Infertility in Obstetrics and Gynecology

Infertility

• Infertility is the inability to conceive after one year of regular, unprotected marital life and intercourse.

Background

• The general incidence of infertile couples is 10-15%.
• Half of those who do not conceive in the first year will do so in the second year, with a cumulative pregnancy rate over 90%.
• The chances of conceiving in any given menstrual cycle are less than 20%.

Types of Infertility

• Primary infertility: a couple who has never conceived.
• Secondary infertility: a couple who has previously conceived, regardless of the pregnancy outcome.

Causes of Infertility

Sexual Problems

• Too frequent intercourse produces immature sperm.
• Infrequent intercourse may lead to coitus away from the fertile time.
• Coital difficulties: impotence, vaginismus, dyspareunia.
• Vaginal wash after intercourse may interfere with sperm motion.
• Use of lubricants may interfere with sperm motion.

Male Factor Infertility

• Causes:
  • Impaired spermatogenesis
  • Anti-sperm antibodies
  • Obstruction of seminal tract
  • Defective delivery of sperm
• Investigations:
  • Semen analysis
  • Normal semen parameters:
    • Volume: ≥ 1.5 ml
    • pH: ≥ 7.2
    • Sperm count: ≥ 15 million per ml
    • Total sperm count: ≥ 39 million per ejaculate
    • Motility: ≥ 40% total motility, ≥ 32% progressive motility
    • Vitality: ≥ 58% live spermatozoa
    • Morphology: ≥ 4% normal sperms

Female Factor Infertility

• Causes:
  • Ovulatory disorders:
    • Polycystic ovary syndrome (PCOS)
    • Luteal phase defect
  • Tubal factors:
    • Pelvic adhesions
    • Pelvic infection
    • Endometriosis
  • Uterine factors:
    • Congenital anomalies
    • Anatomical abnormalities
    • Chronic cervicitis
• Investigations:
  • History
  • Hormonal profile
  • Ultrasound assessment of ovulation (folliculometry)

Assessment of Ovulation

• Data in the history that suggest normal ovulation:
  • Regular menstrual cycles
  • Mid-cycle ovulatory pain (Mittelschmerz pain)
  • Ovulatory discharge: minimal increase of clear watery discharge
  • Ovulation spotting: few drops of blood due to transient drop in estrogen level with rupture of the follicle
  • Premenstrual symptoms: e.g. mastalgia, spastic dysmenorrhea

Tubal Factor Infertility

• Assessment:
  • Hystero-salpingography (HSG)
  • Laparoscopy
• Findings:
  • Hydro-salpinx
  • Tubal block

Uterine Factor Infertility

• Assessment:
  • Hystero-salpingography (HSG)
  • Hysteroscopy
• Findings:
  • Intrauterine adhesions (= Asherman's syndrome)
  • Intrauterine septum

Basic Workup for Infertility

• Detailed history and physical examination
• Evidence of ovulation
• Semen analysis
• Hormonal profile:
  • Serum FSH
  • Serum LH
  • Serum prolactin
  • Thyroid function tests
• Trans-vaginal ultrasound and folliculometry
• Hystero-salpingography (HSG)

Further Investigations

• Laparoscopy
• Hysteroscopy

Treatment

• Sexual problems: advise and correct, AIH
• Male factor infertility:
  • Mild, moderate: medical treatment then AIH
  • Severe: ICSI
• Ovulatory factor:
  • Induction of ovulation
  • IVF/ICSI
• Tubal factor:
  • IVF/ICSI
• Unexplained infertility:
  • Induction of ovulation ± AIH
  • IVF/ICSI