21- Female & Male Infertility,Sexual Dysfunction

Female and Male Infertility, Sexual Dysfunction

• Infertility is defined as one year of unprotected intercourse without conception.
• Approximately 85-90% of couples conceive within one year.
• Infertility affects approximately 10-15% of couples.
• Fecundability is the probability of pregnancy in a single cycle, typically 20-25% in healthy couples.
• Fecundity is the probability of a single cycle resulting in pregnancy.

Learning Objectives

• Definition of infertility
• Incidence of infertility
• Causes of infertility
• Research methods for infertility
• Male factors contributing to infertility
• Concepts of sexuality
• Risk factors for sexual dysfunction (SD)

Epidemiology of Infertility in the US

• The crude birth rate decreased from 55 per 1,000 in 1790 to 14.1 per 1,000 in 2001.
• This represents a nearly 75% decline over 200 years.
• Factors contributing to this decline include increased education and career opportunities, later marriage and higher divorce rates, improved contraception, delayed childbearing, and decreased family size.

Normal Reproductive Efficiency

• The percentage of couples who will conceive within a certain time frame.
• Within 3 months, 57% of couples conceive.
• Within 6 months, 72% of couples conceive.
• Within 1 year, 85% of couples conceive.
• Within 2 years, 93% of couples conceive.

Indications for Infertility Evaluation

• Couples who have failed to conceive after one year or more of unprotected intercourse.
• Women over age 35.
• Women with irregular menstrual cycles.
• Women with a family history of early menopause.
• Women with a history of previous ovarian surgery, chemotherapy, or radiation.
• Women who demonstrate a poor response to exogenous gonadotropin stimulation.

Female Infertility Evaluation: History

• Gravity and Parity
• Cycle length and characteristics
• Coital frequency and sexual dysfunction
• Duration of infertility and results of previous evaluations and treatments
• Past surgeries, indications, and outcomes
• Previous abnormal Pap smears
• Current medications and allergies
• Occupation and tobacco, alcohol, and drug use
• Family history of birth defects, early menopause, or reproductive failure
• Symptoms of thyroid disease, pelvic or abdominal pain, galactorrhea, hirsutism, and dyspareunia

Male Factor Infertility: Medical History

• Congenital abnormalities
• Undescended testes
• Prior paternity
• Frequency of intercourse
• Exposure to toxins
• Previous surgeries
• Previous infections and treatment
• Medications and Drugs
• General health (diet, exercise, review of systems)

Physical Examination

• Weight and body mass index (BMI)
• Thyroid enlargement, nodule, or tenderness
• Breast secretions and characteristics
• Signs of androgen excess
• Pelvic or abdominal tenderness
• Vaginal or cervical abnormalities, secretions, or discharge
• Masses, tenderness, or nodularity in the adnexa or cul-de-sac

Screening Tests

• Pap smear
• Blood type, Rh factor, and antibody screening (Rh-negative women)
• Screening for cystic fibrosis
• Screening for TORCH (sexually transmitted diseases)
• Hepatitis B, Chlamydia (RNA/DNA based testing)
• Hepatitis C antibody
• HIV-1 antibody
• Syphilis testing

Causes of Infertility

• Ovulatory dysfunction (15%)
• Tubal or peritoneal pathology (30-40%)
• Male factors (30-40%)
• Unexplained infertility (15-20%)

Causes of Infertility (Proportions)

• Couples: ovulatory dysfunction (15%), unexplained infertility (10%), unusual problems (5%), tubal and pelvic pathology (35%), and male problems (35%)
• Women: ovulatory dysfunction (40%), unexplained infertility (10%), unusual problems (10%), tubal and pelvic pathology (40%),

Causes (Male/Female Factors)

• Various endocrine, anatomic, and other disorders are present in infertility.
• Male Factor: Hypothalamic dysfunction (Kallmann's syndrome), pituitary failure, hyperprolactinemia, exogenous androgens, thyroid disorders, adrenal hyperplasia, congenital absence of vas deferens, obstruction of vas deferens, and congenital abnormalities of the ejaculatory system
• Ovulatory Factor (cont.): Gonadal dysgenesis, premature ovarian failure, ovarian tumor, ovarian resistance, metabolic disease (thyroid disease, liver disease, renal disease), and obesity.

