INFERTILITY

Dr Somsubhra De
Assistant Professor Dept of OBG

Definition
Types

Primary infertility
Inability of couples conceiving after staying together and having regular unprotected intercourse for two year

Secondary infertility
Inability of couples conceiving after an initial phase of fertility

Incidence

Couples after ONE month 20%

Couples after ONE year 80%

Couples after TWO years 90%
10% couples are infertile after TWO yrs

Causes

Male

40%

Female

40%

Combined 20% (10% is UNEXPLAINED)

Causes in MALE

Causes in MALE
Failure to produce sperms

Incomplete development of testes Late descent/ non descent of testes Previous orchitis due to mumps Damage to testes due to X Ray, trauma Exposure of testes to heat Diseases like TB, diabetes etc

Causes in MALE
Obstructive azoospermia Trauma Surgeries like herniorrhaphy Epididymitis by TB Absence of vas Congenital obstruction of epididymis

Causes in MALE
Failure to deposit Sperms

Impotence Premature ejaculation Retrograde ejaculation Tricyclic antidepressants

Causes in FEMALE

Causes in FEMALE
Ovarian factors

PCOS Hyperprolactinemia Hypothyroidism Premature ovarian failure Luteal phase defect

Causes in FEMALE
Tuboperitoneal factors

Endometriosis PID Postabortal/ Post MTP

Causes in FEMALE
Other factors Uterine Cervical Vaginal Coital errors Lubricants Anxiety

Assessment of a Infertile couple

History
Man and wife questioned separately and then together

Examination
External genitalia of both partners In females in addition: body habitus, breast and thyroid, acne and hirsutism

Assessment of Male infertility

Clinical
Physical examination as before

Semen Analysis
3 days abstinence Obtained by masturbation into a clean wide mouthed container

Testicular biopsy

WHO criteria Semen Analysis Report Volume: Liquefaction time: Sperm count: Sperm Motility: Morphology: 2 6 ml 30 minutes >20millions/ml >50% motile >30% normal

Assessment of Female infertility

Clinical
Physical examination as before

USG
Uterus and ovaries, follicular imaging and endometrial thickness (10mm at the time of ovulation)

Hormonal assays
FT4, TSH, PRL, FSH, LH

Assessment of Female infertility

Tubal Patency tests

HSG
Sonosalpingography Hysteroscopy

Laparoscopy

Hysterosalpingography
Procedure

Radio opaque water soluble dye is injected into the cervix and noted

Gives information about each tubes, site of obstruction and also about the uterine cavity and its abnormalities
Within Day 10 of menses

Hysterosalpingography
Dangers

Severe pain leading to collapse Intravasation of the dye Peritoneal infections

Generalized sensitivity reactions

Hysterosalpingography
Contraindications

Immediately prior to menses

After curettage
Recent acute salpingitis Suspected TB /lower genital tract infections

Hysterosalpingography

Normal Picture

ARCUATE UTERUS

BICORNUATE UTERUS

BILATERAL TUBAL BLOCK

UNILATERAL TUBAL BLOCK

Normal laparoscopy view

Normal laparoscopic Dye test

Treatment
For Male

Correction of impotence, premature ejaculation Improve the sperm by clomiphene, hCG, hMG and GnRh TESA, MESA Correction of varicocele

Treatment
For Female

Hormone therapy
For ovulation disorders mainly. Clomiphene citrate, gonadotrophins, bromocriptine etc

Operatives
For tubal reconstructions mainly. Laparoscopic ovarian drilling in PCOS improves ovulation

ART if all Treatment fails

For Male infertility

For Female infertility

ICSI with ET
IVF with ET