Introduction

to Infertility

Division of Reproductive
Endocrinology
Department of Obstetrics
and Gynecology
Gadjah Mada University
 Introduction
The inability to create a desired pregnancy
that culminates in the birth of a child is
likely to create a life crisis for women and
their partners.
Women seeking fertility treatment looking
for care, counsel and health teaching.
Infertility is more common in older women.
Moreover, increased age reduces the
efficacy of treatment.
© 2008, March of Dimes Foundation
 Infertilty
Infertility is inability of a couple to
conceive after one year of sexual
intercourse without contraception
 Primary infertility: The inability to conceive
after 1 year of unprotected intercourse for a
woman younger than 35, or after 6 months of
unprotected intercourse for a woman 35 or
older (Speroff & Fritz, 2005).
 Secondary infertility: The inability of a woman
to conceive who previously was able to do so
(Speroff & Fritz, 2005).
 Causes of Infertility
Couples

(Speroff & Fritz, 2005)

© 2008, March of Dimes Foundation
 Causes of Infertility
Women

© 2008, March of Dimes Foundation

(Speroff & Fritz, 2005)
 INCIDENCE AND TREAMENT
 The overall incidence of infertility has
remained relatively unchanged over the
past 3 years.
 However, the evaluation and treatment of
infertility has changed dramatically during
that time.
 THREE MAJOR DEVELOPMENT
1. The introduction of IVF (Invitro Fertilization)
and other ARTs.
2. Changes in population demographic
3. The advances in ART and concerns about
the age-related decline in fertility

Consequently, infertile couples are now more

likely to seek medical advice, evaluation
andtreatment.
 Which Investigations!!

There is a very long list of

investigations for the diagnosis of
infertility, unfortunately there is no
consensus on which tests are
essential before reaching the
exact diagnosis
 Infertility investigation
 Semen analysis
 Tubal patency by hysterography or
laparoscopy
 Mid luteal progesterone for the diagnosis of
ovulation
 Ultrasound
 Postcoital test
 Antisperm antibodies assays
 Endometrial dating
 Varicocele assessment
 Chlamydial testing
 Hysteroscopy
 Hydrolaparoscopy
Basically there are 4 factors
required for getting pregnant :
 Sperm
 Ovum
 Conception
 Implantation

Investigations of infertility
 Sperm
transport
to the side
of
fertilization
 OOCYTE BLASTO CYST

OVULATION - FERTILIZATION – TRANSPORTATION – DEVISION

 When should woman go to see a
doctor?
 Women in their 30s who've been trying to
become pregnant for six months should
speak to their doctors as soon as possible.
 Women with the following issues should
speak to their doctors:
 irregular periods or no menstrual periods
 very painful periods
 Endometriosis
 pelvic inflammatory disease
 more than one miscarriage
What Increases the Risks?
 Age
 Stress
 Poor diet
 Smoking
 Alcohol
 STDs
 Overweight
 Underweight
 Caffeine intake
 Too much exercise
 Many of the risk factors for both male
and female infertility are the same, they
include:
 Age. After about age 32, a woman's fertility
potential gradually declines.
 Infertility in older women may be due to :
 A higher rate of chromosomal abnormalities that
occur in the eggs.
 Older women are also more likely to have health
problems that may interfere with fertility.
 The risk of miscarriage also increases with a
woman's age.
 Tobacco smoking. Men and women who
smoke tobacco may reduce their chances
of becoming pregnant and reduce the
possible benefit of fertility treatment.
Miscarriages are more frequent in women
who smoke.
 Alcohol use. For women, there's no safe
level of alcohol use during conception or
pregnancy.
 Being overweight. Among American
women, infertility often is due to a
sedentary lifestyle and being overweight.
 Being underweight. Women at risk include those
with :
 eating disorders, such as anorexia nervosa or bulimia
 women following a very low-calorie or restrictive diet.
 Strict vegetarians also may experience infertility problems
due to a lack of important nutrients such as vitamin B-12,
zinc, iron and folic acid.
 Too much exercise.
 In some studies, exercising more than seven hours a week
has been associated with ovulation problems.
 Strenuous exercise may also affect success of in vitro
fertilization.
 On the other hand, not enough exercise can contribute to
obesity, which also increases infertility.
 Caffeine intake.
 Studies are mixed on whether drinking
too much caffeine may be associated
with decreased fertility.
 Some studies have shown a decrease in
fertility with increased caffeine use while
others have not shown adverse effects.
 If there are effects, it's likely that
caffeine has a greater impact on a
woman's fertility than on a man's.
 High caffeine intake does appear to
increase the risk of miscarriage.
The Age Factor

 A woman's fertility
naturally starts to decline
in her late 20's.
 After age 35 a woman's
fertility decreases rapidly.
 A woman is born with all
the eggs she'll have, and
with time, the supply
diminishes.
 PHYSIOLOGY OF REPRODUCTIVE AGING

During fetal life, germ cells rapidly proliferate by mitosis

AGE  GERM CELLS

16-20 WEEKS GESTATION 6.000.000 – 7.000.000

AT BIRTH 1.000.000 - 2.000.000
PUBERTY 300.000 – 500.000

READY TO DEVELOP 400 – 500 oocytes will

(Over the next 35-40 years of ovulate, the rest are lost
reproductive life) through atresia.

