Infertility Notes 2024 - University of Limpopo

SHEL 012: Infertility Lecturer : Dr. Matome L Mpholwane Email : [email protected] Department : Physiology and Environmental Health Office : Old Q Block 1043  Fundamentals of Infertility General Outcomes Describe infertility, its potential causes, and its treatments...

SHEL 012: Infertility Lecturer : Dr. Matome L Mpholwane Email : [email protected] Department : Physiology and Environmental Health Office : Old Q Block 1043  Fundamentals of Infertility General Outcomes Describe infertility, its potential causes, and its treatments Specific Outcomes ✓Define infertility ✓Explain the types of infertility ✓Factors required for fertility in male and female ✓Explain causes of infertility ✓Identify diagnostic tests of infertility ✓Explain the management/treatment of male and female infertility  What is infertility? ✓Infertility: A disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. ✓Infertility affects millions of people and has an impact on their families and communities. ✓Estimates suggest that approximately one in every six people of reproductive age worldwide experience infertility in their lifetime.  Infertility ✓ Woman in approximately 35% of infertile couples ✓ Men in about 35% ✓ Both partners in approximately 20% ✓ Unknown cause 10% of cases ✓ Infertility in 85–90% of cases can be diagnosed > about 50–60% can be treated successfully ✓ Treatment fails > a couple may want to consider adopting a child  Infertility classification ✓Primary infertility: Couples who have never been able to conceive ✓Secondary infertility: Difficulty in conceiving after already having conceived ✓Unexplained infertility: When fertility testing hasn't found a cause to explain a person or couples' infertility (can be either primary or secondary) ✓Conception depends on fertility potential of both male and female partner  SEEKING MEDICAL HELP FOR INFERTILITY First step > diagnose the cause of couple’s problem ✓ Evaluation or “infertility work-up” on the woman, the man, or both partners. Both partners ✓ general physical examination ✓ medical history of illnesses including sexually transmitted diseases, surgeries ✓ medications ✓ sexual habits such as frequency of intercourse.  SEEKING MEDICAL HELP FOR INFERTILITY Evaluation or “infertility work-up” on the woman ✓ Asked for a history of her menstrual cycle ✓ Her cycle, if occurring followed using the sympto-thermal method and/or hormone assay ✓ If she is ovulating, pelvic ultrasound, laparoscopy, or the administration of dyes or gas can be used to check if her uterus or oviducts are blocked ✓ Endometrial biopsy can assess the condition of her uterine lining ✓ Postcoital test (Huhner’s test) woman’s cervical mucus is checked for sperm number and condition within 2 h of coitus  SEEKING MEDICAL HELP FOR INFERTILITY Evaluation or “infertility work-up” on the man ✓ Semen can be collected and a sperm analysis performed checked ejaculated in normal volume (at least 1.5 ml) sperm count is low ▪ Luteinizing hormone (LH) ▪ Testosterone ▪ Sample of testicular tissue (testicular biopsy) > spermatogenesis ✓ Assess sex accessory glands and ducts ✓ Immunological tests > if the man is producing antibodies to his own sperm  Male infertility In the male reproductive system, infertility is most commonly caused by: ✓Problems in the ejection of semen ✓Absence or low levels of sperm ✓Abnormal shape (morphology) and movement (motility) of the sperm Male infertility may be caused by: ✓Obstruction of the reproductive tract causing dysfunctionalities in the ejection of semen. ✓ This blockage can occur in the tubes that carry semen (such as ejaculatory ducts and seminal vesicles). Can be caused by surgical trauma during vasectomy Blockages are commonly due to injuries or infections of the genital tract. ✓Hormonal disorders leading to abnormalities in hormones produced by the pituitary gland, hypothalamus and testicles. Hormones such as testosterone regulate sperm production. Example of disorders that result in hormonal imbalance include pituitary or testicular cancers.  Male infertility may be caused by: ✓Testicular failure to produce sperm. For example, due to varicoceles or medical treatments that impair sperm-producing cells (such as chemotherapy). ✓Abnormal sperm function and quality. Conditions or situations that cause abnormal morphology and motility of the sperm negatively affect fertility. For example, the use of anabolic steroids can cause abnormal semen parameters such sperm count and morphology.  