INFERTILITY

By
JENCY N JAMES
MSC NURSING - I YEAR
INTRODUCTION
DEFINITION
Infertility is defined as failure to conceive within
one or more years of irregular unprotected coitus
 TYPES
• Primary infertility
• Secondary infertility
FACTORS ESSENTIAL FOR CONCEPTION
• Healthy spermatozoa should be deposited high
in the vagina at or near the cervix
• The spermatozoa undergo changes and acquire
motility
• The motile spermatozoa should ascend through
the cervix into the uterine cavity and fallopian
tubes
• There should be ovulation
Cont…
• The fallopian should be patent and the oocyte
should be picked up by the fimbriated end of
tube
• The spermatozoa should fertilize the oocyte at
the ampulla of tube
CAUSES OF INFERTILITY
• MALES
▫ Defective spermatogenesis
▫ Obstruction of the efferent duct system
▫ Failure to deposit sperm high in the vagina
▫ Errors in the seminal fluid
Cont…
• FEMALES
▫ Ovulatory dysfunction
▫ Tubal disease
▫ Uterine factors
▫ Cervical factors
▫ Vaginal factors
DEFECTIVE
SPERMATOGENESIS
• Spermatocytes is controlled predominantly by
the genes on Y chromosomes
• 74 days are required for the complete process of
spermatogenesis
• FSH stimulates spermatogenesis
CAUSES
• Congenital
▫ Undescended testes
▫ Kartagener syndrome
▫ Hypospadiasis
• Thermal factors
• Infection
• General factors
• Endocrine
• Iatrogenic
• Genetic and immunological
OBSTRUCTION OF THE EFFERENT
DUCTS
• Due to infection like tubercular, gonococcal , or
surgical trauma.
FAILURE TO DEPOSIT SPERM HIGH IN
THE VAGINA
Causes
• Erectile dysfunction
• Ejaculatory duct
• Hypospadias
• Sperm abnormality
ERRORS IN THE SEMINAL FLUID
• Usually high or low volume of ejaculate
• Low fructose content
• High prostaglandin content
• Undue viscosity
Causes of female
infertility
Ovulatory dysfunction
• Anovulation or oligo-ovulation
▫ Decreased released of GnRH from hypothalamus
▫ Polycystic ovarian syndrome
▫ Elderly women
▫ Premature ovarian syndrome
LUTEAL PHASE DEFECT
• Inadequate growth and function of corpus
luteum
• Inadequate progesterone secretion
• As a result there is inadequate secretory changes
in the endometrium which hinders implantation
LUTEINIZED UNRUPTURED FOLLICLAR
SYNDROME
• The ovum is trapped inside the follicle and get
luteinized
• May be associated with pelvic endometriosis or
with hyperprolactinamia
TUBAL FACTORS
• Obstruction of the tubes due to:-
• Pelvic infections
• Peritubal adhesion
• Endosalpingeal damage
• Previous tubal surgery
• Polyps
• Tubal spasm
UTERINE FACTORS
• Uterine hypopalsia
• Inadequate secretory endometrium
• Fibroid uterus
• Endometritis
• Congenital malformation of uterus
CERVICAL FACTORS
• Congenital elongation of cervix
• Second degree uterine prolapse
• Inappropriate composition of the cervical mucus
▫ Excessive, viscous or purulent discharge
▫ Antisperm or sperm mobilizing antibodies
VAGINAL FACTORS
• Atresia of vagina
• Transverse vaginal septum
• Septate vagina
• Narrow introitus
INVESTIGATION
OBJECTIVES
• To detect the etiological factors
• To rectify the abnormality in an attempt to
improve the fertility
• To give assurance with explanation to the couple
if no abnormality is detected.
