REVIEW OF ANATOMY AND PHYSIOLOGY OF REPRODUCTIVE SYSTEM ANATOMY AND PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM Internal Female Structures

Uterus Fallopian tubes Ovaries Vagina External Female Structures Mons Pubis. Labia Majora & Minora. Clitoris. Vestibule. Perineum

Uterus The uterus is a hollow, pear shaped muscular organ. The uterus measures about 7.5 X 5 X 2.5 cm and weight about 50 60 gm. Its normal position is anteverted (rotated forward and slightly antiflexed (flexed forward)

The uterus divided into three parts Fundus Body of the uterus Cervix Layers of the uterus Perimetrium Myometrium Endometrium The uterus is held in place by the following ligaments: Broad ligaments
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 Uterosacral ligaments Round ligaments Cardinal (lateral cervical) ligaments The Function of the uterus Menstruation ----the uterus sloughs off the endometrium. Pregnancy ---the uterus support fetus and allows the fetus to grow. Labor and birth---the uterine muscles contract and the cervix dilates during labor to expel the fetus Fallopian tubes The two tubes extended from the cornu of the uterus to the ovary. It runs in the upper free border of the broad ligament. Length 8 to 14 cm average 10 cm

Its divided into 4 parts Interstitial part Isthmus Ampulla Infundibulum Functions Gamete transport (ovum pickup, ovum transport, sperm transport). Final maturation of gamete post ovulate oocyte maturation, sperm capicitation. Fluid environment for early embryonic development. Transport of fertilized and unfertilized ovum to the uterus.

Ovaries Oval solid structure, 1.5 cm in thickness, 2.5 cm in width and 3.5 cm in length respectively. Each weights about 48 gm. Ovary is located on each side of the uterus, below and behind the uterine tubes

Structure of the ovaries Cortex Medulla Hilum Functions of the ovary Secrete estrogen & progesterone. Production of ova Vagina It is an elastic fibro-muscular tube and membranous tissue about 8 to 10 cm long. Lying between the bladder anteriorly and the rectum posteriorly. The vagina connects the uterus above with the vestibule below. The upper end is blind and called the vaginal vault. The vaginal lining has multiple folds, or rugae and muscle layer. These folds allow the vagina to stretch considerably during childbirth. The reaction of the vagina is acidic, the pH is 4.5 that protects the vagina against infection. Functions of the vagina To allow discharge of the menstrual flow. As the female organs of coitus.

 To allow passage of the fetus from the uterus. Cyclical Changes in Endometrium Basilar zone remains relatively constant Functional zone undergoes cyclical changes: produce characteristic features of uterine cycle in response to sex hormone levels

The Uterine Cycle Also called menstrual cycle. It is a repeating series of changes in endometrium. It Lasts from 21 to 35 days. Average 28 days. Responds to hormones of ovarian cycle: It includes 3 phases: Menstrual Phase Proliferative Phase Ovulatory Phase Secretory Phase

Menstrual Phase: it is the phase of endometrial sloughing, Lasts 17 days, Sheds 3550 ml blood. If pregnancy does not follow

Degeneration of corpus luteum

Fall in the level of oestrogen and progesterone

Shedding of endometrium

Menstrual Flow
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Proliferative Phase: This phase follows menstruation and lasts for about 5 to 10 days. This phase is also known as follicular phase. Increased follicle stimulating hormone during first day of cycle

Few ovarian follicles are stimulated

Development of follicles (folliculogenesis)

Under influence of hormones

Dominant follicle continue to grow

Mature follicle (graffian follicle) forms ovum

It starts secreting increasing amount of estradiol and oestrogen

Oestrogen initiates proliferation of endometrium Ovulatory phase: Through a signal transduction cascade initiated by luteinizing hormone

Proteolytic enzyme secreted by follicles

That degrades the follicular tissue at the site of blister

Forms a hole called Stigma

Oocyte leaves the ruptured follicle

Then move out into peritoneal cavity through stigma

Where it is caught by fimbriae Secretory phase: This phase is also called luteal phase. This phase begins after ovulation and ends with menstruation. After ovulation, due to the effect of luteinizing hormone

The follicle lining develop into corpus luteum

It produces large amount of progesterone and small amounts of oestrogen

Endometrium becomes edematous and secretory glands produce increased amounts of watery mucus

