Infertility basics

Definition
• Infertility is inability of a couple to
conceive after one year of sexual
intercourse without contraception
How frequently do people
conceive?
0 Natural pregnancy rates
0 (best rates at age 22-23 y.o., decline significantly after
35, abruptly after 40)
0 ART pregnancy rates
(try to) Look for the
diagnosis!
0 There is a very long list of investigations for the
diagnosis of infertility, however there is no consensus
on which tests are essential before reaching the exact
diagnosis
 What are you looking for?
0 Is the woman ovulating? How is the fertility potential?
0 Is tere a mechanical factor? Are the tubes patent?
0 Is there a male factor? What is the quality of the
sperm?
(never forget the) Male Factor
0 Conventional semen analysis
0 A variety of sperm function tests such as in vitro
mucous penetration test, hamster egg penetration test
and post coital test.
0 Expensive and not realible
Assessment of ovulation
0 Basal body temperature
0 Mid luteal serum progesterone
0 Endometrial biopsy
0 Ultrasound monitoring of ovulation (detects timing).
Tubal factor
0 Hysterosalpingography
0 Laparoscopy
0 Falloscopy
0 Hysterosonography
0 Hydrolaparoscopy.
Others
0 The peritoneal factors are assessed by laparoscopy
0 The uterine factor by hysterosalpingography and
hysteroscopy.
0 Immunological factors are evaluated by a variety of
special tests.
Controverses
0 A lack of agreement exists among trained infertility
specialists with regard to the diagnostic tests to be
performed and their prognostic utility as well as
criteria of normality
Take Care
0 Care must be taken to avoid exploitation of the infertile
couple with expensive unnecessary tests
Concept to keep in mind
A simplified approach will lead to a
significant reduction in both the time
and cost of investigating an infertile
couple.
Diagnostic tests
0 Diagnostic tests for infertility should be categorized
into three categories based on the correlation with
pregnancy rates
The first category
includes tests which have an established correlation with
pregnancy as:
0 Semen analysis
0 Mid luteal progesterone for the diagnosis of ovulation.
0 Tubal patency by hysterography or laparoscopy
Semen analysis
0 Remains the mainstay in investigating male fertility
potential.
0 Serial semen samples (at least two) should be
assessed in the same laboratory
Criteria
According to the WHO the lower limit of the
normal semen testing is
> 20 million/mL.
>40% progressive motility
>30% normal forms
Collection of semen sample
• by masturbation
• after min 3 days abstinence, max 7 days
• temp (15C to 38C)
• deliver quickly
0 As many as 25% of proven fertile men have sperm
concentration
below 20 million/ml
CASA vs. conventional analysis
0 In a randomized controlled trial, the determination of
motility characteristics as obtained by CASA systems is
of limited value
0 CASA (computer assisted semen analysis) is not
superior to conventional semen analysis
(Krause ,1995 )
Testicular biopsy
0 For selected cases
0 Only in tertiary centers
0 Needs semen retrieval and cryopreservation facilities
 Hysterosalpingography

0 Although HSG is of low sensitivity, its high

specificity makes it a useful screening test for
ruling out the tubal obstruction.
0 In case of abnormal finding, diagnostic
laparoscopy with dye transit (e.g. methyl
blue test) is the procedure of choice
Advantages
0 HSG is cheaper
0 Performed as an outpatient procedure
0 Although often painful has a low incidence of
complications
Serum chlamydial antibodies vs HSG

Chlamydia antibody testing

Cervical swab test – Chlamydia
- Mycoplasma
- Ureaplasma
Confirmation of Ovulation
The only true proof of ovulation is the
recovery of an ovum

Or pregnancy
Conception after HSG
HSG has a low prognostic value, the outcome
of HSG adds little to predicting the
occurrence of pregnancy.
However, when HSG shows bilateral
obstruction, the chance of getting pregnant is
only minimal.
Some evidence that conception rates
increase during the 6 mths following HSG.
Confirmation of Ovulation
Serum progesterone in the mid-luteal phase on
day 22-26 is the method of choice
Endometrial biopsy is not a routine step in the
investigations of infertility .
However, Ultrasonography
0 US examination of the pelvis is useful
especially for the ovary.
0 Transvaginal sonography is the method of
choice for women who are having ovulation
induction
The second category
Includes tests which are not consistently
correlated with pregnancy as
0 zona-free hamster egg penetration tests
0 post coital test
0 antisperm antibodies assays.
Sperm function tests
0 should not be routine investigations
complex
expensive
not always provide clinically useful information)
Postcoital test

0 Comparing impact of infertility investigations

with and without the postcoital test showed
closely similar cumulative pregnancy rates at
24 months, the postcoital test is not an
essential procedure
The third category
Includes tests which seem not to correlate
with pregnancy as:
0 endometrial dating - the prognostic value
of endometrial thickness is not universally
accepted
0 varicocele assessment
Thyroid / Prolactin assay

Recommended, although there is no value in

measuring thyroid function or prolactin in
women with a regular menstrual cycle, in the
absence of galactorrhoea or symptoms of
thyroid disease
BBT/LH

0 There is no evidence that the use of BBT

charts and luteinizing hormone detection
methods to time intercourse improves
outcome.
Hysteroscopy