MALE
• HISTORY
• Examination
• Investigations
• Semen analysis
• Karyotype analysis
• Immunological tests
FEMALE
• History
• Examination
• Diagnosis of ovulation
• Diagnosis of tubal or peritoneal factors
• Diagnosis of uterine pathology
• Diagnosis of cervical pathology
DIAGNOSIS OF OVULATION
• Indirect
• Direct
• Conclusive
INDIRECT
• Menstrual history
• Evaluation of peripheral or endorgan changes
• BBT
• Cervical mucus study
• Vaginal cytology
• Hormone estimation
• Endometrial biopsy
• Sonograpgy
BASAL BODY TEMPERATURE
• There is biphasic pattern of temperature
variation in ovulatory cycle
• Procedure
▫ Note the oral temperature daily before rising from
the bed
▫ Record the temperature on chart
▫ Note the days of intercourse
INTERPRETATION
CERVICAL MUCUS STUDY
• Alteration in the physicochemical properties of
the cervical mucus occurs due to the effect of
estrogen and progesterone
• Disappearance of fern pattern beyond 22nd day
of the cycle is suggestive of ovulation
• Persistence of fern pattern beyond 22nd day
suggest anovulation.
VAGINAL CYTOLOGY
• A smear on day 25 or 26 of the cycle reveals
features of progesterone effect if ovulation
occurs.
HORMONE ESTIMATION
SERUM PROGESTRONE
• Estimation of serum progesterone is done on 8th
and 21 day of a cycle
• An increase in value from less than 1ng/ml to
greater than 6ng/ml suggest ovulation
Cont..
Serum LH
• Daily estimation of serum LH at the mid cycle
can detect the LH surge.
• Ovulation occurs about 34 – 36 hours after
beginning of the LH surge.
• It coincides about 10-12 hours after the LH peak
Cont……
SERUM ESTRADIOL
• It attains the peak rise approximately 24 hours
prior to LH surge and about 24 – 36 hrs prior to
ovulation
URINARY LH
• Ovulation occurs within 14-26 hrs of detection of
urine LH surge and almost always within 48 hrs
DIRECT
• Laparoscopy
Laparoscopic visualization of recent corpus
luteum or detection of the ovum rom the aspirated
peritoneal fluid from the pouch of douglas
• Luteal phase defect
• Luteinized unruptured follicle
CONCLUSIVE
• Pregnancy is the surest evidence of ovulation
TUBAL FACTORS
INSUFFLATION TEST
Principle:
• Principle lies with the fact that the cervical canal
is in continuity with the peritoneal cavity
through the tubes.
• Entry of air or co2 into the peritoneal cavity
when pushed transcervically under pressure
gives evidence of tubal pregnacy
Cont…
• TIME : done at the post mentrual phase at least
2 days after stoppage of mentrual bleeding.
• LIMITATION: done in the presence of pelvic
cavity
• OBSERVATION: the patency is confirmed by
▫ Fall in the pressure when raised beyond 120mmhg
▫ Hissing sound heard on auscultation of illiac fossa
▫ Shoulder pain experienced by the patient
HYSTEROSALPINGOGRAPHY
• Dye is inserted transcervically
• Can detect the side and site of the block in the
tube
• Can reveal any abnormality in the uterus
• It involves radiation risk
SONOHYSTEROSALPINGOGRAPHY
• Normal saline is pushed within the uterine
cavity with the Foley catheter
• Catheter balloon is inflated at the level of the
cervix
• USG of the uterus and the fallopian tube is done
• It can detect uterine malformations, synechiae
and polyps
• It also detects tubal pathology
Cont..
FALLOSCOPY
• Study of the entire length of the tubal lumen
• Helps to visualize the tubal ostia, mucosal
pattern, intratubal polys and debris
UTERINE FACTORS
• Usually associated with subfertility
HYSTEROSCOPY
Diagnostic
• Visualizing the uterine cavity and tubal ostia
Therapeutic
• Polypectomy of endometrial polyps
• Submucous resection of myoma
• Hysteroscopic adhenolysis
• Resection of uterine septum
CERVICAL FACTORS
POSTCOITAL TEST
• To assess the quality of cervical mucus and the
ability of sperm to survive in it.
SPERM CERVICAL CONTACT TEST
• Invitro cross over test
• Compare the donor sperm and donor cervical
mucus
TREATMENT OF INFERTILITY
• Assurance
• Body weight
• Smoking and alcohol
• Coital problems
MALE INFERTILITY
Indication
• Extreme oligospermia
• Azoospermia
• Low volume ejaculate
• impotency
MANAGEMENT
• General care
• Hypogonadotropic hypogonadism
▫ hCG 5000IU IM once or twice weekly
▫ FSH (75-150IU) with hCG
▫ Dopamine agonist (cabergoline) to improve libido,
potency and fertility
• Pulsatile GnRH therapy for GnRH deficiency
• Clomiphene citrate 25mg orally daily for 3
months. Increases FSH,LH testosterone
Cont….
