2.

02  
September  27,  2017  
 
INFERTILITY  
Dr.  Carolina  Paula  C.  Martin  
Department  of  Obstetrics  and  Gynecology  

OUTLINE   • The  incidence  of  infertility  steadily  increases  in  women  after  age  30  
I. Infertility   • Peak  of  fertility-­‐  25  years  of  age  
II. Epidemiology   • Steep  decline-­‐  after  35  years  of  age  
III. Age  and  Infertility   • Time  of  exposure  %  Pregnancy  
IV. Causes  of  Infertility  in  Couples   o 3  months  57%  
V. Causes  of  Infertility  in  Women   o 6  months  72%  
a. Formal  Evaluation   o 1  year  93%  
b. Initial  Consultation   o 2  years  93%  
c. Recommendations   • Incidence:  8-­‐15%  
d. Optimal  Evaluation  of  the  Infertile  Female   • Normal  fertility  
e. Diagnostic  Evaluation   o Per  cycle:  20-­‐22%  
f. Initial  Interview   o 3  months:  50%  
VI. Primary  Diagnostic  Tests  for  Infertility   o 6  months:  60%  
VII. Tests  in  Healthy  Asymptomatic  Woman   o 12  months:  80%  
VIII. Documentation  of  Evaluation   o 18  months:  90%  
IX. Ovulation   • 3-­‐fold  increase  in  office  visits  for  infertility  work-­‐up  
X. Ovulation  Instruction  To  Patients   • Increase  in  media  coverage  of  ARTs  
XI. Ovulatory  Dysfunction   • Delayed  marriage  and  postponement  of  childbearing  
XII. Aging  And  Female  Fertility    
XIII. Ovulation  Induction  
XIV. Tubal  Factors   AGE  AND  INFERTILITY  
a. Pelvic  Inflammatory  Disease   • (+)  association  of  age  of  women  and  reduced  fecundability  
b. Optimal  Evaluation  Of  Infertile  Female   • Decreased  fecundability  usually  begins  in  early  thirties  and  
XV. Diagnostics   accelerates  in  the  late  30s  &  early  40s  
a. Hysterosalpingogram   o Peak  age  for  fertility  –  25  years  
b. Laparoscopy   o Steep  decline  –  after  35  years  
XVI. Male  Infertility   • Age  related  decline  in  fertility  attributed  to  oocyte  depletion  
a. Semen  Analysis   • Increase  in  FSH  as  a  woman  approaches  menopause  change  in  
XVII. Assisted  Reproductive  Technology  (ART)   oocyte  number  and  competence  
a. Intrauterine  Insemination   • Day  3  FSH  >  15mlU/ml  –  reduced  pregnancy  rate  in  IVF  
XVIII.When  To  End  The  Treatment   • Among  fertile  couples  who  have  coitus  in  the  week  before  ovulation,  
XIX. Factors  Affecting  Infertility   there  is  only  about  a  20%  (monthly  fecundibility  of  0.2)  chance  of  
XX. Cervical  Factors   developing  a  clinical  pregnancy  in  each  ovulatory  cycle.  
XXI. Uterine  Factors   • Infertile  couples  who  conceive  do  not  have  higher  rates  of  
XXII. Infections   spontaneous  abortion  or  perinatal  mortality  than  age-­‐matched  
Black  texts-­‐powerpoint  presentation   control  subjects.  
Italicized  texts  –  transers’  notes  from  Doc  Martin    
  CAUSES  OF  INFERTILITY  IN  COUPLES  
INFERTILITY  
• Inability  to  conceive  after  1  year  of  unprotected  intercourse  without  
Ovulatory  
pregnancy    
dysfunction  
• Infertility  is  a  disease,  defined  by  the  failure  to  achieve  a  
15%  
successful  pregnancy  after  12  months  or  more  of  regular  
unprotected  intercourse     Unusual  
• In  women  older  than  35  years  old,  the  time  line  when  evaluation   problems,  
should  begin  should  be  after  6  months  of  regular  unprotected   5%   Male  
intercourse     Problems  
• Primary  infertility:  no  previous  pregnancy  has  occurred     Unexplained   35%  
• Secondary  infertility:  previous  pregnancy  has  occurred,  although,   Cause,  10%  
not  necessarily  a  live  birth     Tubal  and  
• Fecundability:  probability  of  achieving  pregnancy  within  a  single   Pelvic  
menstrual  cycle  (20-­‐25%)     Pathology  
35%  
• Fecundity:  probability  of  achieving  a  live  birth  within  a  single  cycle    
• Each  couple  will  present  different  level  of  desire  to  pursue  infertility  
Figure  1.  Causes  of  infertility  in  couples.  
investigations  and  therapy    
 