Suppression of follicle stimulating hormone and luteinizing hormone

No support to corpus luteum

Fall in the level of progesterone and estrogen

Menstruation The activities of the ovary and the uterus are coordinated by negative- and positive-feedback responses involving gonadotropin releasing hormone (GnRH) from the hypothalamus, follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary, and the hormones estrogen and progesterone from the follicle and corpus luteum. A description of the events follows): The hypothalamus and anterior pituitary initiate the reproductive cycle: The hypothalamus monitors the levels of estrogen and progesterone in the blood. In a negative-feedback fashion, low levels of these hormones stimulate the hypothalamus to secrete GnRH, which in turn stimulates the anterior pituitary to secrete FSH and LH. The follicle develops: FSH stimulates the development of the follicle from primary oocyte through mature stages. The follicle secretes estrogen: LH stimulates the cells of the theca interna and the granulosa cells of the follicle to secrete estrogen. Inhibin is also secreted by the granulosa cells. Ovulation occurs: Positive feedback from rising levels of estrogen stimulate the anterior pituitary (through GnRH from the hypothalamus) to produce a sudden midcycle surge of LH. This high level of LH stimulates meiosis in the primary oocyte to progress toward prophase II and triggers ovulation. The corpus luteum secretes estrogen and progesterone: After ovulation, the follicle, now transformed into the corpus luteum, continues to develop under the influence of LH and secretes both estrogen and progesterone. The endometrium thickens: Estrogen and progesterone stimulate the development of the endometrium, the inside lining of the uterus. It thickens with nutrient-rich tissue and blood vessels in preparation for the implantation of a fertilized egg. The hypothalamus and anterior pituitary terminate the reproductive cycle:Negative feedback from the high levels of estrogen and progesterone cause the anterior pituitary (through the hypothalamus) to abate the production of FSH and LH. Inhibin also suppresses production of FSH and LH.
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 The endometrium either disintegrates or is maintained, depending on whether implantation of the fertilized egg occurs, as follows: 1. Implantation does not occur: In the absence of FSH and LH, the corpus luteum deteriorates. As a result, estrogen and progesterone production stops. Without estrogen and progesterone, growth of the endometrium is no longer supported, and it disintegrates, sloughing off during menstruation. 2. Implantation occurs: The implanted embryo secretes human chorionic gonadotropin (hCG) to sustain the corpus luteum. The corpus luteum continues to produce estrogen and progesterone, maintaining the endometrium. (Pregnancy tests check for the presence of hCG in the urine.) In addition to influencing the reproductive cycle, estrogen stimulates the development of secondary sex characteristics in females. These include the distribution of adipose tissue (to the breasts, hips, and mons pubis), bone development leading to a broadening of the pelvis, changes in voice quality, and growth of various body hair. The organs of male reproductive system are Testes A system of ducts Epididymis Ductus deferens Ejaculatory ducts Spermatic cord Urethra Accessory sex glands Seminal vesicles Prostate Bulbourethral glands Supporting structures Scrotum Penis

1. Testes These are paired oval glands in the scrotum 5cm long and 2.5cm in diameter, containing seminiferous tubules in which the sperm are produced. The process by which the seminiferous tubules of the testes produce sperms are called spermatogenesis. Cells of seminiferous tubules
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Spermatogenic cells These cells are sperm forming cells. Sertoli cells These cells are also called as sustentacular cells. Provide nourishment, support and protection to the spermatozoa. Produce fluid for sperm transportation and secrete the hormone inhibin that effect the testosterone and FSH. Leydig cells The cluster of cells which are present between the spaces of seminiferous tubules are called leydig cells or interstitial cells. These produce the male sex hormone testosterone. 2.A system of ducts a. Epididymis The epididymis is a comma-shaped organ that lies adjacent to each testis. Each of the two epididymides contains a tightly coiled tube, the ductus epididymis. sperm complete their maturation and are stored until ejaculation. During ejaculation, smooth muscles encircling the epididymis contract, forcing mature sperm into the next tube, the ductus deferens. The walls of the ductus epididymis contain microvilli called stereocilia that nourish sperm. b. Ductus deferens (vas deferens) It is the tube through which sperm travel when they leave the epididymis. Sperm are stored in the ductus deferens until peristaltic contractions of the smooth muscles surrounding the ductus force sperm forward during ejaculation.

c. Ejaculatory ducts These are short tubes that formed by the union of duct from the seminal vesicle and ampulla of the ductus deferens.

