GROUP 2

PRESENTERS
ISIKANDA MATAA
BEAUTY MUNTANGA
 INFERTILITY
SPECIFIC OBJECTIVES
At the end of the lecture, students
should be able to;
Define infertility
State the demographic distribution of
infertility
State the types of infertility
State the pathogenesis of infertility
 SPECIFIC OBJECTIVES
CONTINUES
List the risky factors among men and
women
List the physical
examinations/investigations carried
out on couples unable to conceive.
Mention some measures taken to
control infertility/treatment
State complications of infertility
 INTRODUCTION
Infertility is the inability to conceive after
one year of unprotected intercourse.
Although the overall incidence of infertility
remains relatively unchanged over the past
thirty years, the number of office visits to
the physicians by couples seeking
treatment have tripled due to the
availability of treatment options for
infertility, (Callahan and Caughey, 2007).
 INTRODUCTION
CONTINUES..
Infertility can result from either
female or male related factors.
However, whatever the cause,
infertility may have profound
psychological effects on the couple.
Partners may become anxious and
marital discords may occur.
 DEFINITIONS
Infertility is childlessness in a
population of women of reproductive
age (Mendiola etal, 2008).
Infertility is the inability to conceive
after 1 year of unprotected
intercourse (Callahan and Caughey,
2007).
 BRIEF PHYSIOLOGY OF MALE
REPRODUCTION
The male reproductive organs responsible
for the production, maturation and
delivery of spermatozoa in the female
reproductive tract are the testes, ductal
system, accessory glands and supporting
structures.
Each testis contains 200 to 300 lobes,
within which are tightly coiled
seminiferous tubules contains primitive
sex cells (spermatogonia) present at birth.
 BRIEF PHYSIOLOGY
CONT..
At puberty, the process of
spermatogenesis starts and
continues throughout life.
The spermatozoon provides one-half
of the genetic material required to
create a new life. Each spermatozoon
has a head, neck, body and tail, each
with specialized function.
 BRIEF PHYSIOLOGY
CONT.
The testes produce androgens, the
most important being testosterone
which is produced by the interstitial
cells (leydigs cells).
Testosterone is important for; -
Maleness and male sexual behaviour
The development and maintenance of
male secondary sex characteristics and
the functions of the accessory organs.
 BRIEF PHYSIOLOGY
CONT.
Protein anabolism
Inhibition of the anterior pituitary secretion
of the gonadotropins, follicle stimulating
hormone (FSH) and interstitial cell
stimulating hormone. FSH stimulates the
seminiferous tubules of the testes to
produce spermatozoa.
The sperms undergo a ripening process as
they pass through the ductal system
before ejaculation.
 BRIEF PHYSIOLOGY
CONT..
The seminal vesicles, which are two
in number are lobulated glands lined
with secretory epithelium which lies
to the posterior of the bladder.
 BRIEF PHYSIOLOGY
CONT..
They secret a thick, nutritive alkaline
fluid that mixes with sperm on
ejaculation. This fluid accounts for
30% of the volume of the seminal
fluid and contains fructose and
protein, which is essential to sperm
motility and metabolism.
 BRIEF PHYSIOLOGY
CONT
The prostate glands found in the pelvic
cavity, behind the symphysis pubis,
surrounding the uppermost part of the
urethra secretes a thin, milky, alkaline
fluid that make up 60% of the seminal
fluid.
The fluid creates an environment more
hospitable to sperms by giving protection
from the normally acidic environment of
the male urethra and female vagina.
 BRIEF PHYSIOLOGY
CONT.
The penis is an important erectile
organ which facilitates penetration
and ejaculation into the female
organ.
 BRIEF PHYSIOLOGY OF FEMALE
REPRODUCTION
The female reproductive system consists
of the internal organs (which are the
ovaries, the uterus, the fallopian tubes
and the vagina) and the external organs
which are the vulva and mammary glands.
A woman is born with approximately
100,000 follicles, though the number
reduces to approximately 30,000 by
adolescence.
 BRIEF PHYSIOLOGY
CONT.
Each follicle contains an immature
ovum known as an oocyte
(Stellenberg and Bruce, 2007).
The ovulatory cycle begins at 12 to 13
years of age. The hormones
responsible for the cyclic changes are
FSH, luteinizing hormone (LH),
oestrogen and progesterone.