• Must  involve  both  partners    
1. Male  problems  and  Tubal  and  pelvic  pathology  (35%  each)  
 
2.  Ovulatory  dysfunction  (15%)  
EPIDEMIOLOGY    
• 90%  of  couples  should  conceive  after  12  months  of  unprotected   From  Collins:  14,  141  couples  in  21  publications  
intercourse  85-­‐90%  normal  couples  will  eventually  conceive  in  1   • Ovulatory  disorders-­‐  27%  
year   • Male  Factors-­‐  25%  
• 10-­‐15%  will  need  assistance   • Tubal  disorders-­‐  22%  

1  of  6   [GG  |  Joy,  Vian,  KC,  Jade]  

 
 Infertility  
 
• Endometriosis-­‐  5%   • Women  with  regular  monthly  menstrual  cycles  should  be  informed  
• Others-­‐  4%   that  they  are  likely  ovulating  and  may  not  need  further  diagnostic  
• Unexplained  factors,  17%-­‐  most  are  hypofertile  some  are  able  to   tests  
conceive  without  treatment,  it  may  take  several  years,  diminishing    
probability  as  time  goes  on.   Diagnostic  Evaluation  
Not  actual  causes  of  infertility:   • Directed  towards  identifying  the  cause  
• Antisperm  antibodies   • Determine  the  pace  and  extent  of  infertility  
• Luteal-­‐phase  deficiency    
• Subcinical  genital  infection   Initial  Interview  
• Subclinical  endocrine  abnormalities-­‐  hypothyroidism  or   • Inform  about  normal  human  fecundibility  ad  how  these  decrease  
pyperprolactenemia  in  ovulatory  women  are  actual  causes  of   with  increasing  age  of  the  female  >  30  and  duration  of  infertility  >  3  
infertility   years  
• No  difference  in  fecundity  if  treat  or  not  treat   • The  various  tests  in  the  diagnostic  valuation  and  the  reasons  why  
  they  are  performed  
CAUSES  OF  INFERTILITY  IN  WOMEN   • Sequence  of  performing  these  tests,  their  degree  of  discomfort,  cost,  
and  time  in  the  cycle  at  which  they  should  be  performed  
• Available  therapies  and  its  prognosis  
Unusual   • Inform  that  after  a  complete  diagnostic  infertility  evaluation,  
problems,   unidentified  cause  for  infertility  is  up  to  20%  
5%   • Methods  to  increase  the  fecundity  of  couples  with  a  normal  
diagnostic  evaluation  such  as  controlled  ovarian  hyperstimulation  
Ovulatory  
and  intrauterine  insemination,  as  well  as  assisted  reproductive  
problems  
techniques  (ARTs)  
35%  
Unexplained    
Cause,  10%   At  initial  consult:  
Tubal   1. Complete  history  and  physical  examination  
obstruction   2. Preconceptional  counseling  
35%   3. Instruction  to  coital  timing  
4. Evaluation  of  both  partners  
 