It is the passageway for the ejection of sperm and secretions of the seminal vesicles.

d. Spermatic cord it contains blood vessels, lymphatic vessels, nerves, the ductus deferens, and the cremaster muscle. It connects each testis to the body cavity, entering the abdominal wall through the inguinal canal.

Varicocele it refers to the swelling in the scrotum due to the dilation of the veins that drains testes. e. Urethra It is the passageway for urine and semen (sperm and associated secretions). Three regions of the urethra are distinguished:

The prostatic urethra passes through the prostate gland. The membranous urethra passes through the urogenital diaphragm (muscles associated with the pelvic region).

The spongy (penile) urethra passes through the penis.

3.Accessory sex glands These secrete substances into the passageways that transport sperm. These substances contribute to the liquid portion of the semen: a.Seminal vesicles secrete into the vas deferens an alkaline fluid (which neutralizes the acid in the vagina), fructose (which provides energy for the sperm), and prostaglandins (which increase sperm viability and stimulate female uterine contractions that help sperm move into the uterus).
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b.Prostate gland It secretes a milky, slightly acidic fluid into the urethra. Various substances in the fluid increase sperm mobility and viability. c.Bulbourethral glands It secrete an alkaline fluid into the spongy urethra. The fluid neutralizes acidic urine in the urethra before ejaculation occurs. 4.Supporting structures a.Scrotum It is a sac consisting of skin and superficial fascia that hangs from the base of the penis. A vertical septum divides the scrotum into left and right compartments, each of which encloses a testis. The external scrotum positions the testes outside the body in an environment about 3C below that of the body cavity, a condition necessary for the development and storage of sperm. The following two muscles help maintain this temperature if the external conditions get too cold:

The dartos muscle is located in the superficial fascia of the scrotum and septum. Contraction of this smooth muscle creates wrinkles in the scrotum skin. The wrinkling thickens the skin, reducing heat loss when external temperatures are too cold.

The cremaster muscles extend from the internal oblique muscle to the scrotum. Contraction of these skeletal muscles lifts the scrotum closer to the body when external temperatures are too cold.

During the seventh month of fetal development testes decends into the scrotum through the inguinal canal. The condition in which testes do not decend into the scrotum is called cryptochidism.

b.Penis It is a cylindrical organ that passes urine and delivers sperm. It consists of a root that attaches the penis to the perineum, a body (shaft) that makes up the bulk of the penis, and the glans penis, the
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enlarged end of the body. The glans penis is covered by a prepuce (foreskin), which may be surgically removed in a procedure called circumcision. Internally, the penis consists of three cylindrical masses of tissue, each of which is surrounded by a thin layer of fibrous tissue, the tunic albuginea. The three cylindrical masses, which function as erectile bodies, are as follows:

Two corpora cavernosa fill most of the volume of the penis. Their bases, called the crura (singular, crus) of the penis.

A single corpus spongiosum encloses the urethra and expands at the end to form the glans penis. The bulb of the penis, an enlargement at the base of the corpus spongiosum.

Sperm Each day about 300 sperms complete the process of spermatogenesis. It is about 60um long. Parts of sperm A head it contains nucleus. Around the nucleus a covering is present which is called acrosome. A tail which is divided into 4 parts. Semen It is a mixture of sperm and seminal fluid, a liquid that consists of secretions of the Seminiferous tubules Seminal vesicles Prostate Bulbourethral glands Neck Middle piece Principal piece End piece

Volume 2.0 ml or more Sperm Concentration 20 million/ml or more Motility 50% forward progression
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25% rapid progression Viscosity Liquification in 30-60 min Morphology 30% or more normal forms pH 7.2-7.8 WBC Fewer than 1 million Hormonal regulation of spermatogenesis

The hypothalamus begins secreting gonadotropin releasing hormone (GnRH) at puberty. GnRH stimulates the anterior pituitary to secrete follicle stimulating hormone (FSH) and luteinizing hormone (LH).

LH stimulates the interstitial cells in the testes to produce testosterone and other male sex hormones (androgens). (In males, LH is also called interstitial cell stimulating hormone, or ICSH.)

