INFERTILITY - MALE AND FEMALE - OPTIONS

1. Dr Angelo Smith MD
WHPL

2.  Failure of a couple to conceive after
1 year of regular intercourse without
use of contraception
 Primary infertility – No prior
pregnancies
 Secondary infertility – Prior pregnancy

3.  Infertility affects 10-15% of reproductive-age
couples in the world.
 Approx. 85% of couples achieve pregnancy within 1
year
 Conception rate (fecundability)
 25% conceive within 1 mo.
 60% conceive within 6 mo.’s
 75% conceive within 9 mo.’s
 90% conceive within 18 mo.’s

4. Successful conception requires a specific series of events:
1. Ovulation of competent oocyte
2. Production of competent sperm
3. Juxtaposition of sperm and oocyte in a patent reproductive tract
4. Fertilization
5. Generation of a viable embryo
6. Transport of the embryo to the uterine cavity
7. Implantation of the embryo into the endometrium

5.  Major causes of of infertility:
 Female factor – 60%
 Ovulatory dysfunction
 Abnormalities of female reproductive tract
 Peritoneal factors
 Reproductive aging
 Male factor – 20%
 Abnormal semen quality
 Abnormalities of male reproductive tract
 Idiopathic – 15%
Infertility in ~ 20-40% of couples has multiple causes

6.  Female
 Duration of infertility and prior evaluation or therapy
 Menstrual cycle (length and characteristics)
 Symptoms associated with ovulation (e.g. breast tenderness,
bloating, mood changes)
 Full OBHx and GynHx
 Prior pregnancies, surgeries, or STD’s
 Sexual history (frequency of intercourse)
 Chronic medical illness
 Family history (infertility, birth defects, genetic disorders)
 Social history (smoking, EtOH, drugs)

7.  Male
 Prior children
 Genital tract infections
 Genital surgery or trauma
 Chronic medical illness
 Medications (e.g. Furantoins, CCB)
 EtOH, drugs, or smoking
 Sexual history (frequency of intercourse)

8.  Female
 Height, weight , BMI
 Pelvic exam
 Masses
 Tenderness (Adnexa, Cul-de-sac)
 Structural abnormalities (Vagina,Cervix, or Uterus)
 Male
 Evidence of androgen deficiency
 Structural defects (e.g. varicocele, hernia)

12. Initial
evaluation
Further evaluation
Male
Factor
•Semen
analysis
•Urologic
evaluation
•FSH, LH, and
testosterone level
•Genetic evaluation
•Epididymal sperm
aspiration (PESA, MESA)
•Testicular biopsy

13. Element Reference value
Ejaculate volume 1.5-5.0 mL
pH > 7.2
Sperm concentration > 20 million/mL
Motility > 50%
Morphology > 30% normal forms
 Semen analysis
 Following 2-4 day period of abstinence
 Repeated x1 for accuracy

15.  Urologic evaluation
 Physical Exam
 Varicocele
 Congenital absence of vas
deferens (CAVD)
Transrectal ultrasound
Vasography, Seminal
vesiculography
Epididymal sperm aspiration
(PESA or MESA)

16.  Endocrine evaluation
 Indication: Oligospermia (< 10million/mL) or sexual dysfunction (decreased
libido, impotence)
 FSH, LH, testosterone
 Genetic evaluation
 Indication: Azoospermia (no sperm)
 CF (Cystic fibrosis) mutation
 Karyotype (Klinefelter’s, Y chromosome deletion)
 Testicular biopsy
 Indication: Nonobstructive azoospermia
 Palpable vasa
 Normal testis volume
 Normal FSH/LH

19. Factor Initial evaluation Further evaluation
Ovulation •History and physical exam
•Basal body temp charting
•Ovulation predictor kit
•Mid-luteal phase
progesterone level
•Endocrine testing
•Endometrial biopsy
Reproductive tract
(uterus or fallopian
tubes)
•Hysterosalpingogram
(HSG)
•Ultrasound
•Saline-infusion
sonography
•Hysteroscopy
•Laparoscopy
Peritoneal Laparoscopy
Reproductive
aging
•FSH, estradiol, or AMH