Figure  2.  Causes  of  infertility  in  women.  
  PRIMARY  DIAGNOSTIC  TESTS  FOR  INFERTILITY  
1. Ovulatory  disorders  and  Tubal  obstruction  (35%  each)   • Documentation  of  ovulation  
2. Endometriosis  (20%)   • Semen  Analysis  
3. Others  causes/  unexplained  (idiopathic)   • Hysterosalpingogram  
  • Hysterosonogram  (Wala  sa  ppt  but  diagnostic  test  of  choice  daw  nila  
• Account  for  30-­‐40%  of  all  cases  of  female  infertility   sa  OM  according  kay  Doc  Martin)  
• Most  easily  diagnosed  and  most  treatable  causes  of  infertility    
• Women  with  minimal  symptoms  are  almost  causes  of  infertility  
o Premenstrual  breast  swelling]  
TESTS  IN  HEALTHY  ASYMPTOMATIC  WOMAN  
o Dysmenorrhea   • CBC,  blood  type,  Rh  factor  
  • Rubella  status  
Formal  Evaluation   • Pap  smear  
Should  begin  (MEMORIZE  DAW  ‘TO):   • Chlamydia  
• After  one  year  of  unprotected  coitus   • Gonorrhoea  screening  
• Female  partner  aged  35  years  and  above   • Syphilis,  HIV  
• History  of  oligomenorrhea/  amenorrhea   • Hepatitis-­‐  for  IVF  
• History  of  pelvic  inflammatory  disease/  endometriosis    
• Male  partner  known  to  be  subfertile   DOCUMENTATION  OF  EVALUATION  
  Basal  Body  Temperature  (BBT)  
Initial  Consultation   • Easiest  and  least  expensive    
• Complete  history  and  physical  examination   • Patient  records  temperature  daily  before  rising    
• Preconceptual  counselling   • Increases  0.5˚  F  over  baseline  temperture  
• Instructions  on  coital  timing   • Temperature  elevation  lasts  10  days  during  luteal  phase    
• Evaluation  of  both  partners  should  begin  at  the  same  time   • Measured  daily/  sublingual    
  • Indirect  presumptive  evidence  of  ovulation    
Recommendations   • Approximate  day  of  ovulation  and  duration  of  the  luteal  phase    
• A  careful  history  and  physical  examination:   • Taken  shortly  after  waking,  6  hours  of  sleep,  prior  to  
o Can  identify  symptoms  or  signs  suggesting  a  specific  cause  for   ambulating    
infertility   • Increases  when  circulating  levels  of  progesterone  increase,  and  a  
o Thereby  help  to  focus  subsequent  diagnostic  evaluation  on  the   sustained  increase  occurs  following  ovulation    
factor(s)  most  likely  responsible   o Biphasic  pattern  
 
 
Midluteal  Serum  Progesterone  
Optimal  Evaluation  of  the  Infertile  Female  
• Indirect  evidence  of  ovulation    
• Menstrual  history  may  be  all  that  is  required   • 3  ng/ml  (10  nmol/ml)  –  Day  21-­‐23  (midluteal)  
o 3  ng/ml  –  presumptive  evidence  for  ovulation  
• Low  levels  are  not  necessarily  diagnostic  of  anovulation    

2  of  6   [GG  |  Joy,  Vian,  KC,  Jade]  

