MCN mod 6.2

• Infertility


  Inability to:

  • Conceive a child
  • Sustain a pregnancy to childbirth (habitual aborters)
  • Get pregnant after at least 1 year of engaging in unprotected sex (subfertility)
• Not all couples become pregnant
• Reasons for infertility


  • 70%: female is infertile

  20%: tubal, vaginal, uterine problems

  20–25%: ovulatory failure = PCOS (ovaries are not able to respond to FSH and LH)

  30%: man is infertile
• Infertility can be associated with both males and females
• Primary subfertility


  No previous conceptions (never results to pregnancy), woman is nulligravida
• Secondary subfertility


  Previous viable pregnancy but the couple is unable to conceive at present (got pregnant but resulted to miscarriage), Despite years of unprotected coitus, the couple still have problems in conceiving
• Sterility


  Inability to conceive because of a known condition (e.g., absence of uterus)
• Coitus


  4x/week is the recommended number, Must be done with space in between days to give enough time for sperms to mature
• Conception will occur:

  • Within 6 months for 50% of couples
  • Within the next 12 months for 85% of couples
• Infrequent coitus


  Conception is likely to occur in longer periods
• Daily coitus


  Done by some couples in hopes to cause early impregnation, Leads to increased difficulty in conceiving, Lowers man's sperm count below optimal fertility
• Normal sperm


  • 20 million/mL of sperm or 50 million/ejaculation, 50% motile (can reach the ovum), 30% with normal shape and form (can reach the chance of fertilizing the ovum)
• Factors affecting male infertility

  • - Limited sperm count
  • Impaired sperm motility
  • Ineffective ejaculation and deposition
  • Disturbed sperm production
• Semen analysis


  • 2-4 days of sexual abstinence
  • Patient ejaculates by masturbation at the clinic into a clean, dry specimen jar or a condom without spermicide
  • Spermatozoa are examined under microscope within 1 hour
  • Count number of sperm in the specimen, appearance and motility are noted

  
• Sperm penetration assay and antisperm antibody testing

  Determines whether a man's sperm, once they reach an ovum, can penetrate it effectively
• Increasing sperm count and motility

  • Abstain from coitus for 7–10 days, Intercourse on the 11th day to collect sperm cells
  • Changes in lifestyle: Loose clothing, No long periods of sitting and prolonged hot baths, Lessen alcohol intake
• Addressing sperm transport concerns

  • Surgery may be costly and a positive outcome is not guaranteed
  • Intrauterine insemination (IUI): Extracting sperm from a point above the blockage and injecting it into the vagina or uterus of the partner
  • Abstinence or condom use for ~6 months if the immobilization of sperm is due to immunologic reasons
• Sperm transport disorders


  Suspected when FSH and LH hormones, which stimulate the production of sperm, are adequate but the sperm count remains limited
• Ejaculation concerns


  Identified with a sexual history
• Increasing sperm count and motility

  1. Abstain from coitus for 7–10 days

  2. Intercourse on the 11th day to collect sperm cells

  3. Rationale: allows adequate rest for maturation of sperm
• Changes in lifestyle


  1. Loose clothing

  2. No long periods of sitting and prolonged hot baths

  3. Lessen alcohol intake
• Addressing sperm transport concerns

  1. Surgery may be costly and a positive outcome is not guaranteed

  2. Intrauterine insemination (IUI): Extracting sperm from a point above the blockage and injecting it into the vagina or uterus of the partner

  3. Abstinence or condom use for ~6 months if the immobilization of sperm is due to immunologic reasons

  4. Administration of corticosteroids to decrease immune response and antibody production, thereby addressing sperm immobilization

  
• Addressing ejaculation concerns


  1. Psychological or sexual counseling

  2. Use of phosphodiesterase inhibitors (Sildenafil (Viagra) and tadalafil (Cialis)) to induce smooth muscle relaxation and increasing the blood flow to the penis, leading to an erection