Testosterone produces the following effects: Testosterone stimulates the final stages of sperm development in the nearby seminiferous tubules. It accumulates in these tissues because testosterone and FSH act together to stimulate sustentacular cells to release androgen-binding protein (ABP). ABP holds testosterone in these cells.

Testosterone entering the blood circulates throughout the body, where it stimulates activity in the prostate gland, seminal vesicles, and various other target tissues.

Testosterone and other androgens stimulate the development of secondary sex characteristics, those characteristics not directly involved in reproduction. These include the distribution of muscle and fat typical in adult males, various body hair (facial and pubic hair, for example), and deepening of the voice. Requirements for Conception Production of healthy egg and sperm Unblocked tubes that allow sperm to reach the egg
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The sperms ability to penetrate and fertilize the egg Implantation of the embryo into the uterus Finally a healthy pregnancy INFERTILITY

It is defined as a couples inability to achieve a pregnancy after at least a one year of regular unprotected intercourse. Types Primary infertility It refers to a couple who has never had a child. Secondary infertility It means that at least one conception has occurred, but currently the couple cannot achieve a pregnancy. Etiology Male causes Sperm abnormalities Oligospermia Asthenospermia Teratospermia Low sperm level Retrograde ejaculation Structural abnormalities Anorchia Cryptochidism Hypospadias Tube blockage Syringomyelia

Genetic factors Damaged DNA Defective acrosome Inherited disorders like Klinefelter syndrome Polycystic kidney disease

Autoimmunity Secretions of antibodies against the sperms

Medications Corticosteroids Methotrexate Phenytoin

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Cystic fibrosis

Ca channel blockers

Medical conditions STDs Mycoplasm Severe injury Diabetes Cushing syndrome Chronic anaemia Liver or kidney failure Thyroid disease Varicoceles Ejaculatory duct obstruction Impotence

Environmental and life style causes Free radicals Exposure to Estrogen like chemicals Hydrocarbons Bicycling Radiotherapy Smoking Malnutrition, Obesity Narcotics Testicular overheating Emotional stress Sexual issue

Hormonal factors Hypogonadism Testosterone deficiency

Infections Mumps Glandular infections HIV infections prostatitis

Female causes Ovarian and ovulation factors polycystic ovarian syndrome Anovulation Inadequate corpus luteum Uterine factors Tubal factors Tubal obstruction Uterine fibroid Uterine polyps Congenital malformations of uterus

Vaginal factors Vaginismus Vaginal obstruction

Cervical factors Cervical stenosis Antisperm antibodies Non-receptive cervical mucus

Other causes Prolonged use of contraceptives

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Endometriosis Pelvic adhesions Pelvic inflammatory disease Tubal occlusion and dysfunction

Sexually transmitted diseases Inadequate body fat Lack of proper growth and development

Diagnostic evaluations History collection Duration of infertility since marriage or any previous fertility events. Frequency and timing of intercourse. Sexual history (before and after marriage), any sexually transmitted diseases. Working conditions; exposure to toxins, chemicals or radiation. History of any medication and allergies. Childhood medical problems, injuries and illness. Any history of chronic medical conditions like diabetes, tuberculosis, infections and any history of previous surgery. Family history of reproductive problems.

Physical examination of female reproductive system A thorough gynecologic examination should include an evaluation of hair distribution, clitoris size, Bartholin glands, labia majora and minora, and any condylomata acuminatum or other lesions that could indicate the existence of venereal disease. The inspection of the vaginal mucosa may indicate a deficiency of estrogens or the presence of infection. The evaluation of the cervix should include a Papanicolaou test and cultures for gonorrhea, chlamydia, Ureaplasma urealyticum,and Mycoplasma hominis. Bimanual examination should be performed to establish the direction of the cervix and the size and position of the uterus to exclude the presence of uterine fibroids, adnexal masses, tenderness, or pelvic nodules indicative of infection or endometriosis.