37 YEARS 25.000
Menopause 1.000
 MENSTRUAL CHARACTERISTIC
 Menstrual characteristics in older women
correlate with number of follicles
remaining.
 The ovaries of regularly menstruating
contain 10-fold more follicles than those of
peri-menopusal women having irregular
and infrequent menses.
 Follicles are virtually absent in the ovaries
of postmenopausal women.
 Time required for conception in
couples who will attain pregnancy
Time of exposure % Pregnant

3 months 57%

6 months 72%

1 year 85%

2 years 93%
Common Causes of Infertility

 Severe endometriosis
 Pelvic Inflammatory Disease (PID)
 Ovulation disorders
 Elevated prolactin
 Polycystic ovary syndrome (PCOS)
 Early menopause
 Benign uterine fibroids
 Pelvic adhesions
Endometriosis

 Occurs when the uterine tissue

implants and grows outside of
the uterus, affecting the function
of the ovaries, uterus and
fallopian tubes.
 Scar tissue can block the
fallopian tubes and prevent the
egg from entering the uterus.
 There is a 25-35% rate of
infertility in moderate to severe
cases of Endometriosis
 The incidence of infertility
attributable to endometriosis is
difficult to assess.

It is estimated that between 30% and 50% of

women with endometriosis have some degree
of infertility

Severe disease may distort pelvic

anatomy

Impaired egg Distortion of the Inhibited

release fallopian tubes ovum pick up
 The most common places for implantation
are:
 the ovaries, fallopian tubes, bladder and
intestines, uterine wall, and the lining of the
pelvis.
 In very rare cases it may be found in the lungs,
surgical wounds (cesarean section scars), brain
tissue and the vaginal wall.
 Can Endometriosis cause infertility ?
 Adhesions (scar tissue) can block the fallopian
tubes and prevent the egg from entering the
uterus.
 There is a 25-35% rate of infertility in moderate to
severe cases of Endometriosis, resulting primarily
from damage incurred to the ovaries and fallopian
tubes.
 Pelvic Inflammatory Disease
 Pelvic inflammatory disease (PID) is a spectrum of infections
of the female genital tract that includes endometritis,
salpingitis, tuboovarian abscess, and peritonitis.
 Infection of the uterus (womb), fallopian tubes and
other reproductive organs is a common and serious
complication of some sexually transmitted diseases
(STDs), especially chlamydia and gonorrhea.
 PID can damage the fallopian tubes and tissues in
and near the uterus and ovaries.
 Untreated PID can lead to serious consequences
including infertility, ectopic pregnancy, abscess
formation, and chronic pelvic pain.
Pelvic Adhesions
 Pelvic adhesions are
bands of scar tissue
that bind organs after
pelvic infection,
appendicitis, or
abdominal or pelvic
surgery
 This scar tissue
formation may impair
fertility.
UTERINE FIBROID

 Fibroids are benign

tumors in the wall of
the uterus
 May cause infertility
by blocking the
fallopian tubes
 Ovarian failure/ovarian
dysfunction :
 Ovarian failure can be a consequence of
medical treatments, or the complete failure
of the ovaries to develop (Turner's
Syndrome).
 Ovarian failure can also occur as a result
of treatments such as chemotherapy and
pelvic radiotherapy for cancers in other
body areas. These therapies destroy eggs
in the ovary.
 Guidelines of infertile
investigations
1. Investigation of infertility in the female
should not be commenced until the male
has been evaluated.
2. There should be discussion with both
parters so that the outline of the
investigation is understood.
3. Sexuality patterns of the couples should be
discussed as it is quite surprising at times
how little an infertile couple know about this
subject.
 1. Male investigations
 conventional semen analysis
 A variety of sperm function tests such as in
vitro mucous penetration test, hamster egg
penetration test and post coital test.

2. Assessment of ovulation
 Basal body temperature
 Mid luteal serum progesterone
 Endometrial biopsy
 Ultrasound monitoring of ovulation.
 3. Tubal factor
(Possibility of conception)
 Hysterosalpingography (HSG)
 Laparoscopy
 Falloscopy
 Hysterosonography
 Hydrolaparoscopy.
 Other more specific
inverstigations :
 The peritoneal factors are assessed by
laparoscopy
 The uterine factor by hysterosalpingography
and hysteroscopy.
 Immunological factors are evaluated by a
variety of special tests.

Hysteroscopy (HSC)
 HSC is not a routine investigation of infertile
couples as there is no evidence linking
treatment of uterine abnormalities with
enhanced fertility. (RCOG,1999)
 1. Take Care
Care must be taken to avoid exploitation of
the infertile couple with expensive
unnecessary tests
( ESHRE Capri Workshop 1996)

2. 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.
(Strandell 2000)
 Collection of semen sample

 by masturbation
Temp (15C to 38C)
deliver quickly
Husband should not have sexual
intercourse 3 to 4 days before essesment.
 Note : As many as 25% of proven fertile
men have sperm concentration
below 20 million/ml
 Hysterosalpingography (HSG)
 Although HSG is of low sensitivity, its high
specificity, makes it a useful screening test for
ruling in tubal obstruction.
 In case of abnormal finding, diagnostic
laparoscopy with dye transit is the procedure
of choice (Swart et al, 1995)
Advantages
 HSG is cheaper
 Performed as an outpatient procedure
 Although often painful has a low incidence of
complications ( RCOG, 1999 )
 Conception after HSG
 HSG has a low prognostic value, the outcome
of normal HSG adds little to predicting the
occurrence of pregnancy.
 Supprisingly, after a normal HSG 40%
become pregnant (Mackey, 1979).
 However, when HSG shows bilateral
obstruction, the chance of getting pregnant is
only minimal.
(Maas et al, 1997)

Precaution
 Before uterine instrumentation (as HSG or HSC)
appropriate antibiotic prophylaxis against
chlamydia should be given ( RCOG,1999 )
 Summary
 From the above data, it seems that
serum progesterone for detection of
ovulation, hysterosalpinghography for
tubal patency and semen analysis are
the basic essential tests for diagnosis of
infertility.
 Other tests may have a role in special
situations or as a part clinical trials.
 Laparoscopy should be reserved as a
further diagnostic procedure or in
combination with endoscopic surgery