Case 4 TG

• Infertility


  Inability to conceive after 1 year of unprotected coitus
• Primary infertility


  Infertility occurring in one who has never had pregnancy
• Secondary infertility


  Infertility occurring in one who has had a prior pregnancy, not necessarily a live birth

  
• Fecundability


  Probability of achieving pregnancy within a single menstrual cycle. The fecundability of a normal couple is estimated to be 20-25%
• Fecundity


  Probability of achieving a live birth within a single cycle
• Causes of infertility


  • Male factor
  • Ovarian factor
  • Cervical factor
  • Uterine factor
  • Tubal factor

  
• Male factor infertility


  • It 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
  • Decreases in sperm parameters have been noted in fertile men, the clinical relevance for fecundability is unknown
  • If sperm concentrations decline by 21-47%, fecundability would decrease by 7-15%
• Causes of male factor infertility

  • Sperm volumes
  • White blood cells
  • Immature sperm cells
  • Varicocele
  • Azoospermia
• Azoospermia


  Absence of spermatozoa in the ejaculate

  
• Types of azoospermia


  • Pretesticular
  • Testicular
  • Posttesticular
• Causes of pretesticular azoospermia


  • Endocrine
  • Coital disorders
• Causes of testicular azoospermia

  • Genetic
  • Congenital
  • Infective
  • Antispermatogenic agents
  • Vascular
  • Immunologic
  • Idiopathic
• Causes of posttesticular azoospermia


  • Obstructive
  • Epididymal hostility
  • Accessory gland infection
  • Immunologic
• Decreased ovarian reserve


  The size of the nongrowing, or resting, primordial follicle population in the ovaries, which determines the number of growing follicles and the "quality" or reproductive potential of their oocytes

  
• Reproductive aging is related to the stock of primordial follicles that are established early in fetal life and decline to near zero at menopause

  
• An association between the age of the woman and reduced fertility has been well documented, with the decline in fecundability beginning in the early 30s but accelerating during the late 30s and early 40s
• Chronological age is the strongest determinant of reproductive success in spontaneous and ART cycles because it is a predictor of ovarian reserve
• The age of the oocyte, rather than the age of the endometrium, that accounts for the age-related decline in female fertility
• Ovulatory factors


  Disorders of ovulation account for 30-40% of all cases of female infertility

  
• Polycystic Ovarian Syndrome (PCOS)

  • The most common cause of oligo-ovulation and anovulation — both in the general population and among women presenting with infertility
  • Presence of at least 2 of the 3 criteria: oligo and/or anovulation, clinical and/or biochemical hyperandrogenism, polycystic ovaries
  • Insulin resistance is thought to play a central role in the pathogenesis in the subset of patients characterized by increased BMI, hyperinsulinemia, and significant hyperandrogenism
  • A different form of insulin resistance intrinsic to PCOD is part of the underlying disease mechanism in thin women with PCOS
• Hyperprolactinemia


  Caused by pituitary microadenoma
• Hypogonadotropic Hypogonadism


  • Reflects dysfunction within the hypothalamic-pituitary axis, characterized by low serum LH, FSH, and estradiol
  • Causes include central space occupying lesions, low BMI, and congenital hypothalamic failure
• Hypothyroidism


  • Associated with irregular menses, likely from anovulation
  • Spontaneous ovulatory cycles resume when euthyroid status is achieved using thyroxine supplementation
• Cervical factor infertility


  • Caused by poor mucous quality, which can be due to anovulation, anatomic factors, infection, or certain medications
  • Antisperm antibodies can also cause cervical factor infertility
• Uterine factor infertility


  Pathologies within the uterine cavity are the cause of infertility in as many as 15% of couples seeking treatment and are diagnosed in greater than 50% of infertile patients

  
• Causes of uterine factor infertility

  • Congenital anomalies
  • Acquired abnormalities (leiomyomas, endometrial polyps, Asherman's syndrome)
  • Disorders of endometrial function and luteal phase defect

  
• Tubal factor infertility


  • Accounts for 25-35% of infertility
  • Usually associated with previous pelvic inflammatory disease or previous pelvic or tubal surgery
• Luteal phase defect


  Controversy surrounding the existence, diagnosis, and treatment of luteal phase defect
• Luteal phase defect


  • Present when two endometrial biopsies demonstrate a delay in histologic development of endometrium of more than 2 days beyond the actual day cycle
  • Proposed mechanisms include inadequate production of progesterone following ovulation, improper GnRH pulsatility causing insufficient gonadotropin production during the LH surge, and inadequate endometrial responsivity to progesterone
• Tubal factor


  Accounts for 25-35% of infertility
• Noninfectious causes for tubal factor

  • Tubal endometriosis
  • Salpingitis isthmica nodosa
  • Tubal polyps
  • Tubal spasm
  • Intratubal mucous debris
• Tubal factor


  • Damage or obstruction of fallopian tubes — usually associated with previous PID or previous pelvic or tubal surgery
  • C. trachomatis and N. gonorrhoeae are common pathogens associated with PID and infertility
  • Peritubal and periovarian adhesions — from PID, surgery, or endometriosis
• Incidence of infertility after PID

  • 1 episode — 12% (8%*)
  • 2 episodes — 23% (19.5%*)
  • 3 episodes — 54% (40%*)
• Sterilization reversal


  • Pregnancy rates following microsurgical tubal reanastamosis for sterilization reversal are 55-81%, with most pregnancies occurring within 18 months of surgery
  • Ectopic pregnancy rates following the procedure are generally less than 10% but may approach 18%
  • Main predictors of success are: age younger than 35 years, isthmic-isthmic or ampulo-ampullar anastamosis, final anastomosed tubal length greater than 4 cm, and less-destructive sterilization methods such as use of rings or clips

  
• Pregnancy rates after reversal

  • Pomeroy technique — 75%
  • Fallope rings or clips — 67%
  • Unipolar electrocautery — 58%

  
• Unexplained infertility


  When cause of infertility remains unknown after basic investigation
• Unexplained infertility


  • May be due to previously unsuspected conditions, such as uterine leiomyomas, endometriosis, and peritubal adhesions, which could be detected by laparoscopy
  • Diagnostic laparoscopy in the management of unexplained infertility is controversial
  • It is reasonable to start fertility treatment empirically in women with unexplained infertility and normal HSG without assessment of the pelvis by diagnostic laparoscopy

  
• Semen analysis


  Measures semen volume, sperm concentration, sperm motility, and sperm morphology
• Additional semen analysis tests

  • pH
  • Fructose levels
  • WBC count
• Semen analysis


  • 2-3 days abstinence usually recommended (minimum of 2 to a maximum of 7 days prior to semen analysis)
  • Collection: by masturbation, clean container (condoms contain spermicidal agents) kept at ambient temperature
  • Examination within 1-2 hours after collection (30 minutes to 1 hour to prevent dehydration and degradation)