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Physical examination of male reproductive system A physical examination of scrotum and testes for detection of undescended testes, varicoceles, absence of vas deference, cyst, size and texture of testes. Penis may be examined for the warts, discharge from the urinary tract and altered location of urethral opening. Routine records of blood pressure, pulse rate, and temperature. Measure height and weight to calculate the body mass index Attention should be directed to congenital abnormalities of the genital tract (eg, hypospadias, cryptorchid, congenital absence of the vas deferens). Testicular size, urethral stenosis, and presence of varicocele are also determined. A history of previous inguinal hernia repair can indicate an accidental ligation of the spermatic artery. Diagnostic tests for males 1.)Semen analysis This is a very important test for the male infertility. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating semen into a clean container. A laboratory analyzes semen specimen for quantity, color, and presence of infections or blood, approximate number of total sperm cells, sperm motility/forward progression. This is the most common type of fertility testing. Semen deficiencies are often labeled as follows: Normal Values for SA Volume 2.0 ml or more Sperm Concentration 20 million/ml or more Motility 50% forward progression 25% rapid progression Viscosity Liquification in 30-60 min Abnormal Values for SA Oligospermia or Oligozoospermia decreased number of spermatozoa in semen Aspermia - complete lack of semen Hypospermia - reduced seminal volume Azoospermia - absence of sperm cells in semen

Morphology 30% or more normal Teratospermia - increase in sperm with abnormal morphology forms pH 7.2-7.8 Asthenozoospermia - reduced sperm motility
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 WBC Fewer than 1 million

Abnormal volume Retrograde ejaculation Infection Ejaculatory failure

2. semen function test

Hamster test

Human zona penetration test

Acrosome reaction test

Computer aided sperm motility analysis

Hamster test in this test the hamster eggs (after removing their covering) are used to observe the penetration of human sperms into the eggs. Fertilization of eggs less than 5-20% indicates the infertility. Human zona penetration test in this the dead human eggs are removed from the ovaries and used to observe the penetration of human zona by the sample of sperm which indicates whether the sperm can penetrate the outer covering of an egg. Acrosome reaction test it is used to test the ability of the sperms enzyme rich covering to dissolve. Computer aided sperm motility analysis to detect the motility of sperms to penetrate the eggs. 3.)Hormone testing. Testosterone level FSH (spermatogenesis- Sertoli cells) LH (testosterone- Leydig cells 4.) Transrectal and scrotal ultrasound. Ultrasound can help to look for evidence of conditions such as retrograde ejaculation and ejaculatory duct obstructionlar, testicular cancer.

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5.) Post ejaculatory urine examination

It helps to detect the retrograde ejaculation and infections.

6.) Antisperm antibodies blood tests for antisperm antibodies are conducted in case of reversed vasectomy, clumping of sperms during semen analysis, injury to testes.

7.) Testicle biopsy

For detecting obstruction in transportation system if sperm if the sperm count is low when the production of sperms is normal. Biopsies of both testes or different regions give accurate results. They requires incisions under anaesthesia. Epididymis should be carefully detected.

Tests for women 1.)Post coital test a microscopic examination of cervical mucus within 2-24 hours of intercourse is done to detect the presence or absence of live sperms; cervical mucus should be cultured for the presence of infection if no live sperm is observed.

2.)Hysterosalpingography. This test evaluates the condition of uterus and fallopian tubes. Fluid is injected into uterus, and an X-ray is taken to determine if the cavity is normal and ensure the fluid progresses through fallopian tubes. Blockage or problems often can be located and may be corrected with surgery. 3.)Laparoscopy. Performed under general anesthesia, this procedure involves making a small incision (8 to 10 millimeters) beneath navel and inserting a thin viewing device to examine fallopian tubes, ovaries and uterus. The most common problems identified by laparoscopy are endometriosis and scarring. It also can detect blockages or irregularities of the fallopian tubes and uterus. Laparoscopy generally is done on an outpatient basis.

4.)Hormone testing. Hormone tests may be done to check levels of ovulatory hormones as well as thyroid and pituitary hormones.
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5.)Ovarian reserve testing. Testing may be done to determine the potential effectiveness of the eggs after ovulation. This approach often begins with hormone testing early in a woman's menstrual cycle. 6.)Genetic testing. Genetic testing may be done to determine whether there's a genetic defect causing infertility. 7.)Pelvic ultrasound. Pelvic ultrasound may be done to look for uterine or fallopian tube disease. Endometrial biopsy, to verify ovulation and inspect the lining of the uterus. 8.)Pap smear test PHARMACOLOGICAL TREATMENT Anovulation 1.)Clomiphene citrate an anti-estrogen drug designed as a fertility medicine for women, is controversial. Vitamin E helps counter oxidative stress, which is associated with sperm DNA damage and reduced sperm motility. A hormone-antioxidant combination may improve sperm count and motility. Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth. Antiestrogen Combines and blocks estrogen receptors at the hypothalamus and pituitary causing a negative feedback Increases FSH production stimulates the ovary to make follicles