Other factors contributing to male infertility ✓Defective spermatogenesis ✓Obstruction of efferent duct ✓Failure to deposit sperm high in the vagina ✓Errors in the seminal fluid  Defective spermatogenesis ✓Congenital: due to undescended testes, spermatogenesis is depressed ✓Hypospadias: birth defect in boys in which the opening of the urethra is not located at the tip of the penis ✓Thermal factor: ✓Varicocele: an enlargement of the veins within the loose bag of skin that holds the testicles (scrotum). ✓Infection: Mumps, orchitis damage spermatogenesis ✓Gonadotrophin suppression: It happens in malnutrition, Heavy smoking, and high alcohol consumption  Defective spermatogenesis ✓Endocrine factors: Raised FSH levels is seen in idiopathic testicular failure ✓Loss of sperm motility ✓Gynecomastia: increase in the amount of breast gland tissue in boys / men ✓Genetic: Klinefelter's syndrome (44+ XXY) ✓Iatrogenic: Cytotoxic drugs, radiation therapy, and antidepressants drugs are likely to obstruct spermatogenesis  Failure to deposit sperm high in the vagina ✓Erectile dysfunction ✓Ejaculatory defects premature retrograde absence of ejaculation ✓Hypospadias Errors in the seminal fluid ✓Low fructose content ✓High prostaglandin content ✓Unusually low volume of ejaculation Diagnosis of male infertility ✓History collection: ✓Physical examination : General appearance, external genitalia ✓Semen analysis test: Semen volume, sperm motility, semen culture ✓Genetic test: Sex chromosome and somatic mutation ✓Endocrine test: Serum testosterone, serum LH and FSH  Assessing male infertility ✓Semen Analyses: Obtained by masturbation, after 3 days of abstinence from sexual activity Semen is kept warm and sent to laboratory, within an hour from production ✓Sperm function tests: Done to evaluate the function of the sperms Hamster Egg Penetration Assay (HEPA) and the Hemizona Assay (HZA) can help to assess the ability of sperm to penetrate an ova ✓Urine analyses: Assesses untreated urinary tract infections and STDs  Male infertility testing ✓Scrotal ultrasound ✓Hormone testing: Determine blood level of hormones produced by the pituitary gland and testicles ✓Testicular biopsy: ✓Makes use of a fluid/cell sample from the testicle with a needle ✓Anti-sperm antibody tests: Used to check for immune cells (antibodies) that attack sperm and affect their ability to function  Treatment of male infertility The treatment of male partner is indicated in: ✓Extreme oligospermia ✓Azoospermia ✓Low volume ejaculation ✓Impotency  Treatment consist of: ✓Improvement of general health Reduction of weight in obese Avoiding heavy smoking and alcohol ✓Avoiding medications ✓Medications to treat specific causes ✓Specific treatment ✓Avoidance of occupations that may elevate testicular temperature ✓Surgical management  Avoiding medications Medication that interferes with the spermatogenesis such as: ✓Beta-blockers ✓Anti-depressants ✓Cytotoxic drugs ✓Cimetidine  Medication to treat specific Causes ✓Human chorionic gonadotropin (HCG), Hydroxymethylglutaryl-CoA (HMG-coA) for hypogonadism ✓Dopamine agonists (cabergoline) to improve low libido ✓Clomiphene citrate ✓Antibiotics for genital tract infection  Female infertility In the female reproductive system, infertility may be caused by a range of abnormalities of the: ✓Ovaries ✓Uterus ✓Fallopian tubes ✓Endocrine system ✓And other factors??  Female infertility may be caused by: ✓Tubal disorders such as blocked fallopian tubes. Which are in turn caused by untreated sexually transmitted infections (STIs) Or complications of unsafe abortion, postpartum sepsis or abdominal/pelvic surgery. ✓Uterine disorders. Which could be inflammatory in nature (such as such endometriosis), Congenital in nature (such as septate uterus) Or benign in nature (such as fibroids)  Female infertility may be caused by: ✓Disorders of the ovaries. Such as polycystic ovarian syndrome Other follicular disorders ✓Disorders of the endocrine system Causing imbalances of reproductive hormones. The endocrine system includes hypothalamus and the pituitary glands. Examples of common endocrine disorders affecting the reproductive system include pituitary cancers and hypopituitarism. Other causes of female infertility  Ovulation problems ✓Hormonal imbalance: FSH or LH secretion ✓Anovulation ✓Polycystic ovarian disease ✓Eating disorders such as anorexia or bulimia ✓Stress ✓Alcohol or drug use ✓Intense exercise that causes a loss of body fat  Fallopian tube damage ✓Previous infection due to gonorrhoea ✓Fibroids ✓Endometriosis: Appearance of endometrial tissue outside the womb ✓Ectopic pregnancy ✓Congenital defects  Detection and diagnosis of female infertility ✓Laboratory tests: Measurement of FSH and Progesterone ✓Endometrial biopsy is performed to verify ovulation ✓Hysterosalpingography ✓Laparoscopy ✓Pap smear to check for signs of infection  Assessing female infertility ✓Female Endocrine System Evaluation: Basal Body Temperature Charting (BBT): Elevated progesterone rises body temperature BBT chart which demonstrates a 12 - 14 days elevation in temperature ✓Endometrial Biopsy: Performed post-ovulation (7 – 12 days) Provide information about BBT and serum progesterone testing Can be used to diagnose endometritis  Assessing female infertility ✓Female Endocrine System Evaluation: ✓Endometrial Biopsy: ✓Urinary Luteinizing Hormone Detection: Predicts LH surge Urinary LH surge typically occurs one to two days before to the rise in BBT Approximately 12 to 60 hours before ovulation  Assessing the pelvis ✓ Hysterosalpingogram (HSG): Detects uterine anomalies (septate, unicornuate, bicornate) Detects Tubal anomalies or blockage ✓Hysteroscopy: An operative procedure