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APPROACH TO INFERTILITY
Presenter :
Dr. Varughese George
Moderator :
Dr. G.
Mangala
Introduction
• Infertility - Failure of a couple to conceive/achieve
a clinical pregnancy after 12 months or more of
regular unprotected coitus.
• Subfertility - Any form of reduced fertility with
prolonged time of unwanted non-conception.
• Fecundability - Probability of achieving a
pregnancy within one menstrual cycle. (In a
healthy young couple, it is 20 percent)
• Fecundity - Probability of achieving a livebirth
within a single cycle.
Factors Essential for
Conception
• Healthy spermatozoa should be deposited high
in the vagina at or near the cervix (male factor).
• Spermatozoa should undergo changes
(capacitation, acrosome reaction) and acquire
motility (cervical factor).
• Motile spermatozoa should ascend through
the cervix into the uterine cavity and the
fallopian tubes.
• There should be ovulation (ovarian factor).
Factors Essential for
Conception
• Fallopian tubes should be patent & oocyte
should be picked up by the fimbriated end of
the tube(tubal factor).
• Spermatozoa should fertilize oocyte at the
ampulla of the tube.
• Embryo should reach the uterine cavity after 3–
4 days of fertilization.
• Endometrium should be receptive (by
estrogen, progesterone, IGF-l, cytokines,
integrins) for implantation, and the corpus
luteum should function adequately.
Causes of Infertility
• Male Infertility (30%)
• Female Infertility (30%)
• Both Male & Female Infertility(30%)
• Unexplained (10%)
Causes Of Male Infertility
Pre-testicular Testicular Post-testicular Endocrine
- Gonadotropin deficiency
- Obesity
- Diabetes Mellitus
- Thyroid dysfunction
- Hyperprolactinemia Psychosexual –– Erectile dysfunction –– Impotence Drugs –– Antihypertensives –– Antipsychotics Genetic –– 47 XXY (Klinefelter’s Syndrome) –– Y chromosome deletions –– Single gene mutation
- Immotile cilia (Kartagener) syndrome
- Cryptorchidism
- Infection (mumps orchitis)
- Toxins: Drugs, smoking, Radiation
- Varicocele
- Immunologic
- Sertoli-cell-only syndrome
- Primary testicular failure
- Oligoastheno- teratozoospermia Obstruction of efferent duct
- Congenital –– Absence of Vas deferens (Cystic fibrosis) –– Young’s syndrome
- Acquired Infection ––Tuberculosis ––Gonorrhea - Surgical –– Herniorrhaphy –– Bladder neck surgery –– Vasectomy - Others –– Ejaculatory failure ––Retrograde ejaculation
Approach to Male
Infertility
History
Type of lifestyle (heavy smoking,
alcoholism)
Sexual practices
Erectile dysfunction and ejaculatory
disorders
Sexually transmitted diseases
Surgery in genital area
Drugs
Any systemic illness.
Approach to Male
Infertility
Physical examination
Testicular size
Undescended testes
Hypospadias
Scrotal abnormalities (like varicocele)
Body hair
Facial hair
Approach to Male
Infertility
Semen Analysis
- During transport to laboratory, the specimen should be kept as close to body temperature as possible.
- Specimen obtained near the testing site in an adjoining room.
- Condom collection containing spermicidal agent is not recommended.
- Collection of ejaculate post coitus interruptus is not recommendated.
- Two semen specimens should be examined that are collected 2-3 weeks apart
Approach to Male
Infertility
Semen Analysis
Test Result Physical examination Time to liquefaction, viscosity, volume, pH, color. Microscopic examination Sperm count, vitality, motility, morphology, and proportion of white cells Immunologic analysis Antisperm antibodies (^) SpermMAR test (^) Immunobead test Bacteriologic analysis Detection of infection Sperm function tests Postcoital test, cervical mucus penetration test, Hamster egg penetration assay, hypoosmotic swelling of flagella, and computer- assisted semen analysis
Approach to Male
Infertility
Semen Analysis
Physical Examination
Viscosity :Slightly viscous and easily drawn into a
pipette.
Incompletely liquefied specimens will be
clumped and highly viscous.
Increased viscosity and incomplete
liquefaction will impede sperm motility.
Factors affecting semen viscosity
• Dehydration
• Infections of prostate/seminal vesicles
• Drugs
Approach to Male
Infertility
Semen Analysis
Physical Examination
Volume: N= 1.5-5 ml
Decreased volume frequently associated
with infertility indicates improper functioning
of one of the semen-producing organs.
Low volume ejaculates are caused by 3 disorders :
- Ejaculatory disorders: Neurological diseases,Diabetes,Prior
surgeries & Medications; can cause retrograde ejaculation,
aspermia or both.
- Genital tract obstructions : Prostate cysts,inflammatory
disorders,Infections, Scars from prior surgeries.
- Congenital anomalies : Seminal vesical
aplasia (absence), congenital absence of the vas deferens
Approach to Male
Infertility
Semen Analysis
Microscopic Examination
Sperm Motility
• 1st laboratory assessment of sperm function
• essential for penetration of cervical mucus,
traveling through the fallopian tube, and
penetrating the ovum.
• should be assessed as soon as possible after
liquefaction within 1 hour following ejaculation,
to limit the deleterious effects of dehydration,
pH or changes in temperature on motility
Approach to Male
Infertility
Semen Analysis
Microscopic Examination
Sperm Motility
• A drop of semen is placed on a glass slide,
covered with a coverslip that is then
ringed with petroleum jelly to prevent
dehydration, and examined under 40×
objective.
• At least 200 spermatozoa are counted in
several different microscopic fields.