2.)Follicle-stimulating hormone or FSH (Gonal-F, Follistim): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected. 3.)Gonadotropin-releasing hormone (Gn-RH) analog: These medicines are often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray. Adverse effects Hyperstimulation of the ovaries Multiple gestation
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Fetal wastage

4.)Metformin (Glucophage):this medicine for women who have insulin resistance and/or PCOS. Citrate or FSH is taken with the combination of metformin. This medicine is usually taken by mouth. 5.)Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of prolactin. Prolactin is a hormone that causes milk production. Many fertility drugs increase a woman's chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born too early (prematurely). Premature babies are at a higher risk of health and developmental problems.

ASSISTED REPRODUCTIVE TECHNOLOGIES (ART) is a group of different methods used to help infertile couples. ART works by removing eggs from a woman's body. The eggs are then mixed with sperm to make embryos. The embryos are then put back in the woman's body. 1.)Intrauterine insemination (IUI) It is an infertility treatment that is often called artificial insemination. In this procedure, the woman is injected with specially prepared sperm. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI. IUI is often used to treat: Mild male factor infertility Women who have problems with their cervical mucus Couples with unexplained infertility

2.)In vitro fertilization (IVF) It means fertilization outside of the body. IVF is the most effective ART used when a woman's fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus. 3.)Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer
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It is similar to IVF. Fertilization occurs in the laboratory. Then the very young embryo is transferred to the fallopian tube instead of the uterus. 4.)Gamete intrafallopian transfer (GIFT) It involves transferring eggs and sperm into the woman's fallopian tube. So fertilization occurs in the woman's body. Few practices offer GIFT as an option. 5.)Intracytoplasmic sperm injection (ICSI) It is often used for couples in which there are serious problems with the sperm. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube. 6.)Surrogacy Women with no eggs or unhealthy eggs might also want to consider surrogacy. A surrogate is a woman who agrees to become pregnant using the man's sperm and her own egg. The child will be genetically related to the surrogate and the male partner. After birth, the surrogate will give up the baby for adoption by the parents. 7.)Gestational Carrier Women with ovaries but no uterus may be able to use a gestational carrier. This may also be an option for women who shouldn't become pregnant because of a serious health problem. In this case, a woman uses her own egg. It is fertilized by the man's sperm and the embryo is placed inside the carrier's uterus. The carrier will not be related to the baby and gives him or her to the parents at birth. 8.)Alternatives Donor oocyte Patients with poor ovarian reserve have a rather low chance of overcoming infertility; yet, some of them, along with patients with premature menopause and patients with physiologic menopause, are interested in having a child. The only alternative for these patients is adoption or an oocyte donation Donor oocyte is the counterpart of donor sperm. The source of the oocyte can be anonymous or known (ie, younger relative, designated donor). Ideally, the donor should be aged 21-30 years, although the age can extend to 35 years. The donor undergoes ovulation induction according to the standard IVF protocol. Meanwhile, the recipient takes increasing doses of estrogens to synchronize her endometrium in preparation

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for a fresh embryo transfer. This technique is similar to the one described under Frozen embryo transfer Because oocyte cryopreservation is still in a preliminary stage of development, only fresh oocytes without quarantine are used. However, the donor must be screened for numerous transmissible diseases (eg, HIV, syphilis, hepatitis, gonorrhea, chlamydia) according to FDA regulations, and a complete physical and gynecological evaluation is performed. The donor patient also undergoes a psychological evaluation. The recipient patient also has a psychological evaluation. The oocyte recipient and her partner are required to have the same kinds of screening tests as the oocyte donor. The legal aspects of the procedure and future offspring must be discussed. A thorough consent form must be signed by all parties involved 9.)Donor sperm Men who cannot produce sperm or women who do not have a partner and wish to become pregnant may opt for donor sperm. Many opt to use sperm banks, which require strict and rigorous infectious testing. The sperm donor may choose to be known or anonymous. After deposition, the samples are frozen and quarantined for at least 6 months. Once repeat infectious testing is confirmed to be negative, the sample is available for selection and intrauterine insemination or IVF is performed in sync with the patient's cycle. 10.)Donor embryo Donor embryo is the earliest form of adoption. As stated in the embryo cryopreservation consent form, the couple must sign an advance directive regarding embryo ownership and disposition. Those directives should include statements regarding (1) embryo donation to another couple, (2) donation of the embryos for research, or (3) disposition of the embryos after thawing. Donor embryo is one option the patient can choose; therefore, those embryos can be donated according to the IVF program policy. Embryo donation programs must follow the regulations established for tissue donors, which require that all screening tests must be performed before embryo cryopreservation, with the tests being repeated at least 6 months later. The same screening tests are required for the recipient couple. Anatomic Abnormalities

