Maternal

• Infertility


  Inability to conceive a child or sustain a pregnancy to birth
• Sterility


  Inability to conceive because of a known condition, such as absence of a uterus
• Subfertility


  When a pregnancy has not occurred after at least 1 year of engaging in unprotected coitus
• Types of Subfertility


  • Primary Subfertility - no previous conceptions
  • Secondary Subfertility - there have been a previous viable pregnancy, but the couple is unable to conceive at present
• In 40% of couples with subfertility problem, the cause is multifactorial
• In about 30% of couples, it is the man who is subfertile
• Causes of fertility problems in women

  • 20%-25% experience ovulatory failure
  • 20% experience tubal, vaginal, or uterine problems
  • About 10% of couples, the cause is unknown
• 50% of couples who engage in coitus at an average of 4x a week will conceive within 6 months, and 85% within 12 months
• Couples who engage in coitus daily, hoping to cause early impregnation, may actually have more difficulty conceiving than those who space coitus to every other day
• Subfertility increases with age
• Women who are using oral, injectable, or implanted hormones for contraception may have difficulty becoming pregnant for several months after discontinuing
• Sperm count


  The number of sperm in a single ejaculation or in a milliliter of semen
• Normal sperm count


  • Minimum of 20 million/mL of seminal fluid or 50 million per ejaculation
  • At least 50% of sperm should be motile, and 30% should be normal in shape and form
  • Must be produced and maintained at a temperature slightly lower than body temperature to be fully motile
• Conditions that may inhibit sperm production

  • Congenital abnormalities such as cryptorchidism (undescended testes)
  • Varicocele (varicosity of the spermatic vein)
  • Trauma to the testes
  • Surgery on or near the testicles that impaired testicular circulation
  • Endocrine imbalances
  • Drug use or excessive alcohol
  • Environmental factors
• Obstruction or impaired sperm motility

  • Obstruction may occur at any point along the pathway that spermatozoa must travel to reach the outside
  • Benign hypertrophy and infection of the prostate gland
  • Infection of the seminal vesicles
  • Anomalies of the penis: Hypospadias, Epispadias, Extreme obesity
• Erectile dysfunction


  Formerly called impotence, caused by psychological problems, cerebrovascular accident, Parkinson's disease and some medications
• Premature ejaculation


  Ejaculation before penetration, a factor that may interfere with the proper disposition of sperm
• Anovulation


  Absence of ovulation, the most common cause of subfertility in women
• Causes of anovulation


  • Genetic abnormality such as Turner's syndrome
  • Hormonal imbalance caused by conditions like hypothyroidism
  • Chronic or excessive exposure to x-rays or radioactive substances, general ill health, poor diet and stress
  • High glucose or insulin levels disrupting FSH and LH production
• Pelvic Inflammatory Disease (PID)


  Infection of the pelvic organs (uterus, fallopian tubes, ovaries, and their supporting structures) caused by many organisms, especially chlamydia and gonorrhea
• About 12% of those who acquire PID are left subfertile
• PID invasion of fallopian tubes is most apt to occur at the end of menstrual period
• There is apparently a higher incidence of PID among women who use IUD
• Uterine problems


  • Congenitally deformed uterine cavity may limit implantation sites
  • Poor secretion of estrogen or progesterone from the ovary can result in inadequate endometrium formation, interfering with implantation and embryo growth
• Cervical problems


  • If coitus is not synchronized, cervical mucus may be too thick for the spermatozoa to penetrate
  • Infection/inflammation of the cervix (erosion) can cause the cervical mucus to thicken
  • A polyp may further compromise sperm penetration
• Vaginal problems


  • Infection of the vagina can cause the pH of the vaginal secretions to become acidotic, limiting or destroying the motility of spermatozoa
  • Some women have sperm-immobilizing antibodies in their blood plasma that act to destroy sperm cells
• Fertility Assessment


  1. Health History

  2. Physical Assessment

  3. Fertility Testing
• Semen Analysis


  After 2-4 days of sexual abstinence, the man ejaculates by masturbation into a clean, dry jar, and the number of sperm in the specimen are counted and then examined under a microscope within 1 hour
• Normal semen parameters


  • Average ejaculation: 2.5 to 5.0 mL of semen
  • Average normal sperm count: 50 to 200 million/milliliter
• Sperm Penetration Assay and Antisperm Antibody Testing

  • Sperm penetration studies may be scheduled to determine a man's sperm, once they reach the ovum can penetrate it effectively
  • Poorly motile sperm or those with poor penetration can be injected directly into woman's ovum under laboratory conditions
• Ovulation Monitoring


  Ask a woman to record her basal body temperature (BBT) for at least 4 months, as a temperature rise should last approximately 10 days
• Tubal Patency


  • Sonohysterography - an ultrasound technique designed for inspecting the uterus
  • Hysterosalpingography - a radiologic examination of the fallopian tubes using a radiopaque medium
• Subfertility Management


  1. Increasing Sperm Count and Motility

  2. Reducing Presence of Infection

  3. Hormone Therapy

  4. Surgery