 
 Infertility  
 
• Serum  progesterone     AGING  AND  FEMALE  FERTILITY  
o No  universal  standard  value     • Women  35  years  old  and  above  
o >10  ng/ml=  adequate  luteal  function     o Earliest  evaluation  
• Doc:  “presumptive  evidence  of  ovulation”   o Declining  ovarian  reserve  (DOR)  
  o Serum  Day  2-­‐3  FSH  
LH  Monitoring   o Serum  AMH  
• Applicable  only  if  the  patient  has  regular  menses   • AMH  is  very  good  in:  
• Reproducible  method  of  predicting  ovulation   o Determining  the  most  appropriate  simulation  program  
• Ovulation  occurs  34-­‐36  hours  after  LH  surge  and  10-­‐12  hours  after   o Pre-­‐treatment  counselling  for  couples  to  make  an  appropriate  
LH  peak   and  informed  consent  
• Detection  of  true  elevation  difficult    
• LH  Kit  
  FSH   AMH  
o Predictor  of  mid  cycle  LH  surge  
o (+)  one  day  after   Timing   Day  2-­‐3  of  menses   Anytime  
  Normal  Values   5-­‐10  minutes   >2  ng/mL  
Endometrial  Biopsy   Declining  Ovarian   >10  IU/mL   0.05  ng/mL  
• Secretory  endometrium  confirms  ovulation   Reserve      
• Diagnostic  of  luteal  phase  defects     Fluctuating   Constant  
• 2-­‐3  days  before  expected  onset  of  menses   1. AMH  is  produced  
  by  primordial  
Ultrasound  Monitoring   follicles  
• Development  of  dominant  follicle  until  ovulation  takes  place   2. High  levels  seen  
Note    
• Ovulation  =  decrease  in  follicular  size  and  (+)  fluid  in  cul  de  sac   in  PCOS  since  
• Usually  –  21-­‐23  mm   there  is  increased  
• 17-­‐29mm  (?)   follicles  but  not  
• Transvaginal  UTZ,  performed  serially   maturing  
• Size  and  number  of  developing  follicles    
• Presumptive  evidence  of  ovulation  and  luteinization  
o Demonstrate  progressive  follicular  growth  or  sudden  collapse  of  
OVULATION  INDUCTION  
preovulatory  follicle   Clomiphene  Citrate  (CC)  
  • First  line  
OVULATION   • Estrogen  antagonist  
• MOA:  acts  by  competing  with  endogenous  estrogen  for  estrogen  
• Women  with  oligomenorrhea  or  amenorrhea  who  wish  to  conceive   binding  sites  in  the  hypothalamus,  blocks  negative  feedback  of  
should  be  treated  with  ovulation  induction  drugs  regardless  of   endogenous  estrogen  →GnRH  released  →  FSH/LH  cause  oocyte  
whether  they  have  occasional  ovulatory  cycle-­‐  for  such  women   maturation  
direct  or  indirect  measurement  of  progesterone  is  unnecessary  until   • Starting  dose:  50  mg/day  for  5  days  
after  therapy  is  initiated.  
• Start  on  2nd  day  or  5th  day  of  menses  
  • Can  be  performed  for  6-­‐12  cycles  
OVULATION  INSTRUCTIONS  TO  PATIENTS   • Document  ovulation:  BBT,  Progesterone  levels,  endometrial  biopsy,  
• Daily  intercourse  for  3  consecutive  days  at  midcycle  optimal   UTZ  Ovulation  expected  5-­‐10  days  after  last  tablet  
time  in  the  cycle  unless  oligospermic   • Doc:  Follicle  monitoring  can  be  done  after  expected  ovulation  about  
• Intercourse  should  occur  for  2  consecutive  days  around  the  LH   10-­‐13  days  after  the  last  tablet  then  its  frequency  is  every  other  day  
surge   • If  no  ovulation,  increase  dose  by  50  mg/day  
o Egg  disintegrates  less  than  a  day  after  it  reaches  the  ampulla  of   • Most  pregnancies-­‐  1st  6  months  
the  oviduct   • Gonadotropins  
o Normal  sperm  retains  its  fertilizing  ability  for  up  to  72  hours   • Pulsatile  GnRH  therapy  
o Preferable  to  have  sperm  in  the  oviduct  prior  to  the  arrival  of   • Bromocriptine  and  dexamethasone  supplementation  
the  oocyte   • The  association  between  ovarian  cancer  risk  and  gonadotrophins  or  
• Intercourse  3x  a  week  (witwiiiw  :PPP)   prolonged  clomiphene  use  remains  uncertain  
  • Patients  should  be  counselled  about  the  putative  risks  of  ovarian  
OVULATORY  DYSFUNCTION   cancer  associated  with  ovulation  induction  therapy.  
 
• Aging  (>35  yo)  
• Smoking   Follicle  Monitoring  Clues  
• Overweight   • 1.8-­‐  2  cm  follicle  –  mature  follicle  à  ruptures  
• Substance  abuse   • Endometrium  0.8-­‐1  cm  
• Alcohol   • Trilaminar  endometrium  
• Caffeine   • Corpus  luteum  
• Chemical  exposure   • Group  II  ovulation  disorders  
• Medical  problems   • At  least  the  first  cycle  of  treatment  to  ensure  that  they  are  taking  a  
• Conditions   dose  that  minimizes  the  risk  of  multiple  pregnancy  
o Polycystic  ovary  syndrome    
o Premature  ovarian  failure   Clomiphene  Failure  
o Thyroid  problems   • No  evidence  of  pregnancy  after  a  successful  induction    
o Hyperprolactinemia   • Recommendations:    
o Endometriosis   • Reevaluate  the  couple    
  • Intrauterine  insemination    

3  of  6   [GG  |  Joy,  Vian,  KC,  Jade]  

 
 Infertility  
 
Clomiphene  Resistance   • With  comorbidities,  offer  laparoscopy  and  chromotubation  (dye)  so  
• No  evidence  of  ovulation  at  150  mg  dose   tubal  and  other  pelvic  pathology  can  be  assessed  at  same  time  
• Options:    
o Extend  clomiphene  citrate  to  10  days   Hysterosapingogram  /  Hysterosonogram  
o Addition  of  insulin  sensitizing  agents-­‐  metformin   • 1st  line    
o Add  a  glucocorticoid  to  clomiphene  citrate   • Day  8-­‐10  of  menstrual  cycle    
o Suppressive  therapy  before  induction   • Prophylaxis  started  2  days  prior  to  procedure  (doxycycline)  
o Letrozole-­‐  aromatase  inhibitor,  for  ovulation  problems,    
unexplained  infertility,  breast  cancer   Laparoscopy  
 
