INFERTILITY –

DEFINITION,
CAUSES,
DIAGNOSTIC
PROCEDURES
AND
COUNCELLING
 DEFINITION
 Infertility
is the lack of conception after 1
year of unprotected sexual intercourse.
(Hughes and Hammond 1990)
 Primary infertility: identifies those women
who have never conceived.
 Secondary infertility: indicates those women
who have formerly been pregnant but have
not conceived during one or more years of
unprotected intercourse.
 FEMALE CAUSES
 Ovulation
 Hypothyroidism
 Hypothalamic anovulation
 Hyperprolactinaemia
 Luteal phase defect: there is decreased
hormone production by the corpus luteum as
well as decreased level of FSH and LH.
 Polycystic ovaries
 Excessive male hormone (androgens)
 Physical stress, psychological stress and
extreme lifestyle changes.
Conti..
 Cervical infertility
 Inadequate or inhospitable cervical mucus due
to the presence of local sperm antibodies or
due to low pH of the mucus at midcycle.
 Cervical stenosis( tight internal os)
 Infections of the cervix with common sexually
transmitted diseases (chlamydia, gonorrhea, or
trichomonas, as well as mycoplasma hominis
and ureaplasma urealyticum)
 Loss of mucus due to amputation of the cervix,
cone biopsy or diathermy.
 Conti
Pelvic causes
 Scar tissue or "adhesions"
 Endometriosis
 Tubal factor infertility
 Pelvic inflammatory disease (PID):
usually caused by invasion of either
gonorrhea or chlamydia from the cervix up
to the uterus and tubes.
 Benign tumors (fibroids)
 Conti..
Uterine causes
 Thin or abnormal uterine lining
 Anatomic problems (polyps,abnormal shape
of the uterus, septum within the uterus,
mullerian anomalies, prior exposure to DES
Diethylstilbestrol)
 Uterine atrophy, absence
 Tuberculous endometritis
 Intrauterine adhesions ( Asherman’s
syndrome) due to previous overzealous
curettage or previous surgery on the uterus.
 Conti..
Coital errors
 Apareunia and Dyspareuni
 Frequency and timing of coitus: coitus has to take
place every 48 hours during the fertile period to
offer the optimum chance of conception.
Unexplained Infertility
 Difficulty in picking up the egg by fallopian tube
 Failure of implantation of the embryo into the
uterus
 Failure of the sperm to fertilize the egg when in
contact with each other
MALE CAUSES:
 Exposure to hazardous toxins,
chemicals, or radiation
 Infections such as mumps, or venereal
diseases
 Testicular injury (sports or work injury)
 Childhood illness (failure of a testicle to
descend properly)
 Immune reaction against sperm
(antisperm antibodies)
 conti
 Blockage of one of the ducts allowing
flow of sperm from the testicle
 Injury, infection or prior vasectomy
 Genetic absence of these ducts
(cystic fibrosis)
 Testicular failure and other hormonal
problems
 Chronic medical illness (thyroid
disease, diabetes, and hypertension)
 Spinal cord injuries and paralysis
 Varicocele
 DIAGNOSTIC
HISTORY AND PROCEDURES
PHYSICAL EXAMINATION:
 Ages, occupations, previous marriages
 Duration of marriage and the period of time
during which contraception has been
practiced.
 Past gynecological, surgical, medical
history.
 Exposures to tobacco, alcohol,
environmental toxins
 A history of sexually transmitted diseases
 A careful menstrual history
 Conti.

