Infertility in Obstetrics and Gynecology

Infertility

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

Background

• General incidence of infertile couples is 10-15%.
• Half of those who don't 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 is 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 or infrequent intercourse.
  • Coital difficulties (impotence, vaginismus, dyspareunia).
  • Vaginal wash after intercourse.
  • Use of lubricants interferes with sperm motion.

Male Factor Infertility

• Causes:
  • Impaired spermatogenesis.
  • Anti-sperm antibodies.
  • Obstruction of the 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 problems (polycystic ovary syndrome, luteal phase defect, premature ovarian failure).
  • Tubal factors (pelvic adhesions, pelvic infection, endometriosis).
  • Uterine factors (congenital anomalies, anatomical abnormalities).
  • Cervical factors (antisperm antibodies, chronic cervicitis).

Ovulatory Factor

• Assessment of ovulation:
  • History.
  • Hormonal profile.
  • Ultrasound assessment of ovulation (folliculometry).
• Data in the history that suggest normal ovulation:
  • Regular menstrual cycles.
  • Mid-cycle ovulatory pain.
  • Ovulatory discharge.
  • Ovulation spotting.
  • Premenstrual symptoms.

Tubal Factor

• Assessment:
  • Hystero-salpingography (HSG).
  • Laparoscopy.

Uterine Factor

• Assessment:
  • Hystero-salpingography (HSG).
  • Hysteroscopy.

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.
• Male factor:
  • Mild to 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.