• Recommendations:  
Surgical  Therapy   o Women  with  mild  tubal  disease,  tubal  surgery  may  be  more  
• Ovarian  drilling   effective  than  no  treatment.    
  o In  centers  with  expertise-­‐  treatment  option.  
Luteal  Phase  Defect   o Indicated  when  there  is  evidence  or  strong  suspicion  of  
• 2  endometrial  biopsy  shows  delay    >12  days  beyond  menstrual   endometriosis,  pelvic/  adnexal  adhesions,  significant  tubal  
cycle  day   disease.  Considered  before  applying  aggressive  treatments  
• Short  luteal  phase  by  basal  body  temperature  -­‐  temperature   with  significant  cost  and  risk.  
 
elevation  <11  days  
o Less  than  11  days  ang  2nd  half  of  cycle   Management  
• Pathophysiology:   • Tubal  &  peritoneal  –  entirely  surgical  correction  of  proximal,  distal,  
o decrease  in  progesterone  secretion  thereby  decrease  in   or  combined  
secretory  endometrium  à  failure  of  implantation  and  early    
abortion   MALE  INFERTILITY  
o Inadequate  follicular  development   • Male  fertility  peaks  at  35  
o Inadequate  FSH  secretion  
• Sharply  decreases  after  45  
o Abnormal  LH  secretion  
• Increased  risk  of  chromosomal  trisomies  
• Clomiphene  citrate,    50  mg  day  5-­‐9  
• Complete  male  evaluation  
• Progesterone,  14  days  
• Abnormal  semen  analysis  
 
• Unexplained  infertility  
Ovarian  Hyperstimulation  Syndrome   • History  reveals  an  abnormal  male  reproductive  history  
• 0.5%  women  receiving  gonadotropins   • Refer  to  a  urologist  or  a  reproductive  specialist  
• Life  threatening    
• Massive  fluid  shifts,  ascites,  and  pleural  effusion   Causes  of  Male  Infertility  
• Cause:  large  cystic  ovaries  with  high  E2  levels  and  VEGF  (inc  
vascular  permeability  and  vascularity)  
• HCG  triggers  the  syndrome  
• Treatment:  supportive  
 
TUBAL  FACTORS  
• Causes  of  Tubal  Damage  
o Pelvic  Inflammatory  Disease  
o Septic  abortions  
o Ruptured  appendicitis  
o Endometriosis  
 
Pelvic  Inflammatory  Disease  (PID)  
• Tubal  infertility    
o 10-­‐12%  chance    of  infertility  after  1  PID  
o 23-­‐35%  chance  of  infertility  after  2  PID  
o 54-­‐75%  chance  of  infertility    after  3  PID    
  Fig.  3:  Leading  causes  of  Male  Infertility  
Tubal  Patency:  Optimal  Evaluation  of  Infertile  Female    
• Recommendations:     Semen  Analysis  
o Evaluation  of  tubal  patency  is  a  key  component  of  the   • Optimal  period  of  abstinence  is  2-­‐3  days  
diagnostic  workup  in  infertile  couples.     • Obtained  by  masturbation  and  collected  in  a  clean  plastic  container  
o All  available  methods  for  evaluation  of  tubal  factors  have   • Taken  to  the  laboratory  within  1-­‐2  hours  of  collection  
technical  limitations  that  must  be  considered  when  any  one   • Ideally  collected  at  the  laboratory  
technique  yields  abnormal  results.   • If  collected  at  home,  in  room  temperature  and  should  be  examined  
o Further  evaluation  with  a  second,  complementary  method  is   within  one  hour  
prudent  whenever  specific  diagnosis  or  best  treatment    
strategy  is  uncertain   Parameter   Normal  Values  
 
<2  mL  (2-­‐6  mL)  
DIAGNOSTICS   Volume   Low  –  retrograde  ejaculation  
• Women  with  no  comorbidities  (PID,  prev  ectopic,  endometriosis)   High  –  long  period  of  abstinence  
should  be  offered  HSG  to  screen  for  tubal  occlusion-­‐  reliable,  less  
Sperm  Concentration   <20  million/mL  (to  60  
invasive,  efficient  use  of  resources,  hysterosonography  