Leukocytospermia
▫ Infection of genital tract
▫ Doxycycline and erythromycin given for 4 weeks
• Genetic abnormality
▫ Surgical
▫ Vasovasostomy
▫ orchiopexy
• Impotency
FEMALE INFERTILITY
Ovulatory dysfunction
• Anovulation
Common factor for female infertility
• General
• Drugs
▫ Clomipherene therapy – 50mg to 250mg
▫ Given for 5 days
▫ Gonadotrophins
Cont..
Luteal phase defect
• Natural progesterone suppositories 100mg trice
daily
Luteinized unruptured follicle
• hCG 5000-10000IU
Surgery
Laparoscopic ovarian drilling
▫ Multiple puncture is done in the cysts
▫ Reduces intra ovarian androgen levels and helps
in ovulation
TUBAL FACTORS
Tubal factors are only corrected by surgery
FIMBRIOPLASTY
SALPHINGOGRAPHY
LAPAROSCOPY
Cont…
Cervical factors
• Estrogen 1.25mg orally to improve the quality of
cervical mucus
Immunological factors
• Dexamethasone 0.5mg for antisperm antibodies
INTRAUTERINE INSEMINATION
INTRAUTERINE INSEMINATION
• Intrauterine insemination (IUI) is a fertility
treatment that involves placing sperm inside a
woman’s uterus to facilitate fertilization.
GOAL
To increase the number of sperm that reach the
fallopian tubes
Causes
• Low sperm count
• Decreased sperm mobility.
• Unexplained infertility
• A hostile cervical condition, including cervical
mucus problems
• Cervical scar tissue from past procedures which may
hinder the sperms’ ability to enter the uterus
• Ejaculation dysfunction
Procedure
• The IUI procedure will then be performed around the
time of ovulation
• 24-36 hours after the surge in LH hormone.
• A semen sample will be washed by the lab to
separate the semen from the seminal fluid.
• A catheter will then be used to insert the sperm
directly into the uterus.
Intrauterine insemination
Contraindication
• Women who have severe disease of the fallopian
tubes
• Women with a history of pelvic infections
• Women with moderate to severe endometriosis
ASSISTED REPRODUCTIVE TECHNOLOGY
• Assisted reproductive technology (ART) is the
technology used to achieve pregnancy in
procedures such as fertility medication, in vitro
fertilization and surrogacy.
• It is reproductive technology used primarily
for infertility treatments.
Procedures
• In vitro fertilization
• Gamete intra fallopian transfer
• Zygote intra fallopian transfer
• Intracytoplasmic sperm injection
• Embryo or oocyte donation
In vitro fertilazation
• In vitro fertilization (IVF) is a process of
fertilization where an egg is combined with
sperm outside the body, in vitro ("in glass").
• The fertilised egg (zygote) undergoes embryo
culture for 2–6 days, and is then transferred to
the same or another woman's uterus.
Indication
• Tubal disease
• Unexplained fertility
• Endometriosis
• Male factor infertility
• Failed ovulation induction
Procedure
Risks
• Multiple births
• Birth defect
• Spread of infections disease
GAMETE INTRAFALLOPIAN TRANFER
• GIFT is an assisted reproductive procedure
which involves removing a woman’s eggs,
mixing them with sperm, and immediately
placing them into a fallopian tube
Procedure
1.Patients must first have an x-ray to determine the
presence of at least one healthy fallopian tube.
2.Using a laparoscope, eggs are then retrieved from
the ovaries.
3.The male provides a sperm sample the same day
that the eggs are retrieved.
4.The eggs are then mixed with the sperm in a
catheter.
5.The egg and sperm mixture is inserted into the
fallopian tubes with a catheter.
Procedure
Advantages and disadvantages
• IT does not require you to be hospitalized.
• Doctors cannot visibly confirm fertilization or
determine embryo quality with GIFT.