 BRIEF PHYSIOLOGY
CONT.
The hypothalamus releases
gonadotropin-releasing hormone
which stimulates the anterior
pituitary gland to release FSH and LH
responsible for the initial
development of ovarian follicles and
their secretion of oestrogen. LH
further stimulates development of
the ovarian follicles, initiates
ovulation and incites production of
 BRIEF PHYSIOLOGY
CONT..
Oestrogens are responsible for
development and maintenance of
female reproductive structures,
control of fluid and electrolyte
balance and increases protein
anabolism.
 BRIEF PHYSIOLOGY
CONT.
Progesterone is important for
secretory changes in the lining of the
uterus when the endometrium
develops tortuous glands and an
enriched blood supply in redness for
possible arrival of fertilized ovum. It
is also important in maintenance of
pregnancy.
 DEMOGRAPHIC
DISTRIBUTION
Generally, worldwide it is estimated
that one in seven couples have
problems conceiving, with the
incidence similar in most countries
independent of the level of the
countrys development
. Fertility problems affect one in
seven couples in UK. In Sweden,
approximately 10% of couples are
infertile (Mendiola etal, 2008).
 DEMOGRAPHIC DISTRIBUTION
CONT
Among couples who undergo evaluation of
infertility, 40% are attributed purely to
male factors and 40% purely to female
factors.
While factors which are a combination of
both male and female causes are at 10%
of the patient population.
The remaining 10% couples tend to have
no identifiable cause for their infertility
(Callahan and Caughey, 2007).
 TYPES OF INFERTILITY
Primary Infertility
This is infertility which is found among
couples who have never been able to
conceive.
Secondary Infertility
This is failure to conceive after already
having conceived or carried the
pregnancy to term or had a
miscarriage.
 FACTORS LEADING TO
INFERTILITY
FEMALES
Defective Ovulation
Ovarian disorders such as failure of
ovarian hormonal release, presence
of ovarian cysts or tumours,
polycystic ovary disease and ovarian
endometriosis may affect the growth
and release of ovaries.
 FACTORS LEADING TO
INFERTILITY CONT
These are grouped in three (WHO, 2001); -
Hypothalamic-pituitary failure
(hypothalamic amenorrhea).
Hypothalamic-pituitary dysfunction
(polycystic ovarian syndrome (PCOS) is
characterized by oligomenorrhea,
anovulation, luteal phase defects,
hyperprolactinemia and thyroid
dysfunction).
 FACTORS CONT
Ovarian failure (premature ovarian failure,
advanced maternal age).
Systemic diseases such as diabetes
mellitus, coeliac disease and renal failure
can have a negative effect on fertility once
not controlled.
In diabetes mellitus, high insulin levels
leads to increased production of androgens
which leads to reduction in the production
of follicle stimulating hormone.
 FACTORS CONT
Physical disorders such as obesity,
anorexia nervosa or strict dieting.
Excessive exercise may also hinder
ovulation as they are associated with
metabolic alterations.
 FACTORS CONT
Defective Transport
Ovum -Tubal obstruction can occur due
to infections such as gonorrhea,
peritonitis and pelvic inflammatory
disease.
Previous tubal surgery can also lead to
obstruction during the healing process.
Fimbrial adhesions occurs secondary to
previous surgery or endometriosis.
 FACTORS CONT.
Sperm transportation may be
hindered in situations where there
are defects in the vagina such as
vaginismus (psychosexual problems),
presence of an infection (can lead to
dyspareunia and altered sperm
motility).
 FACTORS CONT..
Cervical trauma or surgery (cone
biopsy) may lead to altered cervical
function in the reproductive process.
Also presence of infection or
hormonal defects may lead to hostile
cervical mucus which tends to
destroy sperms. Antisperm
antibodies in mucus tend to destroy
sperms before ascension.
 FACTORS CONT
Defective Implantation occurs in
cases of hormonal imbalance,
congenital anomalies, fibroids and
infection such as endometriosis,
pelvic inflammatory diseases and
chronic salpingitis.
Other factors are cigarette smoking,
pelvic or tubal surgery, intrauterine
adhesions and multiple curettages
and submucosal fibroids.
 FACTORS LEADING TO
INFERTILITY
MALE FACTORS
1. Defective spermatogenesis
Endocrine disorders such as
dysfunction of the hypothalamus
(Kallman), pituitary failure (tumor,
radiation, surgery), adrenal
hyperplasia and thyroid disease.