21.  Ovulation
 Initial evaluation:
 Basal body temp – rise for > 10 days indicates ovulation
 Ovulation predictor kit – detects LH surge in urine
 Further evaluation:
 Mid-luteal phase progesterone level - level > 3 ng/mL provides
qualitative evidence of recent ovulation
 Endocrine testing (TSH, prolactin, FSH, LH, Estradiol, DHEA-S)
 Endometrial biopsy
 Not routinely performed

22.  Reproductive tract
 Initial evaluation:
 Hysterosalpingogram (HSG)
 Detect uterine anomalies (septate or bicornuate uterus, uterine
adhesions, uterine leiomyoma)
 Detect patency of fallopian tubes (occlusion, hydrosalpinx, salpingitis)
 Ultrasound – alternative to HSG to evaluate uterus

23.  Reproductive tract
 Further evaluation:
 Saline-infusion sonography (SIS)
 Hysteroscopy
 Laparoscopic chromotubation

24.  Peritoneal factors
 Laparoscopy
 Endometriosis
 Pelvic/adnexal adhesions

25.  Reproductive aging
 Indications:
 > 35 years of age
 1st degree relative with early menopause
 Previous ovarian insult (surgery, chemotherapy,
radiation)
 Smoking
 Poor response to ovarian stimulation
 Unexplained infertility
 Candidate for IVF

26.  Reproductive aging
 Cycle day 3 serum FSH and estradiol
 Abnormal (“diminished ovarian reserve”)
 FSH > 10 IU/L
 Estradiol > 75-80 pg/mL
 Clomiphene citrate challenge test
 Cycle day 10 serum FSH
 Serum antimullerian hormone (AMH)

27.  Prevalence ~ 15%
 Factors that cannot be identified
 Sperm transport defects
 Inability of sperm to fertilize egg
 Implantation defects

30.  Male Factor
 Avoidance of alcohol
 Scheduled intercourse
 Ligation of venous plexus for significant varicocele
 Intrauterine insemination (IUI) with washed sperm
 Intracytoplasmic sperm injection (ICSI) + IVF
 Donor sperm insemination

31.  Ovulation Induction (Clomid or low dose
FSH)
 IUI (low dose FSH)
 IVF / ICSI (LHRH analogue, high dose FSH
injections, egg collection, embryo
transfer)

32.  Anovulation
 Oral medications:
 Clomiphene citrate
 Dopamine agonists (Bromocriptine) - hyperprolactinemia
 Injectable medications:
 Gonadotropins (FSH/hMG, hCG)
 Laparoscopic “ovarian drilling”
 Complications: Ovarian hyperstimulation, Multiple pregnancy

33.  Reproductive tract abnormality
 Uterine: Myomectomy, Septoplasty, Adhesiolysis
 Tubal: Microsurgical tuboplasty, Neosalpigostomy
 Peritoneal: Laparascopic treatment of endometriosis,
Adhesiolysis
 Idiopathic infertility
 Ovarian stimulation + IUI
 Clomiphene or gonadotropins (hMG, hCG)
 IVF

34.  Used for:
 Severe male factor
 Tubal disease
 Couples who failed other treatments
 Requires
 Controlled ovarian hyperstimulation
 Retrieval of oocytes
 In vitro fertilization and embryo transfer
 Procedures
 IVF + embryo transfer (IVF-ET)
 Intracytoplasmic sperm injection + embryo transfer (ICSI-ET)
 Donor egg IVF + embryo transfer

37. ~ 40% of IVF cycles involve insemination by ICSI

39. 


40. Advantages
 Embryo Selection
 Reduction in number of
embryos for ET
resulting in reduction in
multiple gestations

41.  The psychological stress
associated with infertility must
be recognized and patients
should be counseled
appropriately.

42.  For patients with poor ovarian
reserve
 Alternative to adoption or
childlessness
 Success Rate ~ 50% per cycle