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 Infertility  
 
million/mL)   • The  physician,  support  groups,  and  other  couples  undergoing  
Motility   <50%   infertility  treatment  can  provide  valuable  support  and  guidance.  
Morphology   <30%  normal  forms    

  FACTORS  AFFECTING  INFERTILITY  

  Varicocele  
• Teratozoospermia-­‐  abnormal  morphology/quality  <4%  →  IVF     • Rise  in  testicular  temperature  à  decreased  testicular  volume,  
• Oligozoospermia-­‐  low  sperm  count  <5  M  motile  sperms  →  IVF     impaired  semen  quality,  decreased  in  serum  testosterone  level    
• Athenozoospermia-­‐  Poor  motility      
  Endocrine  Abnormalities  
2010  WHO  Criteria  for  Semen  Analysis   • Hyperprolactinemia    
• Semen  analysis  continues  to  be  the  primary  test  for  evaluating  men   • Hypogonatrophic  hypogonadism  –  decreased  LH  and  FSH  >  
who  have  difficulty  fathering  children   decreased  testosterone      
• Current  test  format  can  be  used  to  determine  the  degree  of  difficulty   • Hypergonadotrophic  hypogonadism  –  increased  LH  and  FSH  >  
one  may  have  in  fathering  a  child.   decreased  testosterone    
• Attributes  such  as  the  number  of  sperm  with  motilities,   • Karyotype  –  47XXY    
morphologies,  DNA  content  and  other  characteristics  necessary    
for  successful  fertilization  and  term  pregnancy  proves  more   CERVICAL  FACTORS  
beneficial.  
• <5%  of  cases    
o Semen  sample  must  be  produced  within  a  specific  time  period  
  • May  be  due  to:    
o Defective  mucus  production    
Medical  and  Surgical  Management  of  Male  Infertility  
o Anti-­‐sperm  antibodies    
• Based  on  the  underlying  cause  of  infertility   o Cervical  stenosis    
• When  applicable,  medical  therapies  are  used  as  an  initial  strategy  to    
improve  sperm  production.   Defective  Mucus  Production  
• Surgical  options  are  also  available  
• At  the  beginning  of  the  menstrual  cycle,  cervical  mucus  is  normally  
o Correct  varicoceles  
scanty,  viscous,  and  very  cellular    
o Reconstruct  obstructed  system  
o Retrieve  sperm  for  assisted  reproduction   • Forms  a  netlike  structure  that  does  not  allow  the  passage  of  sperm    
  • During  the  midfollicular  phase,  secretion  increases  and  reaches  its  
maximum  around  24-­‐48  hours  before  ovulation    
ASSISTED  REPRODUCTIVE  TECHNOLOGY  (ART)   • Post-­‐coital  test:  
• Tubal  infertility   o Assess  quality  of  cervical  mucus    
• Endometriosis   o Presence  and  number  of  motile  sperm  in  the  female  
• Male  factor   reproductive  tract  after  coitus    
• Failed  OI  +  IUI  cycles   o Interaction  between  mucus  and  sperms    
• Unexplained  infertility   o Ferning  pattern;  Spinnbarkeit    
• DIMINISHING  OVARIAN  RESERVE  (because  of  age)   o Performed  1-­‐2  days  before  anticipated  time  of  ovulation  and  
  less  than  2  hours  from  intercourse    
Intrauterine  Insemination   o Cut-­‐off  –  20  sperms/hpf    
• IUI  is  most  effective  for  treating:   o Potential  causes  for  an  abnormal  PCT:    
o Women  who  have  scarring  or  defects  of  the  cervix   § Poor  timing    
o Men  with  low  sperm  counts,  low  motility   § Hormonal  abnormality    
o Men  who  cannot  get  erections   § Production  of  poor  quality  cervical  mucus    
o Men  with  retrograde  ejaculation   § Anatomic  factors    
• Combination  with  ovulation  induction  drugs,  can  increase   § Infection    
§ Medications    
• the  chance  of  pregnancy  
 