performed as a diagnostic procedure or as a therapeutic intervention Used to open the blocked tubes Used for visualization of the internal structure of the tubes  Laparoscopy ✓Only performed after other fertility tests have not resulted in a conclusive diagnosis ✓Often performed on women with unexplained infertility ✓Allows for biopsy of suspect growths and cysts that may be hampering fertility Laparoscopy  Treatment of female infertility Consists of: ✓Fertility restoration drugs ✓Fertility restoration surgeries ✓Assisted reproductive technologies (ART) Also works in favour of the male  Ovulation restoration drugs ✓Drugs used to maintain a normal body weight ✓Clomiphene (induces release of gonadotrophins) ✓Metformin (resume the ovulation process in some Polycystic ovary syndrome (PCOS) women) ✓Gonadotropin therapies ✓Human menopausal gonadotrophins (ovarian stimulation) ✓Follicle stimulating hormone (stimulate development of ovaries) ✓Gonadotrophin releasing hormone analogue (provoke massive release of GnRH into circulation) ✓Bromocriptine (suppress production of prolactin)  Fertility restoration surgery ✓Tissue removal Removes endometrial or pelvic adhesions with lasers or ablation ✓Tubal surgeries If fallopian tubes are blocked or filled with fluid ✓Laparoscopic surgery Removes adhesions and create new tubal opening ✓Salpingectomy Improve chances of pregnancy with IVF  Fertility restoration surgeries ✓Tissue removal: Removes endothelial or pelvic adhesions with lasers or ablation ✓Tubal surgeries: If fallopian tubes are blocked or filled with fluid, tubal surgery improve chances of becoming pregnant ✓Laparoscopic surgery is performed to remove adhesions and create a new tubal opening ✓Salpingectomy: It can improve chances of pregnancy with invitro fertilization  Assisted reproductive technology (ART) Involves removing of eggs from a woman body and mixing with sperm in the laboratory ✓Intrauterine insemination (IUI) ✓Invitro fertilization (IVF) ✓Zygote intrafallopian transfer (ZIFT) ✓Gamete intrafallopian transfer (GIFT) ✓Intracytoplasmic sperm injection (ICSI)  Assisted reproductive technology (ART) ✓In vitro fertilization (IVF) is the most effective ✓Recommended when both fallopian tubes are blocked ✓ART works well when: ✓The woman has a healthy uterus ✓Responds well to fertility drugs ✓Ovulates naturally or uses donor eggs  Invitro fertilization (IVF) ✓IVF is a process by which an egg is fertilized by sperm outside the body (in vitro = in glass) ✓Multiple ova are harvested via a large-bore needle and syringe trans-vaginally under ultrasound guidance ✓Ova are then mixed with sperm ✓Up to 4 of the resultant embryos are transferred to the uterus 2-3 days later  IVF success rates depends on: ✓Age of the partners ✓Reason for infertility ✓Clinic ✓Type of ART ✓If the egg is fresh or frozen ✓If the embryo is frozen or fresh Side effects for IVF ✓Cysts on the ovaries ✓Multiple births ✓Ovarian Hyperstimulation  Gamete intra-fallopian transfer (GIFT) ✓Oocytes retrieved via laparoscopy ✓Oocytes and sperm placed in same catheter ✓Injected directly into the fallopian tube via laparoscopy ✓Embryo travels through the fallopian tube to the uterus for implantation  Zygote intrafallopian transfer (ZIFT) It combines IVF and GIFT Ova are placed in a petri dish with sperm If fertilization occurs The zygote is transferred into fallopian tube Travels through tube to uterus Implants in uterus  Intrauterine insemination (IUI) Procedure in which a catheter is inserted through the cervix into the uterus to deposit a sperm sample directly into the uterus  Intrauterine insemination (IUI) ✓The procedure may help in increasing the chances of pregnancy by: Allowing sperm-ovum contact close to the date and time of ovulation Bringing the sperm very close to the site of fertilization and by passing the cervical factors Sperm preparation increases the sperm density and removes all antigens on the surface of sperm and in seminal plasma ✓IUI is the simplest and the least expensive method of ART ✓IUI alone (natural cycle) does not improve pregnancy chances, hence mild ✓ovarian stimulation is usually recommended  Indications to use IUI At least one Fallopian tube must be normal and patent ✓Mild male infertility ✓Unexplained infertility ✓Ovulatory dysfunction, PCOS ✓Mild endometriosis ✓Cervical factors ✓Immunological factors ✓HIV, HBs Ag infection  ART associated risks To woman ✓Ovarian hyperstimulation syndrome (OHSS) ✓Multiple pregnancies ✓Risk of ovarian cancer (clomid, pergonal) ✓Bleeding and/or infection To baby ✓ICSI associated with problems (XXY) ✓Low birth weight Early referral for fertility testing Female 35 or older (trying for 6 months to get pregnant) Amenorrhoea/oligo menorrhoea Abnormal pelvic exam Prior treatment for cancer HIV, Hep B, Hep C Male Undescended testes Previous urogenital surgery Previous genital pathology  Intracytoplasmic sperm injection (ICSI) The most successful form of treatment for infertile couples ✓Only requires one sperm ✓Injected directly into the egg and the fertilised egg is transferred to the uterus Congratulations……. …….you passed