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Surgical treatments Lysis of adhesions Septoplasty Tuboplasty Myomectomy

Surgery may be performed laparoscopically, hysteroscopically. If the fallopian tubes are beyond repair one must consider in vitro fertilization. Treatment for males Treating retrograde ejaculation and failure of emission Various methods are used to treat these conditions caused by surgery, severe disease, spinal cord injury. 1.)Phosphodiesterase-5(PDE-5) inhibitors are oral medications that are used to treat erectile dysfunction. PDE-5 is an enzyme found in the trabecular smooth muscles that inactivates the cGMP, the nucleotide that causes cavernosal relaxation necessary for the erection. By blocking the inhibition of PDE-5, it facilitates the corporeal smooth muscle relaxation in response to sexual stimulation. It is taken 1 hour before sexual activity. 2.)Alpha-adrenergic agonists Pseudoephedrine, stimulates the muscle contraction and help ejaculation. 3.)Electrovibration This technique is often beneficial if drugs are not effective, particularly with complete failure of emission. These methods can help in sperm collection for intrauterine insemination or ART. In case of retrograde ejaculation, sodium bicarbonate is typically used to reduce the acidity of the urine to prepare sperm for IVF. Urine sample is taken after ejaculation and sperm are separated by washing techniques. 4.)Varicocelectomy It is the surgical correction of varicocele. In this procedure tying off the swollen and twisted veins through the inguinal retroperitoneal approach.

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5.)Orichopexy In this surgery the undescended testes are bring into the scrotum. 6.)Sperm extraction vasal aspiration In this a small scrotal incision is given under anesthesia and syringe is inserted into the vas deferens to suction the leaky sperm into the nourished fluid. The sperms also brought by the general massage of the epididymis and vas deferens. The aspirated sperms are prepared for the intrauterine insemination. Indications Congenital and acquired obstructions of ductal system General guidelines for the couple 1.)Timing and monitoring the sexual activity Male hormone levels are higher in morning. Sexual activity in males are highest in October, conception rate is also higher in this month. Sperm count are higher in winter season than in the summer. Monitoring of basal body temperature is used to determine the time of ovulation as it rises and falls according to the hormone fluctuations. Excellent screening tool for ovulation. 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. Monitoring reproductive hormonal level Serum Progesterone Progesterone starts rising with the LH surge drawn between day 21-24 Mid-luteal phase >10 ng/ml suggests ovulation Adjusting sexual activity some studies shows that having intercourse daily and several times a day before and during ovulation period improves the fertility rate. Athough frequent sexual activity decreases the sperm count per ejaculation, a regular semen supply increases the chances of fertilization.

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2.)changes in life style Exercise moderately. Regular exercise is important. Avoid weight extremes. Being overweight or underweight can affect hormone production and cause infertility. So control the diet and do regularly exercise. Avoid alcohol, tobacco and street drugs. These substances may impair ability to conceive and have a healthy pregnancy. Don't drink alcohol or smoke tobacco. Avoid illegal drugs such as marijuana and cocaine. These also decrease the sperm production. Limit caffeine. Women trying to get pregnant may want to limit caffeine intake. Limit medications. Reducing stress it may improves the sperm quality. Wear loose cloths

3.)Dietary modifications Diet should be rich in fruits, vegetables and wholr grains Animal fat should be avoided, use monosaturated oils. Use fish and fish oils. Take higher amount of antioxidant vitamins C, E and beta- carotene. Daily supplementation of zinc 66mg and folic acid 5 mg increase the sperm count but does not improves the quality of sperms. 4.) psychological support

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