sperm penetration assay (SPA) postcoital examinition of cervical mucus immunologic examination; • Assistant imaging : Unltrasound Hysterosalpingogram Hysteroscopy Laparoscopy

  29. Fertility Evaluation of Male Partner: • Urine analysis: to rule out infection • Endocrine tests: to measure concentrations of hormones testosterone, FSH and LH • Anti-sperm antibodies • Sperm penetration assay: to establish ability of sperm to penetrate egg • Postcoital test (low validity): to establish ability of sperm to penetrate cervical mucus

  30. Normal Values for Semen Analysis Volume > 2.0 mL Sperm concentration > 20 million/mL Motility >50 % morphology >30 % normal Data from WHO, 1992

  31. Fertility Evaluation of Female PartnerExamination and Diagnoses Initial evaluation History Physical exam Irregular menses No ovulation HSG Tubal blockage Normal evaluation HSG or Hysteroscopy Abnormal of uterine Abnormal Semen analysis anovulation Tubal factor unexplained Uterine factor Male factor Further Investigate and Treatment

  32. Methods to monitor ovulation • Luteinizing Hormone monitoring: LH surge; after 34-36 hr occur ovulation; • Basal Body Temperature: simple, cheap, biphasic pattern; • Mid-luteal serum progesterone: > 3ng/mL, peak; • Premenstrual molimina: 95% presence; • Mucus change: thick and cellular, no crystalline fern; • Ultrasound monitoring: follicle size 21-23 mm, fluid in the cul-de-sac.

  33. Evidence of Ovulation Ovulation can be established based on: • Urine test • measures the LH in urine to detect if and when ovulation occurred • Basal body temperature chart • temperature is measured every morning, before woman gets out of bed • elevation in temperature indicates ovulation

  34. Progesterone test • progesterone level in blood is measured on days 21 or 22 of 28-day cycle • Endometrial biopsy • done during premenstrual phase • detects if endometrium undergoes expected changes (consistent with ovulation and production of progesterone)

  35. Fertility Evaluation of Female Partner: Other Tests • Hysterosalpinogram (HSG) • to determine whether fallopian tubes are blocked • Laparoscopy • to evaluate for pelvic disease, such as endometriosis, and check patency of fallopian tubes • Hysteroscopy • to evaluate condition of uterine cavity (polyps, fibroids)

  36. Treatment-female factor CausesTreatment induction of ovulation； tuboplasty, microsurgery； medication or surgery； immune inhibition； anovulation Tubal factor Anatomic factor immunologic azoospermia Assisted Reproductive Technologies (ART) genetic disease after surgery unexplained

  37. Treatment Possibilities:Female Infertility Ovulation disorders Ovulation-inducing drugs Prolactin-suppressing drugs Hyperprolactinemia Surgical procedures Uterine and tubal abnormalities Intrauterine insemination Cervical mucus problems Endometriosis Suppressing hormones or surgical procedure

  38. Treatment of Female Infertility:Induction of Ovulation • Involves the use of medication to stimulate development of one or more mature follicles • Success rates vary considerably and depend on age of the woman, the type of medication used, whether there are other infertility factors present in the couple and other reasons

  39. Induction of ovulation • 1. Clomiphen：ER binding GnRH ,FSH/LH dosage：50 mg, period day 5th， 5days； • 2. Gonadotropin therapy： Indications: Hypogonadotropic hypogonadism; Pituitary dysfunction; COH (controlled ovarian hyperstimulation) in IVF; HMG: human menopausal gonadotropins; FSH 75 IU/LH 75 IU, IM or SC; Recombinant FSH: 75 IU, SC; • 3. HCG: 5000-10000 IU;

  40. Assisted Reproductive Technologies (ART) • Intrauterine insemination ( IUI) • In vitro fertilization and embryo transfer (IVF-ET) Intracytoplasmic sperm injection (ICSI); • Gamete intrafallopian transfer (GIFT)

  41. Intrauterine insemination ( IUI) • Indications: 1. as treatment of male factor infertility; 2. psychological factors; 3. unexplained infertility; 4. genetic defects; • Types: 1. artificial insemination with husband’s sperm (AIH); 2. artificial insemination by donor (AID); • Method: placement of about 0.3 ml of washed, processed and concentrated sperm into the intrauterine cavity by trans-cervical catheterizaion.

  42. In vitro fertilization and embryo transfer (IVF-ET) • Indications: 1. tubal factor; 2. endometriosis; 3. unexplained infertility; 4. IUI failure; 5. Immunologic factors; • Method: 1. Superovulation: COH, GnRH-a/FSH(HMG)/HCG; 2. Aspiration of eggs; 3. Fertilization with capacitated sperm; 4. Culture of fertilized egg in the lab; 5. Replacement of fertilized egg into the uterus;

  43. Gamete intrafallopian transfer (GIFT) • Indications: 1. unexplained infertility; 2. endometriosis; 3. IUI failure; 4. Premature ovarian failure (POF); 5. Immunologic factors; • Method: 1. Superovulation is induced as IVF-ET; 2. HCG injection is given; 3. Follicle are aspirated via laparoscopy; 4. Sperm mixed with egg; 5. Replacement of fertilized egg into fallopian tube;

  44. ART Complications • Multiple gestations • Pre-eclampsia • Ovarian hyperstimulation syndrome (OHSS) • Premature birth • Low birth weight • Long term emotional, social and psychological impact

  45. Infertility: Summary • Infertility is a significant social and medical problem affecting couples worldwide • Female and male factors are equally responsible • Evaluation of both partners is essential • Treatment depends on the cause of infertility and varies from ovulation-inducing drugs to surgery to ART

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