  3. Use of selective serotonin reuptake inhibitors (dapoxetine) for the treatment of premature ejaculation
• Anovulation


  Absence of ovulation or release of ova; problem with hormones
• Anovulation is the most common cause of infertility in women
• Causes of anovulation


  • Genetic abnormality (Turner's syndrome [hypogonadism]): limited ovarian tissue; no ovaries to produce ova
  • Hormonal imbalance: hypothyroidism, hyperprolactinemia, and decreased FSH/LH
  • Ovarian tumors or PCOS (polycystic ovary syndrome): causes feedback stimulation on the pituitary gland
  • Physical/environmental factors: chronic or excessive exposure to X-rays or radioactive substances, general ill health, drug use and excessive alcohol consumption, and stress (causes ↓ LH and FSH)
  • Nutrition and diet: nutrition, poor diet, body weight, and exercise influence the blood glucose–insulin balance
• Polycystic ovarian syndrome (PCOS)


  Condition in which the ovaries produce excess testosterone, thus lowering FSH and LH levels, which then causes irregular and unpredictable menstrual cycles
• Characteristics of PCOS


  • Associated with metabolic syndrome
  • Weight gain happens because of insulin resistance (hyperglycemia)
  • Caused by testosterone dominance
  • Ovaries fail to respond to FSH (for maturation of egg cells) and have benign cysts
  • Ovulation occurs a few times per year
• Tubal transport problems


  Scarring in the passageway of the ovum
• Causes of tubal transport problems

  • Pelvic inflammatory disease (PID): Affects the uterus, fallopian tubes, ovaries, and supporting structures; STIs such as chlamydia and gonorrhea infections are the initial sources of infection
  • Ruptured appendix
  • Abdominal surgery that involves infection (possibly spreads to the fallopian tubes) and has left adhesions
• Uterine problems


  Tumors such as fibromas (leiomyomas or fibroids) that block the entrance of the fallopian tubes into the uterus or limit the space available on the uterine wall for effective implantation; Decreased estrogen/progesterone resulting in inadequate endometrium formation; Endometriosis where the endometrium is not competent enough for the fertilization of ovum

  
• Cervical problems


  Thick cervical mucus that does not allow spermatozoa to penetrate the cervix; Obstruction of the cervical os; Presence of scar tissue and tightening of the cervical os
• Vaginal problems


  pH changes due to infection causing more acidic vaginal secretions which limits/destroys motility of sperm; Presence of sperm-immobilizing or sperm-agglutinating antibodies in the blood plasma
• Ovulation monitoring


  1. Record basal body temperature (BBT) for at least 1 month

  2. Use commercial ovulation test kits to assess increased LH that occurs just before ovulation
• Diagnosis of tubal transport problems

  1. Sonohysterosalpingogram: Sonographic examination of the fallopian tubes and uterus using an ultrasound contrast agent

  2. Sonohysterography: Ultrasound technique designed for inspecting the uterus

  3. Hystero- or uterosalpingography: Radiologic examination of the uterus and fallopian tubes

  
• Sonohysterosalpingogram


  Sonographic examination of the fallopian tubes and uterus using an ultrasound contrast agent introduced into the uterus through a narrow catheter inserted into the uterine cervix

  
• Sonohysterosalpingogram


  • Organ needs to be fluid filled to be examined for clear picture
  • The contrast medium outlines the uterus and fallopian tubes on sonogram to demonstrate patency

  
• Sonohysterography


  Ultrasound technique designed for inspecting the uterus
• Sonohysterography procedure


  1. Uterus is filled with sterile saline

  2. Introduced through a narrow catheter inserted into the uterine cervix

  3. Transvaginal ultrasound transducer is then inserted into the vagina

  4. Inspect the uterus for abnormalities

  
• Hystero- or uterosalpingography


  Radiologic examination of the fallopian tubes using a radiopaque medium