• Success  depends  on  the  cause  of  infertility  
• If  performed  monthly  with  fresh  or  frozen  sperm,  success  rates  can   Anti-­‐Sperm  Antibodies  
be  as  high  as  20%  per  cycle  depending  on  the  (+)  or  (–)  fertility   • Immunoinfertility  is  one  of  several  causes  of  infertility  in  humans    
drugs,  age  of  the  female,  and  the  infertility  diagnosis.   • Although  progress  on  antisperm  immunity  and  infertility  has  
• Ovarian  stimulation   advanced  during  the  past  three  decades,  the  nature  of  a  real  
• Egg  retrieval   antisperm  antibody  (ASA)  is  still  poorly  understood    
• Fertilization  and  embryo  culture    
• Cryopreservation     Cervical  Stenosis  
• Donor  sperm,  eggs,  embryos     • This  can  cause  infertility  by  blocking  the  passage  of  sperm  from  the  
• Surrogacy/  gestational  carrier     cervix  to  the  intrauterine  cavity    
• Ethical  issues     • Can  be  congenital  or  acquired  in  etiology,  resulting  from  surgical  
  procedures  (i.e.,  endometrial  ablation),  infections,  hypoestrogenism,  
and  radiation  therapy    
WHEN  TO  END  THE  TREATMENT    
• Studies  indicate  that  the  chance  for  pregnancy  in  consecutive  IVF    
cycles  remains  similar  in  up  to  four  cycles.  
• However,  many  other  factors  should  be  considered  when   UTERINE  FACTORS  
determining  the  appropriate  endpoint  in  therapy,  including  financial   • Rarely  results  to  infertility    
and  psychological  reserves.   • Non-­‐uterine  causes  must  be  ruled  out  before  metroplasty    
• Members  of  the  IVF  team  can  help  couples  decide  when  to  stop   • Any  uterine  mass  can  reduce  the  chance  of  pregnancy    
treatment  and  discuss  other  options  such  as  egg  and  /or  sperm   • Generally  associated  with  recurrent  loss  of  pregnancy  (i.e.  septate  
donation  or  adoption,  if  appropriate.   uterus)  rather  than  infertility    

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 Infertility  
 
• HSG/Hysteroscopy    
• May  be  due  to:    
o Intrauterine  adhesions    
o Leiomyoma    
o Genital  Tuberculosis    
o Congenital  Deformities    
 
Intrauterine  Adhesions  
• Can  cause  partial  or  complete  obliteration  of  the  endometrium,  
leading  to  menstrual  abnormalities,  amenorrhea  and  infertility    
 
Leiomyoma  
• Depending  on  location,  certain  myomas  can  increase  the  risk  of  
abortion  and  infertility    
• Infertility  may  be  the  result  of  large  intrauterine  leiomyomas  
occluding  the  interstitial  portion  of  the  fallopian  tube  thereby  
preventing  normal  sperm  transport    
 
Genital  Tuberculosis  
• If  HSG  reveals  findings  consistent  with  pelvic  tuberculosis,  
endometrial  biopsy  and  culture  should  be  performed    
 
Congenital  Deformities  
• Congenital  uterine  defects  may  also  cause  infertility    
 
INFECTIONS  
• Chlamydia  salpingitis  
o Insidious,  no  discharge  
o Causes  PID,  infertility  problems  
• Gonorrhea  
o Mucopurulent  discharge  
• Mycoplasma  urealyticum  
o Recovered  in  cervical  mucus  and  semen  of  infertile  couples  
o Treatment  improved  fertility  rate  
 
QUIZ  
Questions:  
1. What  is  primary  infertility  
2. Hormone  that  increases  during  ovulation  that  results  to  an  
increased  basal  body  temperature  
3. Give  2  causes  of  infertility  in  women  
4. Give  2  causes  of  infertility  in  women  
5. Give  3  primary  diagnostic  tests  for  infertility  
6. Give  3  primary  diagnostic  tests  for  infertility  
7. Give  3  primary  diagnostic  tests  for  infertility  
8. Give  1  test  to  document  ovulation  
9. Drug  for  the  induction  of  ovulation  
10. First  line  diagnostic  test  for  tubal  patency  
 
Answers:  
1. Type  of  fertility  in  which  no  previous  pregnancy  has  occurred  
2. Progesterone  
3. Ovulatory  disorders  and  tubal  obstruction  
4. Endometriosis  
5. Documentation  of  ovulation  
6. Semen  analysis  
7. Hysterosalpingogram  
8. Basal  body  temperature,  midluteal  serum  progesterone,  LH  
monitoring,  endometrial  biopsy,  USG  monitoring  
9. Clomiphene  citrate  
10. Hysterosalpingogram  

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