 FACTORS CONT
Systemic disease
Diabetes mellitus (there is an
increase in release of glucagon and
other stress hormones like cortisone
and catecholamine leading to
suppression of reproductive
hormone).
 FACTORS CONT.
Coeliac disease (a disease condition
of early childhood characterized by
steatorrhoea, distended abdomen
and failure to grow). This is caused
by folic acid deficiency.
Renal failure (leads to alters
metabolism, altered hormonal
function and anaemia).
 FACTORS CONT
Testicular disorders
Trauma to the testis may alter their
function.
Environmental factors such as; high
temperatures for men working as
furnace men in industries and putting
on tight clothes that which prevents
free air circulation.
Congenital defects like hydrocele and
undescended testes.
 FACTORS CONT.
Exposure to radiotherapy in
cancer treatment alters hormonal
function and sperm production.
Toxins such as glues, volatile organic
solvents or silicones, physical agents,
chemical dusts, and pesticides tend
to alter the production and
morphology of sperms.
 FACTORS CONT
Tobacco smokers due to nicotine
intake are 60% more likely to be
infertile than non-smokers. Men with
a history of varicocele, mumps,
hernia repair, pituitary tumor,
anabolic steroid use, testicular injury,
and impotence.
 FACTORS CONT
Certain drugs have also been found
to depress semen quantity and
quality (cimetidine, sulfasalazine,
spironolactone, anabolic steroids,
nitrofurans, erythromycin,
tetracyclines and heavy
marijuana/alcohol use). (Callahan
and Caughey, 2007).
 FACTORS CONT.
Defective Transport
Obstruction or absence of seminal
ducts due to infection, congenital
anomalies or trauma.
Impaired secretions from prostate or
seminal vesicles due to infection or
metabolic disorders.
 FACTORS CONT.
Sexual Dysfunction/ineffective delivery
Psychosexual problems (impotence)
Drug induced sexual potency where
ejaculatory dysfunction exists.
Physical anomalies such as hypospadias,
epispadias and retrograde ejaculation
(ejaculation into the bladder).
Impotence.
Decreased Libido
 CLINICAL
MANIFESTATIONS
In men the main clinical
manifestation is inability to father a
child.
History of sexually transmitted
diseases, mumps, orchitis, hernia
repair or trauma to the genitals is
other signs.
Abnormal findings during physical
examinations and laboratory
investigations.
 CLINICAL
MANIFESTATIONS
In females, inability to get pregnant
despite several months of
unprotected sexual intercourse.
Others include; history of
dysmenorrhea, dyspareunia, pelvic
pain associated with movement or
lifting. There may be reports of
amenorrhea, oligomenorrhea, or
menorrhagia.
 CLINICAL MANIFESTATIONS
CONT
Also, there may be history of
spontaneous abortions due to
premature ovarian failure,
headaches, galactorrhea, weight
gain, or hot flashes. A detailed social
history might reveal reasons for
centrally mediated ovulatory
dysfunction including eating
disorders, extreme exercise, or
unusual stress (Tamara and Callahan,
EXAMINATIONS/INVESTIG
ATIONS
Both partners should undergo
physical examinations to eliminate
presence of some physical
abnormality.
EXAMINATIONS/INVESTIG
ATIONS
MEN
Measurement of testicular size and
presence of two testicles.
Identification of the urethra meatus to
rule out hypospadias or epispadias.
Examine for presence of varicocele
Look for presence of lesions which could
indicate history or presence of a
sexually transmitted infection.
EXAMINATIONS/INVESTIGATIONS
CONT
Laboratory investigations include;
semen analysis which is the primary
investigative tool for male infertility.
Sperm count, volume, motility,
morphology, pH, and white blood cell
count are analyzed.
EXAMINATIONS/INVESTIGATIONS
CONT..
Normal values semen volume > 2-
5mls, sperm concentration> 20
million/ml, motility> 50% progressive
motility, morphology> 30% normal
forms and white blood cells< 1
million/ml (WHO, 1992).
EXAMINATIONS/INVESTIGATIONS
CONT.
In case of abnormal sperm analysis,
an endocrine evaluation should be
done which include thyroid function
tests, serum testosterone, prolactin,
and follicle stimulating hormone.
