Learning Objectives #
The Students should be able to:
– Define primary and secondary infertility
– Causes of male and female infertility
– Evaluation and management
– Psychosocial issues associated with infertility
– Discuss ethical consideration
Definition of Infertility #
Infertility is defined as the inability to conceive or carry to term a pregnancy after one year of regular, unprotected intercourse.
on average 75% of couples achieve pregnancy within 6 months, 85% within 1 year, 90% within 2 years.
Primary infertility: infertility in the context of no prior pregnancies
Secondary infertility: infertility in the context of a prior conception
Etiology #
Etiology: Male factors and Femail factors
Female Factors:
ovulatory dysfunction (15-20%)
- hypothalamic (hypothalamic amenorrhea)
- pituitary
- ovarian
- systemic diseases (thyroid, Cushing’s syndrome, renal/hepatic failure)
- congenital (Turner’s syndrome, gonadal dysgenesis, or gonadotropin deficiency)
- stress, poor nutrition, excessive exercise (even with presence of menstruation)
outflow tract abnormality
- tubal factors (20-30%)
- uterine factors (<5%)
- cervical factors (5%)
endometriosis
multiple factors (30%)
unknown factors (10-15%)
Male factors :
- varicocele (>40%)
- idiopathic (>20%)
- obstruction (~15%)
- cryptorchidism (~8%)
- immunologic (~3%)
Investigations:
Participation of both Partners in the initial assessment is ideal.
Male Factor investigation:
- semen analysis
- post-coital (Huhner) test
- other tests (antibody studies, sperm penetration assay)
Female factor investigation:
ovulatory
- Day 3 FSH, LH, TSH, PRL +/- DHEA, free testosterone (if hirsute)
- Day 21-23 serum progesterone
- initiate basal body temperature monitoring (biphasic pattern)
- postcoital test – evaluate mucus for clarity, pH, spinnbarkeit (rarely done)
tubal factors
- HSG (can be therapeutic – opens fallopian tube)
- SHG
- laparoscopy with dye insufflation
peritoneal/uterine factors
- HSG/SHG, hysteroscopy
other
- karyotype
Treatment #
Education – timing of intercourse in relation to ovulation (from 2 days prior to 2 days following presumed ovulation), every other day
Medical
- ovulation induction
- clomiphene citrate (Clomid®) – estrogen antagonist that causes a perceived decreased estrogen state, which results in increased pituitary gonadotropins; this causes increased FSH and LH, leading to ovulation induction (better if anovulatory)
- human menopausal gonadotropin (HMG (Pergonal™)), urofollitropin (FSH [Metrodin®]) – FSH and LH extracted from urine of post-menopausal women
- followed by beta-hCG for stimulation of ovum release
- may add
- bromocriptine (dopamine agonist) if increased hyperprolactinemia
- dexamethasone for women with hyperandrogenism (PCOS, adult onset congenital adrenal hyperplasia), metformin (PCOS)
- uteal phase progesterone supplementation for luteal phase defect
- ASA (81 mg PO OD) daily for women with a history of recurrent spontaneous abortions
surgical/procedural
- Surgery for varicocele if needed
- tuboplasty
- lysis of adhesions
- artificial insemination
- sperm washing
- IVF (in vitro fertilization)
- intrafallopian transfers:
- GIFT (gamete intrafallopian transfer) – immediate transfer with sperm after oocyte retrieval
- ZIFT (zygote intrafallopian transfer) – transfer after 24 hour culture of oocyte and sperm
- TET (tubal embryo transfer) – transfer after >24 hour culture
- ICSI (intracytoplasmic sperm injection)
- IUI (intrauterine insemination)
- ± oocyte or sperm donors
- IVM (in vitro maturation)