Components of the Human Reproductive Process

• Sperm deposited near cervix around ovulation.
• Sperm must ascend into fallopian tubes to fertilize the oocyte (male factor).
• Ovulation of a mature oocyte must be regular and predictable (ovarian factor).
• Sperm captured, nurtured, and released into the uterus and fallopian tubes (cervical factor).
• Receptive uterus for embryo implantation and subsequent growth (uterine factor).
• Fallopian tubes must transport the sperm and embryos (tubal factor).

Abnormalities of Semen Quality

• Semen volume
• Sperm concentration
• Total sperm per ejaculate
• Sperm total motility
• Sperm progressive motility
• Sperm morphology

Transvaginal Ultrasound with Saline Contrast

• Used to evaluate the uterine cavity, fallopian tubes, and surrounding structures.

Hysteroscopy

• Visual examination of the uterine cavity using a thin, lighted instrument.

Sexual Dysfunction

• Sexual health relates to general health in both genders.
• Sexual health is a complex and multidimensional process controlled by neurological, endocrine, and vascular systems.
• Sexual dysfunction prevents a person from experiencing satisfaction from sexual activity (43% of women, 31% men).

Causes of Sexual Dysfunction

• Physical: Diabetes, cardiac/vascular disorders, neurological problems, hormonal imbalances, kidney/liver failure, alcohol use disorder, substance use disorder, side effects of medications like antidepressants.
• Psychological: Work stress, anxiety, concerns about performance, marital/relationship issues, depression, feelings of guilt, body image concerns, past sexual trauma.

Symptoms of Sexual Dysfunction

• (Men) Erectile dysfunction (inability to achieve or maintain an erection), retarded ejaculation, premature ejaculation.
• (Women) Inability to achieve orgasm, inadequate vaginal lubrication, inability to relax vaginal muscles.
• (Everyone) Lack of interest in/desire for sex, Inability to become aroused, Pain during intercourse

Treatment of Sexual Dysfunction

• Treat the underlying physical or psychological cause.
• Medication (Hormone shots, pills, creams, Viagra, Cialis, Levitra etc.),
• Mechanical aids (vacuum devices, penile implants)
• Sex therapy
• Psychotherapy ( Address past trauma, anxiety, fear, guilt, and poor body image)
• Education and communication

Modifiable Risk Factors

• Smoking
• Physical inactivity
• Obesity
• Excessive alcohol consumption
• Drug consumption

Specific Causes of Erectile Dysfunction (ED)

• Chronic Stress
• Over-the-counter medications.
• Various medications, including antidepressants.

Chronic Stress

• Physiological perspective. Increased chronic stress leads to increased cortisol.
• Extended elevated cortisol can have harmful long-term effects.

Other Factors of Infertility

• Ovarian Reserve (evaluated in women over 35)
• Follicle Stimulating Hormone (FSH)
• Estriol
• Anti-Mullerian Hormone
• Inhibin-B
• Antral Follicle Count (by ultrasound)

Methods for Ovulation Confirmation

• Mid-luteal phase progesterone assay (<3 ng/ml indicates no ovulation)
• Basal body temperature (BBT)
• Cervical mucus changes (crystallization pattern)
• Pelvic ultrasonography

Methods for Uterine Cavity Evaluation

• Hysterosalpingography (HSG)
• Standard transvaginal ultrasound
• Transvaginal ultrasound with saline contrast
• Hysteroscopy

This quiz explores the definitions, incidence, and causes of infertility, along with male factors impacting conception. It also covers the concepts of sexual dysfunction and the epidemiology of infertility, particularly in the U.S. Test your knowledge on these critical topics in reproductive health.