These may indicate an imbalance in
hormonal functions.
EXAMINATIONS/INVESTIGATIONS
CONT
Post-coital test done to examine the
interaction between sperm and
cervical mucus. A healthy interaction
occurs when a large number of
forwardly moving sperm are seen in
a thin acellular mucus.
Urine can be taken for microscopy
and blood for presence of STIs like
syphilis.
Screening for chlamydia should be
EXAMINATIONS/INVESTIG
ATIONS
FEMALES
Inspection of the genital area for
lesions indicating history or presence
of STIs
Visualization of cervix to rule out
stenosis, infection and malformations
Examination of breast development as
a sign of previous estrogen function.
EXAMINATIONS/INVESTIGATIONS
CONT
Evaluation of thyroid function by observing
changes in goiter, hair, nails and presence
of tachycardia.
Current estrogen secretion can be observed
by a well rugged, moist vagina with
abundant clear stretchable cervical mucus.
Pap smear and cervical cultures for
gonorrhea and chlamydia should be done in
all women undergoing infertility evaluation.
EXAMINATIONS/INVESTIG
ATIONS
Cervical mucus can be evaluated for
quantity, color, spinnbarkeit, fluidity,
and the presence of ferning.
Post-coital test to evaluate quality
and quantity of cervical mucus.
Pelvic ultrasound can be done to rule
out tumors and cysts.
EXAMINATIONS/INVESTIGATIONS
CONT..
A saline sonohysterogram can
complement the pelvic ultrasound by
allowing better visualization of the uterine
cavity.
Hysterosalpingogram performed for
visualization of tubal patency. Best done in
follicular phase.
Magnetic resonance imaging can be done
to rule out adenomyosis and uterine
anomalies.
EXAMINATIONS/INVESTIGATIONS
CONT
Hysteroscopy and laparoscopy can
also be done to visualize the uterus
when need arise.
Blood hormonal activity estimation.
 MEASURES TO CONTROL
INFERTILITY
It is important that both partners should
be involved in the management of their
infertility and that full explanations are
given to the couple at each stage in the
investigation and treatment. A range of
assisted reproductive techniques is
available to treat infertile couples and it
is important that appropriate treatment
option is offered (Myles, 2003).
 MEASURES TO CONTROL
INFERTILITY CONT..
Treatment should be focused on
elimination of the identified cause.
The first most important primary
treatment of infertility is counseling
to couples to help them improve on
communication and support each
other to minimize stress.
 MEASURES TO CONTROL
INFERTILITY
It is important to treat any sexually
transmitted infection, if any, before
attempting any conception
measures.
Measures to correction conditions
such as diabetes mellitus, renal
failure and coeliac disease should be
carried out.
 MEASURES TO CONTROL
INFERTILITY CONT..
Couples should be encouraged to
improve their coital practice, more
especially every other day near
ovulation with female partner at the
bottom, placing more semen in
contact with the cervix. The woman
should lie on her back with her knees
to her chest for at least 15 minutes
after intercourse.
 MEASURES TO CONTROL
INFERTILITY CONT..
MALES
Men should avoid the use of tight
underwear, saunas and hot tubs, and
unnecessary
environmental exposures such as
radiation, excess heat, and certain
medications as discussed earlier.
Treatment of low sperm density or
motility depends on the causal
agent.
 MEASURES TO CONTROL
INFERTILITY CONT.
Hypothalamic-pituitary failure can be
treated with injections of Menopur
(human menopausal gonadotropins.
This medicine is used to increase
sperm production in men who have
low sperm count as a result of low
hormone levels.
MEASURES TO CONTROL
CONT.
It can also be used in combination
with human chorionic gonadotropin
(HCG), which increases the
production of testosterone in the
testicles and helps the FSH to work.
 MEASURES TO CONTROL
CONT.
Varicocele can be repaired by ligation.
In cases of low semen volume treatment is
by washed sperm for intrauterine
insemination.
Intracytoplasmic sperm injection (ICSI) is
another option for patients with low sperm
density or impaired motility (injection of a
single sperm into an egg, and then placing
the fertilized egg inn the uterine cavity or
fallopian tube).
MEASURES TO CONTROL/TREAT
CONT.
FEMALES
In cases where etiology of ovulatory
dysfunction is identified, 90% of
infertility cases are corrected by
treating the underlying cause.
