GYN 17

• Infertility


  The inability to conceive within one or more years of regular unprotected coitus
• Primary infertility


  Patients who have never conceived
• Secondary infertility


  Previous pregnancy but failure to conceive subsequently
• Fecundability


  The probability of achieving a pregnancy within one menstrual cycle
• In a healthy young couple, fecundability is 20%
• Fecundity


  The probability of achieving a live birth within a single cycle
• About 80% of couples achieve conception within one year of regular intercourse, another 10% within the second year, and 10% remain infertile
• Factors essential for conception

  • Healthy spermatozoa deposited high in the vagina
  • Spermatozoa undergo capacitation and acrosome reaction to acquire motility
  • Motile spermatozoa ascend through the cervix into the uterine cavity and fallopian tubes
  • Ovulation
  • Fallopian tubes are patent and the oocyte is picked up by the fimbriated end
  • Spermatozoa fertilize the oocyte at the ampulla of the tube
  • The embryo reaches the uterine cavity after 3-4 days of fertilization
  • The endometrium is receptive for implantation and the corpus luteum functions adequately
• Due to anovulation, infertility is the rule prior to puberty and after menopause, but pregnancy is possible before menarche and within a few months of menopause
• Conception is not possible during pregnancy as the pituitary gonadal axis is suppressed by hCG and there is no ovulation
• During lactation, ovulation and conception can occur, but in fully lactating women pregnancy is unlikely up to 10 weeks postpartum
• Causes of infertility


  • Male factor (30-40%)
  • Female factor (40-55%)
  • Combined male and female factor (10%)
  • Unexplained (10%)
• Areas of male infertility

  • Defective spermatogenesis
  • Obstruction of the efferent duct system
  • Failure to deposit sperm high in the vagina
  • Errors in the seminal fluid
• Spermatogenesis


  The process by which spermatozoa are produced, controlled by FSH, testosterone, and inhibin B
• Common causes of male infertility

  • Hypothalamic-pituitary disorders
  • Primary testicular disorders
  • Disorders of sperm transport
  • Idiopathic
• Congenital causes of male infertility

  • Undescended testes
  • Kartagener syndrome
  • Hypospadias
• Other causes of male infertility

  • Thermal factors (e.g. varicocele)
  • Infections
  • General factors (e.g. chronic disease, malnutrition, smoking, alcohol)
  • Endocrine factors
  • Genetic factors
  • Iatrogenic factors
  • Immunological factors
• Causes of female infertility

  • Ovulatory dysfunction
  • Tubal disease
  • Uterine factors
  • Cervical factors
  • Pelvic endometriosis

  
• Ovarian factors causing infertility

  • Anovulation or oligo-ovulation
  • Decreased ovarian reserve
  • Luteal phase defect
  • Luteinized unruptured follicle
• Luteal phase defect


  Inadequate growth and function of the corpus luteum, leading to inadequate progesterone secretion and impaired endometrial receptivity
• Luteinized unruptured follicular syndrome

  The ovum is trapped inside the luteinized follicle
• Tubal and peritoneal factors causing infertility

  • Pelvic infections
  • Previous tubal surgery or sterilization
  • Salpingitis isthmica nodosa
  • Tubal endometriosis
  • Polyps or mucous debris within the tubal lumen
  • Tubal spasm
• Uterine factors causing infertility

  • Uterine hypoplasia
  • Inadequate secretory endometrium
  • Fibroid uterus
  • Endometriosis
  • Endometritis
  • Uterine synechiae
  • Congenital uterine malformations
• Cervical factors causing infertility

  • Anatomic defects preventing sperm ascent
  • Scanty cervical mucus
  • Presence of antisperm or sperm immobilizing antibodies
• Vaginal factors causing infertility

  • Atresia of vagina
  • Transverse vaginal septum
  • Septate vagina
  • Narrow introitus causing dyspareunia
• Combined factors causing infertility

  • Presence of factors in both male and female partners
  • Advanced age of wife
  • Infrequent intercourse
  • Apareunia and dyspareunia
  • Anxiety and apprehension
  • Use of spermicidal lubricants
  • Immunological factors
• Infertile couples should be investigated after one year of regular unprotected intercourse with adequate frequency
• Arrow introitus

  Causing dyspareunia
• Dyspareunia


  May be the real problem in such cases
• Combined factors causing infertility


  • Presence of factors both in the male and female partners
• General factors causing infertility

  • Advanced age of the wife beyond 35 years
  • Male spermatogenesis continues throughout life although aging reduces the fertility in male also
• Other factors causing infertility

  • Infrequent intercourse
  • Apareunia and dyspareunia
  • Anxiety and apprehension
  • Use of lubricants during intercourse, which may be spermicidal
  • Immunological factors
• When to investigate infertility


  1. After one year of regular unprotected intercourse with adequate frequency

  2. Interval shortened to 6 months after the age of 35 years of the woman and 40 years of the man
• What to investigate for infertility

  • Semen analysis
  • Confirmation of ovulation
  • Confirmation of tubal patency

  
• Both partners should come at the first visit for infertility investigation

  
• Male history for infertility investigation

  • Age
  • Duration of marriage
  • Contraception used
  • History of previous marriage
  • Sexual dysfunction
  • Anosmia
• Possible mechanisms of subinfertility in women with pelvic endometriosis

  • Ovarian dysfunction
  • Tubal dysfunction
  • Uterine and others

  
• Ovarian dysfunction in pelvic endometriosis

  • Endocrinopathies
  • Defective folliculogenesis
  • Anovulation (PCOS)
  • Luteal phase defect
  • Reduced ovarian reserve
  • Hyperprolactinemia
  • Oocyte maturation defect
  • Luteolysis due to ↑ PGF2a
• Tubal dysfunction in pelvic endometriosis

  • Altered tubal motility
  • Pelvic adhesions, tubal obstruction
  • Distortion of normal tube and ovarian relationship
  • Impaired pick-up of oocyte by the fimbria
• Uterine and other factors in pelvic endometriosis

  • Impaired fertilization
  • Implantation failure
  • Early miscarriage
  • Abnormal endometrial receptivity
  • Dyspareunia (poor coital function)
  • Abnormal peritoneal fluid
  • Abnormal systemic immune response
  • Increased sperm phagocytosis by macrophages