• GIFT cannot be used in patients who have
damaged or blocked fallopian tubes.
ZYGOTE INTRAFALLOPIAN TRANSFER
• ZIFT is an assisted reproductive procedure in
which fertilized embryo is transferred into the
fallopian tube.
PROCEDURE
• Eggs are then collected through an
aspiration procedure.
• Those eggs are fertilized in a laboratory.
• Fertilized eggs are transferred within 24 hours
• The fertilized eggs are then transferred
through a laparoscopic procedure in the
fallopian tube.
CONTRAINDICATION
• Tubal blockage
• Significant tubal damage
• An anatomic problem with the uterus, such as
severe intrauterine adhesions
• Sperm that is not able to penetrate an egg
Intracytoplasmic sperm injection
• Intracytoplasmic sperm injection (ICSI) involves the
direct injection of sperm into eggs obtained from in
vitro fertilization
Procedure
1.The mature egg is held with a specialized
pipette.
2. A very delicate, sharp, and hollow needle is
used to immobilize and pick up a single sperm.
3. The sperm is injected into the cytoplasm, and
the needle is carefully removed.
4. The eggs are checked the following day for
evidence of normal fertilization.
Gestational surrogacy
• Gestational surrogacy is an arrangement in
which a woman carries and delivers a baby for
another person or couple.
• The woman who carries the baby is the
gestational surrogate, or gestational carrier.
Indication
• Irrepairable uterine factor
• Pregnancy may cause severe health risks
• Recurrent unexplained miscarriage
• Prior hysterectomy
HAZARDS OF ART
• Birth defects
• Increased miscarriage
• Perinatal morbidity
• Psychological stress
ETHICAL ISSUES
• The legislation should ban:-
• Creating a clone for any purpose
• Creating a invitro embryo for any purpose other
than human being
• Maintaining an embryo outside the woman
beyond 14th day of its development
• Identifying sex of embryo creating for
reproductive purpose
• Transplanting non human embryo into humans
CONT…
• Changing DNA of human sperm , egg, or embryo
• Paying a woman finantial incentives to be a
surrogate mother
• Counseling any woman under 21 age to become
surrogate mother
• Selling or buying human embryos
RECENT ADVANCES
• Creating three-parent embryos
▫ This involves creating an embryo using
genetic material from three parents.
▫ The technique involves combining parts of
the eggs from two women and fertilizing
them with a man’s sperm
Cont…
Helping immature eggs get up to speed
• A new technique known as in vitro maturation,
or IVM, takes immature eggs from a woman and
grows them in a lab
• When mature, they’re fertilized and implanted.
Cont..
Building sperm in a lab
• Researchers in China have created sperm-like
mouse cells in a Petri dish, which may prove
useful for the millions of couples struggling
with male infertility.
• Since these cells lack tails, they can’t swim
into an egg, and must be injected. But they’re
otherwise viable
Cont..
Squishing embryos to test their strength
• A technique to determine whether an embryo
should be implanted in an in vitro fertilization
procedure
• The trick: Check how squishy it is
• The squishiness predict how well the embryos
will undergo cell division — and, in theory, how
likely they are to thrive.
Cont….
Transplanting a womb to make pregnancy
possible
Swedish doctors have done several successful
uterus transplants, and at least four of their
patients have been able to carry pregnancies to
term in the donated womb.
ABSTRACT
Unexplained infertility: Evaluation of the luteal
phase; results of the National Center for
Infertility Research at Michigan
BY MD CHARLA , MD KUMARAN
Cont…
Objective:
• To evaluate the luteal phase in women with
rigorously defined unexplained infertility.
Result(s):
• Women with unexplained infertility did not differ
in menstrual cycle characteristics, follicular growth
rate or mean preovulatory follicle diameter, or
endometrial biopsy dating.
• The mean levels of Prostaglandin tended to be
lower in the unexplained infertility group
throughout the luteal phase, but only the midluteal
interval reached statistical significance.
CONT..
Luteal phase mean integrated Prostaglandin or urinary
PDG levels of unexplained infertility women did not
differ from those of fertile controls
CONCLUSION
• Women with rigorously defined unexplained
infertility have subtle hormonal anomalies
during the luteal phase when compared with
fertile controls.