MEASURES TO CONTROL/TREAT
CONT
In patients with polycystic ovarian
syndrome (PCOS) related to obesity
and diabetes mellitus, even just
weight loss is enough to lower fasting
insulin levels, testosterone, and
androsteindiones which tend to be
higher in diabetes mellitus.
MEASURES TO CONTROL/TREAT
CONT
PCOS are treated with Clomid and
metformin to establish ovulation and
producing viable pregnancies. If
these treatments are do not succeed,
ovulation induction and pregnancy
can be tempted with a combination
of human gonadotropins and other
reproductive technologies.
MEASURES TO CONTROL/TREAT
CONT
In hypothalamic-pituitary failure
(WHO Group 1), ovulation can usually
be achieved with pulsatile
gonadotropin releasing hormonal
therapy or human gonadotropins.
Patients with ovarian failure have no
treatment because they lack viable
oocytes. The only recommended help
is egg donation, gestational
surrogacy, or adoption.
MEASURES TO CONTROL/TREAT
CONT
Some of the recommended procedures
by the Human Fertilization and
Embryology Authority (HFEA) set up in
1991 to license and regulate clinics are: -
In vitro fertilization (IVF) treatment.
Fertilization occurs outside and then the
embryo is transferred into the mothers
womb after hormonal treatment to
prepare the mother for implantation.
 CONTROL/TREAT CONT
Donor insemination (DI) treatment.
Gamete intrafallopian transfer (GIFT) where
donated sperm or eggs are used in treatment.

Storage of gametes or embryos. Here, clinics

licensed by HFEA have well selected counseled
donors who donate sperms and eggs which are
frozen and later used for artificial insemination
and then zygote intrafallopian transfer (ZIFT),
GIFT and Intracytoplasmic sperm injections (ICSI)
are done respectively.
 SOME DRUGS USED IN
TREATMENT OF INFERTILITY
Clomid
Glucophage
Pergonal
Gonal-F
Lutrepulse
Lupron
Danocrine
 COMPLICATIONS OF
INFERTILITY
Failure to correct infertility has
resulted in many couples left
unhappy, dejected and isolated.
Psychosocial trauma
Multiple gestation pregnancy
Ovarian hyperstimulation
syndrome
Abandonment of sexual intimacy
Ethical issues associated with
infertility
 THE ROLE OF THE
MIDWIFE
The main role of the midwife in
couples with infertility problem is
counseling of the couple to allay
anxiety, provision of written
information that should include a list
of addresses of organizations offering
infertility treatment.
 THE ROLE OF THE
MIDWIFE
Taking of a detailed history of
lifestyle, drug abuse, occupation,
previous and present disease
conditions which could have affected
their fertility is important for ongoing
counseling and support.
 THE ROLE OF THE
MIDWIFE
When a successful conception has
been achieved, then maternity
services will be offered by the
midwife. The midwife will be needed
for psychological care throughout the
pregnancy to allay anxiety.
 CONCLUSION
Infertility is caused by a number of factors
from either the male or female. In both
cases it is important that the couples are
both involved and cooperative in
investigations and correction of the
problem. In order to effectively treat
couples with infertility it is essential that
male infertility be considered in parallel to
evaluation for female factor infertility
(Callahan and Caughey, 2007).
 CONCLUSION
Treatment of infertility is done in line
with the underlying cause. It is
therefore, the duty of the midwife to
offer guidance and psychological
support throughout the couples
treatment.
 REFERENCES
Callahan T. L and Caughey A. B. (2007).
Blueprints; Obstetrics & Gynecology,
4th Edition, Lippincott Williams and Wilkins,
Baltimore.
Fraser .M.D and Cooper. M.A. (2003)
Myles Text book for midwives 14th
Edition Elsevier. Philadelphia.
Fraser, D. M. and Cooper, M. A.(2006).
Myles Text Book for Midwives, African
edition. Mosby, Churchill Livingstone.
 REFERENCES
Mendiola J, Torres-Cantero AM, Moreno-Grau JM, et
al. (Jun 2008).
"Exposure to environmental toxins in males seeking
infertility treatment: a case-controlled study"
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Stellenberg E. L. and Bruce J. C., (2007) Nursing
Practice; Medical-Surgical Nursing for
Hospital and Community, African Edition,
Elsevier, Philadelphia