Berek

• Assessing the scope of infertility is hampered in part by the lack of standardized definitions
• Infertility


  No pregnancy with unprotected intercourse for 1 year or 2 years
• Primary infertility


  No previous pregnancies have occurred
• Secondary infertility


  A prior pregnancy, although not necessarily a live birth, has occurred
• About 90% of couples should conceive within 12 months of unprotected intercourse
• Subfertility


  Often used interchangeably with infertility
• Fecundability


  The probability of pregnancy per cycle or the number of cycles to achieve a pregnancy
• Fecundity


  The probability of achieving a live birth
• Impaired fecundity


  Couples with ≥36 months without conception or physical inability or difficulty in having a child
• The prevalence of infertility in the United States has been variously estimated from 7.4% to 15.5% depending on the methodologic approach used
• Utilization of infertility services in the United States remains low at 17% or 6.9 million women aged 25 to 44 from 2006 to 2010 with higher utilization noted among women age ≥30, non-Hispanic Whites, and higher socioeconomic strata
• Initial encounter with an infertile couple


  • The most important one because it sets the tone for subsequent evaluation and treatment
  • Infertility is a problem of the couple, so the presence of the partner is essential from the initial evaluation
• Initial assessment


  1. Obtain complete medical, surgical, and urologic/gynecologic history from both partners

  2. Review risk factors for infertility

  3. Obtain history on family history, occupational exposures, coital frequency, sexual dysfunction

  4. Perform thorough physical examination of the woman

  5. Refer male partner to urologist if indicated
• The basic investigations that should be performed before starting any infertility treatment are semen analysis, confirmation of ovulation, and documentation of tubal patency
• Main causes of infertility

  • Male factor
  • Decreased ovarian reserve
  • Ovulatory factor
  • Tubal factor
  • Uterine factor
  • Pelvic factor
  • Unexplained
• Male factor is the only cause of infertility in about 20% of infertile couples, but it may be a contributing factor in as many as 50% of cases
• Very few couples have absolute infertility, which can result from congenital or acquired irreversible loss of functional gametes in either partner or the absence of reproductive structures in either partner
• Spontaneous conception is less likely to occur with age >42, infertility duration >4 years, severe endometriosis, or severe tubal disorder, so patients with those features should be strongly encouraged to consider treatment rather than expectant management
• Causes of infertility


  • Male factor
  • Both male and female factors
  • Female factor
  • Unexplained infertility
• Causes of female infertility

  • Ovulatory dysfunction
  • Tubal or peritoneal factor
  • Miscellaneous causes
• Premature ovarian failure


  • Usually irreversible, but spontaneous sporadic ovulation and pregnancy have been reported
  • Associated with increased age, decreased egg quality
  • Predicts decreased chance of successful treatment
  • Associated with increased risk of aneuploidy and miscarriage
• Spermatogenesis


  1. Gonadotropin-responsive cells in the testes include Leydig cells and Sertoli cells

  2. Spermatogonia undergo mitotic division to give rise to spermatocytes

  3. Spermatocytes undergo meiosis to produce haploid spermatids

  4. Maturation of spermatids is called spermiogenesis
• Sperm transport


  1. During ejaculation, mature spermatozoa are released from the vas deferens along with fluid

  2. Semen thins out 20-30 minutes after ejaculation due to proteolytic enzymes

  3. Sperm must undergo capacitation to become competent to fertilize the oocyte

  4. Sperm transport from the posterior vaginal fornix to the fallopian tubes occurs within 2 minutes during the follicular phase
• Fertilization


  1. Capacitated sperm undergo the acrosome reaction near the oocyte

  2. Sperm binds to and penetrates the zona pellucida

  3. Fusion of the sperm with the plasma membrane of the oocyte promotes changes that prevent entry by additional sperm
• Semen analysis


  Measures semen volume, sperm concentration, sperm motility, and sperm morphology
• Significant deviations from the reference limits are generally classified as male factor infertility
• Prolonged abstinence >10 days, even in normozoospermic men, will have reduced total motile sperm count and reduced proportions of sperm with normal morphology
• Drugs that can impair male fertility

  • Impaired spermatogenesis
  • Pituitary suppression
  • Antiandrogenic effects
  • Ejaculation failure
  • Erectile dysfunction
  • Drugs of misuse
• Alcoholism, smoking, and marijuana use negatively impact semen parameters
• Vaginal lubricants such as Astroglide and KY Jelly inhibit sperm motility in vitro
• Astroglide and KY do not appear to affect fecundability in noninfertile couples engaging in procreative intercourse
• Normozoospermia


  All semen parameters normal
• Oligozoospermia


  • Reduced sperm numbers
  • Mild to moderate: 5-20 million/mL
  • Severe: <5 million/mL
• Asthenozoospermia


  Reduced sperm motility
• Teratozoospermia


  Increased abnormal forms of sperm
• Oligoasthenoteratozoospermia


  Sperm variables all subnormal
• Azoospermia


  No sperm in semen
• Aspermia (anejaculation)


  No ejaculate (ejaculation failure)
• Leucocytospermia


  Increased white cells in semen
• Necrozoospermia


  All sperm are nonviable or nonmotile