 Is coitus normal and painless, how frequently it is

practiced and at what time in the cycle.
 A history of any past pregnancies, a thorough
review of all organ systems, and any other relevant
information.
 Drugs, e.g. mefenamic acid taken for
mittelschmerz pain, may interfere with ovulation.
Drugs used for treating hypertension
( guanethidine) may cause impotence and
salazopyrine( for ulcerative colitis),cytotoxic drugs,
immunosuppressives and nitrofurantoin reduces
the sperm count.
 Alcohol intake may reduce the potency and
LABORATORY TESTS
 Hormonal Levels: Blood and urine tests
 High FSH & LH levels and low estrogen
levels suggest premature ovarian failure.
 High LH and low FSH may suggest
polycystic ovary syndrome or luteal phase
defect.
 High FSH and high estrogen levels on the
third day of the cycle predict poor success
rates in older women trying fertility
treatments.LH surges indicate ovulation.
 Blood tests for prolactin levels and thyroid
function are also measured.
 clomiphene challenge test
 Used to test for ovarian reserve.
With this test, FSH is measured
on day 3 of the cycle. The
woman takes clomiphene orally
on days 5 and 9 of the cycle.
Then FSH measured on the tenth
day. High levels of FSH either on
day 3 or day 10 indicate a poor
chance for a successful
outcome.
 Tissue Samples: To rule out luteal phase
defect, premature ovarian failure, and
absence of ovulation, tissue samples are
taken of the uterus 1 - 2 days before a
period to determine if the corpus luteum is
adequately producing progesterone. Tissue
samples taken from the cervix may be
cultured to rule out infection.
 Tests for Autoimmune Disease
Importance of BMI and obesity: BMI
Obesity > 30
Average =25kg/m2
Requires treatment> 28
 IMAGING TESTS AND DIAGNOSTIC
PROCEDURES
 TRANSVAGINAL ULTRASOUND
 ENDOMETRIAL BIOPSY:
Involves scraping a small amount of tissue
from the endometrium shortly before
menstruation is due- between 11 and 13
days following ovulation. It is performed to
determine if the lining of the uterus is
sufficiently developed and can support pre-
embryonic implantation
POST-COITAL TEST
 Give information how the cervical
mucus and sperm interact, to determine
whether the mucus in the cervix is
"hostile" to sperm. The test must be
done within one to two days before or
after ovulation.
A couple should abstain from
intercourse for 2 days before ovulation,
then have intercourse 2-8 hours prior to
the hospital visit for the post-coital test.
Ferning - When the cervical mucus
dries on a microscope slide, it should
take on the appearance of ferns. This
assures that the mucus has been
exposed to adequate levels of estrogen
without any exposure to progesterone.
In other words, that the timing is correct.
 Amount - Cervical mucus production
normally increases dramatically just
prior to ovulation.
 Clarity - It should be very clear,
almost watery.
 Cellularity - There
should be relatively
few cells present,
other than sperm.

 Spinnbarkeit –
This is the stretchiness
of the cervical mucus.
It should be almost
elastic and may stretch
10 cms or more.
HYSTEROSALPINGOGRAM
 It is essentially an x-
ray procedure in
which a dye is injected
through the cervix into
the uterus and
fallopian tubes. The
radio-opaque material
is injected slowly from
a syringe; the amount
required varying from
2-20 ml
 BASAL BODY
TEMPERATURE CHARTING

 To identify the time of

ovulation. Charting involves
taking one's temperature
every morning upon waking
up and recording the results.
When the temperature goes
up 0.5 degrees, the woman is
in the process of ovulating.
HYSTEROSCOPY
 It uses a hysteroscope, which is a thin
telescope that is inserted through the
cervix into the uterus. This procedure
allows to determine whether there are any
abnormalities such as fibroid tumors,
polyps, scar tissue, a uterine septum, or
some other uterine problem
HYSTEROCONTRAST SONOGRAPHY
HyCoSy
 A combination of air and saline or contrast
medium (Echovist-200) is introduced into
the uterus transcervically. The flow of the
medium seen in some unanaesthetised
women is more through the uterus and
tubes, and its spill in the pelvis with water
soluble than with oily or non-ionic media is
monitores by ultrasound. Complications
like immediate pain, vomiting, shock and
hypotension can occur.
FALLOPOSCOPY
 The falloposcopy is a visual examination of
the inside of the fallopian tubes. This
involves the insertion of a tiny catheter
through the cervical canal and into the
uterus to the fallopian tubes. It is then, an
even smaller fiber optic endoscope is
threaded through the catheter, into the
fallopian tube. From here, the fallopian
tubes can be examined on a monitor from
which a camera is attached on the outside
end of the fallopscope.
 LAPAROSCOPY
 Itrequires general anesthesia and is
performed in an operating room. The
surgeon makes a very small incision below
the belly button and inserts an instrument
called a laparoscope

