INFERTILITY

• Infertility


  The inability to conceive after at least 1 year of sexual intercourse at least four times per week without contraception
• Primary infertility


  No previous history of either partner conceiving or impregnating
• Secondary infertility


  The inability to conceive after a previous successful pregnancy
• Factors contributing to female infertility

  • Vaginal problems
  • Cervical problems
  • Uterine problems
  • Tubal problems
  • Ovarian problems
• Cervical problems


  • Disruption in physiologic changes that normally occur during the preovulatory and ovulatory period that make the cervical environment conducive to sperm survival
  • Mechanical problems, such as cervical incompetence associated with women whose mothers were treated with diethylstilbestrol (DES)
• Tubal problems


  • Functional
  • Structural
• Infertility due to tubal problems is becoming more prominent with the increased incidence of pelvic inflammatory disease (PID). PID leads to scarring that blocks the fallopian tubes
• The increased use of intrauterine devices (IUDs) contributes to the rise in PID because 40% of infections associated with IUD use are asymptomatic and remain untreated
• Endometriosis also can contribute to tubal obstruction
• Factors contributing to male infertility

  • Congenital factors
  • Ejaculation problems
  • Sperm abnormalities
  • Testicular abnormalities
  • Coital difficulties
  • Drugs
• Interactive problems resulting from causes specific to each couple

  • Insufficient frequency of sexual intercourse
  • Poor timing of intercourse
  • Development of antibodies against a partner's sperm
  • Use of potentially spermicidal lubricants
  • Inability of the sperm to penetrate the egg
• Initial assessment of infertility

  • Evaluation of infertility must begin with a Complete health history and physical examination of both partners, and basic laboratory tests, including complete blood count (CBC), thyroid function tests, and urinalysis
• Semen analysis


  • Performed at the height of estrogen stimulation, just before ovulation
• Cervical mucus assessment


  Cervical mucus is thin, has a low viscosity and cellularity, and appears in a large amount at the height of estrogen stimulation. It forms a fernlike pattern when allowed to dry on a glass slide.
• Fern test


  Done at midmenstrual cycle to confirm ferning. If there is no evidence of ferning, estrogen levels have not increased a sufficient amount. If a ferning pattern continues throughout the menstrual cycle, progesterone levels did not rise and the woman did not ovulate.
• Spinnbarkeit test


  Measures the "stretchability" of the cervical mucus and implies that ovulation is about to occur. In the presence of high levels of progesterone the mucus does not stretch and it is very thick.
• Postcoital test


  • The Couple is instructed to have sexual intercourse at the presumed time of ovulation after a 48-hour period of abstinence. Immediately after intercourse, a sample of cervical mucus is examined microscopically to detect characteristics that enhance sperm survival and to assess adequacy of estrogen production.
• Basal temperature recordings


  • The woman takes and records oral temperatures daily when awakening. A biphasic pattern with persistent temperature elevation for 12 to 14 days before menstruation indicates that ovulation has occurred.
• Serum progesterone test


  • A blood sample is drawn during the presumed luteal phase of the menstrual cycle. An adequate progesterone level suggests that ovulation has probably occurred.
• Endometrial biopsy


  • Provides direct histologic information about endometrial tissue. If adequate secretory tissue is identified, secretion of progesterone and luteinizing hormone is normal, indicating that ovulation has occurred.
• Hysterosalpingography


  • Radiopaque dye is injected through the cervix into the uterus. Fluoroscopy shows whether the fallopian tubes fill with dye. A radiograph is taken 24 hours later to determine if the dye has dispersed in the pelvic cavity, an indication of fallopian tube patency.
• Ultrasound imaging


  • Ultrasound waves can be used to determine the patency of the fallopian tubes and the depth and consistency of the lining of the uterus. Sonohysterography is a noninvasive ultrasound technique that can be carried out at any time during the menstrual cycle.
• Hysteroscopy


  • A visual inspection of the uterus through a hysteroscope. A thin hollow tube is inserted through the cervix. It is helpful in detecting uterine adhesions or other abnormalities.
• Other tests


  • Immunoassays of semen and male or female serum are done to determine if antibody formation against the partner's sperm is a factor in infertility. Sperm penetration assay is an in vitro test to determine the ability of the sperm to penetrate the zona pellucida of the ova from superovulated hamsters.
• Management of an underlying problem

  • Alter acidic cervical mucus
  • Remove environmental hazards associated with oligospermia
  • Correct anatomic defects and remove obstructions in the female reproductive tract
  • Ligate varicocele in the man
  • Antibiotic therapy to treat infections
  • Testosterone to treat oligospermia
  • Estrogen therapy to increase the abundance of cervical mucus and enhance ferning and spinnbarkeit
  • Ovulation-induction medications to treat anovulation
  • Sexual therapy
• Artificial insemination


  • Technique used to instill the sperm into the cervix or uterus to aid in conception. Can be by husband (AIH) or by donor (AID). Therapeutic donor insemination (TDI) can be used if the man has an inadequate sperm count, a genetic defect, an irreversible vasectomy, or testicular cancer.
• In vitro fertilization (IVF)

  • Technique used when damaged or obstructed fallopian tubes impair transport of a fertilized egg to the uterus. Other reasons include oligospermia, absence of cervical mucus, presence of antisperm antibodies, when no cause has been determined, and when other options have been attempted and failed.
• Gamete intrafallopian transfer (GIFT)

  • An ovum is surgically retrieved from the ovary and implanted into the fallopian tube. Sperm are then implanted into the fallopian tube. Fertilization may then occur naturally.
• Zygote intrafallopian transfer (ZIFT)


  • The ovum is fertilized externally. The fertilized zygote is then returned to the fallopian tube by an instrument such as a laparoscope.
• Surrogate embryo transfer (SET)

  • The first child resulting from SET was born in 1984. Using hormonal therapy, the menstrual cycles of the donor woman and the recipient woman are synchronized. Sperm of the fertile partner is artificially inseminated in the fertile donor following her normal ovulation. Several days after fertilization occurs, the fertilized egg is washed from the donor's uterus and deposited in the recipient's uterus.
• Surrogate mothering


  • Semen from the infertile woman's partner is artificially inseminated into the host (surrogate mother). After birth, the newborn is given to the infertile couple.
• Medications used for infertility

  • Gonadotropins
  • Androgenic anabolic hormones
  • Estrogen
  • Estrogen agonist (clomiphene citrate)
• Gonadotropins


  • Used for management of infertility, production of ovarian follicular development and growth, followed by administration of human chorionic gonadotropin (HCG)
• Androgenic anabolic hormones


  • May increase sperm count and motility
• Estrogen


  • Used for restoration of hormone balance and maintenance of ovarian function
• Estrogen agonist (clomiphene citrate)


  • Used to stimulate the ovary. Binds with estrogen receptors and increases FSH and LH secretion from the hypothalamus
• Health care resources


  All materials, personnel, facilities, funds, and anything else that can be used for providing health care services
• Health care has long been a limited resource for which there has been an unlimited demand; everyone needs health care
• Health care is still a scarce resource, and, therefore, strategies to allocate health care resources are challenging and ever present
• Issues Involving Access to Care

  • Growing costs
  • Shortage of nurse and physicians
  • Population
  • Differences in quality of care
  • Significant population of uninsured persons
  • Disparities in health care outcomes