DEFINITIONS Infertility: failure of a couple to conceive after 12 months of regular intercourse without the use of contraception in women less

than 35 yrs, and after 6 months regular intercourse for women greater than 35 yrs. American definition After age 35, every month counts Subfertile: inability to conceive after a shorter time period (definitions vary), meaning a couple is less fertile than a typical couple. Primary infertility: never able to conceive Secondary infertility: difficulty conceiving have already conceived (either to pregnancy or had a miscarriage) Fecundability: probability of achieving a pregnancy in one menstrual cycle Normal fertility: most couples conceive within 6 cycles, 80-90% couples conceive within 12 months fertile interval extends from 5 days prior to ovulation to the day of ovulation highest probability of conception if intercourse 1-2 days before ovulation and the day of ovulation semen quality best (motility, morphology, total sperm count) highest if 2-3 days ejaculatory abstinence prior highest pregnancy rates occur if intercourse occurs every 1-2 days, or 2-3 times a week coital position doesnt appear to affect fertility some lubricants affect sperm motility in vitro ovulation prediction maternal (lesser extent paternal) age o probability of conceiving following intercourse on the most fertile day of cycle women age 19-26 yrs: 50% women age 27-34 yrs: 40% women age 35-39 yrs: 30%

Ovulation prediction basal body temp: o progesterone released from corpus luteum after ovulation affects hypothalamus one effect is to increase body temp o take temp before getting out of bed (basal temp) o temp rises by 0.5 1-2 days after LH surge and persists for 10 days o retrospectively diagnoses ovulation (too late to time intercourse) serum progesterone mid-luteal phase (18-24 days after onset of menses) o >2.0ng/ml is consistent with luteinisation, normal 6-25ng.ml o Considerable variation exists as progesterone levels vary with LH pulsations that occur after ovulation o Single value >6ng/ml usually indicates normal corpus luteum function Menstrual molimina: due to progesterone secretion during luteal phase of menstrual cycle o Mastalgia, fluid retention, mood swings, fatigue, headaches Identifying fertile period to permit timing intercourse o cervical mucus changes: demonstrate preovulatory oestrogen effects increased volume of clear stretchy slipper y mucus

urinary LH LH appears in urine 12hrs after appearance in serum LH rise occurs 36 hrs before oocyte release into fallopian tube

Lifestyle factors affecting fertility Based on observational studies subject to bias (i.e. people who smoke also drink alcohol and caffeine) Tobacco females o > 10 cigs/d reduces fertility: tubal changes, cervical changes, damage to gametes, increased spontaneous abortion, ectopic pregnancies o Cigs cause premature aging of ovary oxidative stress and DNA damage to ovarian follicles deplete oocyte pool tobacco male o reduces semen quality (sperm concentration, motility, morphology) overweight female o high BMI insulin resistance hyperinsulinaemia androgen excess (reduces SHBG synthesis, stimulates ovarian androgen production) altered ovarian physiology and anovulation o low BMI suppressed pulsatile secretion GnRH anovulation overweight male o abnormal BMI affects reproductive hormone levels by hypothalamic effect o effect on reproduction remains unclear exercise o > 4 hrs / wk strenuous exercise impairs fertility and can lead to anovulation Reduced progesterone production during luteal phase Changes in GnRH secretion Changes in body fat and diet (i.e. less fat) Changes in leptin Alcohol female. Moderate or heavy consumption prolongs time taken to achieve pregnancy Alcohol male. Heavy consumption impairs gonadal function, but not moderate o Reduced testosterone production o Reduced spermatogenesis Caffeine female. Consumption > 300mg/d (around 150 in espresso) changes oestrogen metabolism Caffeine male. Unclear

Causes of female infertility Ovulatory disorders Primary hypothalamic-pituitary dysfunction o Kallmans syndrome (genetic cause of hypothalamic hypogonadism) o Idiopathic hypogonadotropic hypogonadism o Tumour, trauma, infarct, haemorrhage, radiation to hypothalamus or pituitary o Lactational amenorrhoea (suppression of GnRH secretion by prolactin) o Stress / dietary / exercise hypothalamic suppression o Hyperprolactinaemia Other ovulatory disorders o Polycystic ovary syndrome o Hyper/othyroidism o Adrenal / ovarian hormone producing tumours o Chronic liver / renal disease o Cushings disease o Congenital adrenal hyperplasia Ovarian causes Ovarian failure o Oocyte aging: anovulatory cycles, poor quality oocytes o Endometriosis: growth on ovary tubal adhesions & inflammation; produces inflammatory cytokines disrupting ovarian function o AI disease (SLE, celiac disease, myasthenia gravis), radiation, chemotherapy, smoking accelerates ovarian damage, oxidative damage to oocytes PCOS xs androgens affecting hypothalamus release Tubal causes Tubal adhesions or infection: PID (Chlamydia, gonorrhoea), endometriosis (anatomic distortion) , previous surgery, non tubal infections (appendicitis, IBD) Uterine causes Congenital: mullerian abnormalities i.e. septate uterus Acquired: o Leiomyomata (fibroids): physical barrier to implantation o Prior curettage o Polyps Cervical factors o Congenital malformation o Previous trauma and surgery cervical stenosis o Antibodies to sperm in cervical mucus Early pregnancy loss Antibodies interfering with implantation or early placental damage o Antiphospholipid syndrome (Antiphospholipid antibody) Abnormal autoantibody profile: related to early reproductive failure Genetic causes: chromosomal abnormalities (mosaics, trisomy, translocations) i.e. 45 X Turners syndrome