Laparoscopy picture
of a hydrosalpinx,
fallopian tube that is
blocked and dilated with
fluid.This is evidence of PID
 TESTS FOR MALE
INFERTILITY
 SEMEN ANALYSIS
 The specimen is collected after 3 days of
abstinence, masturbating directly into a dry
and clean wide mouthed glass container.
 The semen analysis should include basic
parameters such as sperm number, motility,
and morphology (shape) The technician
looks at how well the sperm are moving and
counts the total percentage of motile sperm
moving.
 Semen Analysis Parameter Normal Values

Volume 2.0 ml or more

pH 7.2-8.0

Sperm concentration 20,000,000/ml or more

Motility 50% or more with forward progression

Rapid forward progressive motility 25% or more

30% or more normal forms (WHO
criteria)
Morphology -or-
11% or more normal forms (Strict
criteria)

Vitality 75% or more live

White blood cells Less than 1,000,000/ml

SPERM FUNCTION TESTS
 SPERM PENETRATION ASSAY/ HAMSTER
EGG TEST: In this test, the husband's sperm
is mixed with hamster eggs to see whether
they penetrate the eggs. Healthy sperms
penetrate most, specially processed hamster
ova from which the zona has been removed,
and produce a significant degree of
polyspermy per egg.
 Human zona binding assay: In this test, the
husband's sperm is mixed with pieces of human
egg shells (zona pellucidas) to see how many
will bind to the shells. There are a lot less false
positives and false negative results as compared
to the hamster egg test.
 VARICOCELE ASSESSMENT : Varicocele is the
collection of dilated veins in the spermatic cord.
Exact cause for infertility is not known but it may
be associated with ipsilateral testicular volume,
elevated scrotal temperature and pain, impaired
sperm quality- WHO 1992. In 31% cases only
treatment of varicocele has resulted in improves
sperm count.
SPERM ANTIBODY TESTING
 Semen is known to be highly antigenic and
sperm antibodies are a known cause of
infertility. Agglutination is the sticking together
of sperm in variable patterns. It is caused by
anti-sperm antibodies which are usually IgA
or IgG. Further tests like immunobead or
mixed anti globulin reaction (MAR) test can
be done for the detection of these antibodies
in semen.
HORMONAL ASSESSMENT
IN MEN
A raised FSH level reflects failure of
spermatogenesis.
 Low levels of FSH and LH are
diagnostic of hypo-gonadotrophic
hypogonadism.
 Normal FSH levels with normal
testes but azoospermia suggest
obstruction
 Raised LH level with low
testosterone levels indicate Leydig
 INFERTILITY
COUNCELLING
 The basic aim of counseling
is to ensure that the patient
understands the implications
of their treatment choice, the
patient receives adequate
information and emotional
support, and that they can
cope in a healthy way with
the consequences of
treatment.
 IMPLICATION COUNCELLING
 It is to enable couples to understand the
implications of the proposed treatment for
themselves, their family and for any
children born as a result. This may of
particular relevance for couple seeking
treatment with donor eggs, donor sperm,
donor embryos or surrogacy. Genetic
counselling should be offered when there is
an increased risk of passing on an inherited
disease to the offspring. Psychological
counselling should be offered for partners
suffering from psychosexual problems.
 SUPPORT COUNSELLING
 To give emotional support and
information from the start of the
treatment. It is primarily the task of the
clinical team but unfortunately, tension
often erases much of the information,
which has been given, and many patients
will not have fully digested what have
been said. Infertility counselors need to
address these defects and detects any
tensions showed by the patient's poor
understanding
 THERAPEUTIC COUNSELLING
 To help couples understand their
expectation including the prospects
of failure and adjusting to
childlessness, counselling can with
time, help people adjusts and
accepts the situation. Therapeutic
counselling also focuses on certain
issues such as sexual and menstrual
problems
Role of a Counselor
 The role of counselor is to help infertile
couples process their emotions and to
arrive at a situation with which they feel
comfortable and with which they can
live a normal life. It is essential that
counselling must be informal and
effective and not a hindrance and waste
of time. Counselors should have up-to-
date knowledge of infertility and
assisted reproductive treatments.
BIBLIOGRAPHY
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 Speroff L, Fitz M. Clinical Gynecologic Endocrinology
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 Stenchever A. Comprehensive Gynecology. 4th ed.
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