0 HSC is not a routine investigation of infertile

couples as there is no evidence linking
treatment of uterine abnormalities with
enhanced fertility.
Precaution
0 Before uterine instrumentation (as HSG or HSC)
appropriate antibiotic prophylaxis against chlamydia
should be given
Summary for investigations
0 From the above data, it seems that
0 serum progesterone for detection of ovulation
0 day 3 FSH and estradiol for fertility potential
0 hysterography for tubal patency
0 semen analysis

are the basic essential tests for diagnosis

of infertility.
0 Other tests may have a role in special situations or as a
part of clinical trials
0 Laparoscopy should be reserved as a further diagnostic
procedure or in combination with endoscopic surgery
 Testing until uncertainty
vanishes may delay treatment
 What next?
General advice
0 Weight loss for BMI > 30
0 Beware of low BMI’s and nutritional habits
0 Give up smoking! Women (B) and men(C).
0 Regular intercourse throughout the cycle,rather than
the use of temperature charts and LH detection (C)
 Male Subfertility
Oligo/asthenospermia
Drug treatments are ineffective in the treatment of
idiopathic male infertility.

Gonadotrophin is effective for treatment for male

hypogonadotrophic hypogonadism.
 Male Subfertility
Oligo/asthenospermia
IUI offers couples with male subfertility benefit
over timed intercourse, both in natural cycles
and in cycles with ovarian stimulation.
Mild ovarian hyperstimulation is advised in cases
with less severe semen defects (motile sperm
concentration > 10 million).
 Male Subfertility
Oligo/asthenospermia
Intrauterine insemination with or without ovarian
stimulation is an effective treatment where the man has
abnormalities of semen quality, but it has to be
remembered that the pregnancy rates even after
treatment remain very low
 ICSI
Intracytoplasmic sperm injection (ICSI) is indicated in
0 Severe deficits in semen quality
0 Obstructive azoospermia .
0 Non-obstructive azoospermia .
0 Previous IVF cycle with failed or very poor fertilisation.
 Ovulation Disorders
Clomiphene C. ( SERM) is an effective
treatment for anovulation in appropriately
selected women.

Up to 12 cycles of treatment should be

considered.
 Ovulation Disorders
Polycystic ovarian syndrome
Functional derangement of the hypothalamo-
pituitary - ovarian axis associated with
anovulation
Elevated LH/FSH ratio
Classic Stein – Leventhal syndrome
oligomenorhoea, hirsutism, obesity, menstrual
disorders, androgen excess, infertility
 Hyperprolactinaemia
Dopamine agonists are
effective and safe treatment
for women with anovulation
due to hyperprolactinaemia
 PCO:Laparoscopic “Drilling"

Laparoscopic ovarian drilling with

either diathermy or laser is an
effective treatment for anovulation in
women with clomiphene-resistant
PCOS
 PCO: Laparoscopic “Drilling"
There is insufficient evidence of a
difference in pregnancy rates between :
Laparoscopic ovarian drilling after 6-12 m
follow up
&
Gonadotrophins 3-6 cycles .
Multiple pregnancy are considerably
reduced after laparoscopic drilling.
.
Endometriosis :Minimal &Mild
Surgical ablation of minimal
and mild endometriosis
improves fertility in subfertile
women
Endometriosis :Minimal &Mild
Endometriosis
Involves deposits of endometrium outside of uterine
cavity
Common sites : pouch of Douglas, ovary, sigmoid
colon, broad ligament, utero- sacral ligg
Symptomatology: pain (dysmenorrhoea,
dyspareunia ) menstrual disturbance, infertility
occlusion of fallopian tubes, immunological factor

Diagnosis – laparoscopy
black- brown
Commonest appearance : round protruding vesicle which
shows a succession of colours from blue- brown- black
 Endometriosis : Mild
. CONTROVERSY: ovarian
stimulation with IUI is more effective
for them than either no treatment or
IUI alone.
 Endometriosis :
Moderate to Severe
 Endometriosis :Moderate to
Severe
Surgical treatment may improve fertility
but controlled studies and comparisons
with assisted reproduction techniques are
required
 Endometriosis-associated
infertility
Hormonal therapy for ovulation suppression cannot be
recommended as a standard therapy for
endometriosis-associated infertility.

So drug treatments don’t improve conception rate.

RCOG Guidelines : Grade A Recommendation

 Microsurgical Tubal Surgery
Mild distal tubal disease

Dissection of Cutting fimbrio-

Micro scissor fimbriae omental band
Cutting fimbrial adherent to the
band uterus
 Tubal Catheterization
Where proximal tubal
obstruction is suspected, and
there are no other tubal
abnormalities, a tubal
catheterisation procedure
may be attempted
 Moderate to Severe Distal
tubal Disease
. IVF should be considered
as the first line treatment
for moderate to severe
distal tubal disease
 Hydrosalpinges & IVF,
Laparoscopic salpingectomy
should be considered for all
women with hydrosalpinges
prior to IVF treatment
 Unexplained Infertility
Expectant management (no treatment) for
up to three years of trying should be
considered, taking into consideration the
woman's age.
 Unexplained Infertility
The effective treatment for unexplained
infertility is ovarian stimulation in
conjunction with IUI . If failed IVF is
recommended.