Evaluation of female infertility History duration of infertility and results of previous evaluation and therapy menstrual history (cycle length, characteristics) o are cycles ovulatory? Medical, surgical and gynaecological history (STD, PID, pap smears and treatment of abnormalities) o Thyroid dysfunction o Galactorrhoea o Hirsutism o Pelvic/abdominal pain, dyspareunia o Dysmenorrhoea Obstetric history o Evidence of events potentially associated with infertility or adverse outcome in pregnancy Sexual history including frequency of intercourse Family history o Infertility o Birth defects o Genetic mutations Lifestyle features Physical examination BMI (both extremes) Note fat distribution Completeness of development of secondary sexual characteristics (hypogonadotrophic hypodonadism) Thyroid abnormalities Galactorrhoea Androgen excess: acne, hirsutism, male pattern baldness, virilsation o Suggest endocrinopathy: PCOS, adrenal disorder Pelvic exam o Structural abnormalities: Mullerian abnormality, cervical abnormality o Vaginal / cervical infection o Uterine enlargement, irregularity, lack of mobility: uterine anomaly, fibroids, o Adnexal / POD tenderness / nodularity : PID, endometriosis Diagnostic testing Concurrent investigation of male Documentation of normal ovulatory function o Regular period + moliminal symptoms usually always ovulatory o Mid-luteal progesterone level: obtain 1 wk prior to expected onset menses (d21 for 28d cycle) If < 3ng/ml: further testing for anovulation required o Urinary LH testing for LH surge (5-10% FN and FP rate) Serum confirmation recommended if LH surge not detected o Possible, but not routine Serial US to follow follicle development Endometrial biopsy to document secretory changes in endometrium Evaluation for ovarian reserve o 3 day FSH level (d1 = first day of full menstrual flow) Elevated levels suggest insufficient ovarian reserve o CCCT: clomiphenes citrate challenge test (inhibits oestrogen ve FB at hypoT) 100mg clomiphene citrate given on cycle days 5-9 Measure FSH d3 and 10, oestradiol d3 Elevated basal oestradiol suggests insufficient ovarian reserve, as does elevated FSH Adequate ovarian reserve suppression of FSH despite clomiphene o Antral follicle count by US 4-10 antral follicles d 2-4 suggests good reserve

Anti-mullerian hormone (secreted by preantral follicles) Declines with declining ovarian reserve Document patent fallopian tubes o Hysterosalpingogram o Laparoscopy with chromotubation Assessment of uterine cavity o Seen at HSG require further investigation i.e. by US, MRI, hysteroscopy Further investigation as necessary according to findings in history o Laparoscopy: Symptoms of endometriosis: dysmenorrhoea, pelvic pain, deep dyspareunia PID symptoms: history of pelvic pain, complicated appendicitis, pelvic surgery, ectopic pregnancy o Karyotype: early premature menopause (under 40) Concurrent preconception screening

Testing for anovulation Serum prolactin o Hyperprolactinaemia -ve feedback on hypothalamus inhibits GnRH secretion Serum TSH Serum FSH: elevated in ovarian failure Evaluate for PCOS

Causes of male infertility Hypothalamic-Pituitary disease Congenital o Idiopathic hypogonadotropic hypogonadism: sexual infantilism, anosmia o Kallmans syndrome (defect in GnRH secretion): the above with associated other features including colour blindness and hearing difficulties. o Other genetic GnRH defects Acquired o Tumours: i.e. pituitary macroadenoma o Infiltrative disease i.e. TB, haemochromatosis o Vascular lesions: pituitary infarction, aneurysm o Hormones: functional hypogonadotropic hypodonadism Prolactin, androgen, oestrogen, GCS excess o Drugs o Systemic illness Obesity (low SHBG conc, low testosterone concentration) Primary hypogonadism (hypergonadotropic hypogonadism) Congenital or developmental disorders of the testes o Chromosomal abnormalities: Klinefelters syndrome (XXY, XYY etc) (azospermia, often small testes) o Autosomal , X and Y defects causing defective spermatogenesis o Defective androgen receptor or synthesis: normal sexual differentiation and spermatogenesis require androgen and a normally functioning receptor Usually infertile, varying degrees of ambiguous external genitalia / hypodonadism depending on degree of androgen insensitivity o Disorders of oestrogen receptor or oestrogen synthesis o Inactivating mutation of FSH receptor gene o Cryptorchidism (undescended testes) Testicular descent is androgen dependent Cryptorchidism is common in pts with congenital disorders of testosterone secretion or action Degree of germ cell dysfunction is related to duration of suprascrotal location of testes Formerly cryptorchid men with low serum inhibin B and high FSH may be at particularly high risk of infertility Testes are more retractile during the first year many deemed to have undescended testes actually just have a brisk cremasteric reflex o Varicocoele raises temp around testes Acquired disorders of testes o Infection (orchitis: viral esp mumps, bacterial i.e. TB) (Mumps vaccine in Australia since 1981, causes fever, headache, painful swelling of salivary glands, but orchitis more common in adults) o Drugs or radiation: i.e. cytotoxics o Environmental factors: lead, mercury, insecticides, fungicides o Smoking: likely lowers sperm count, effect on fertility unclear o Hyperthermia: evidence only weak despite long being though to impair fertility o Antisperm antibodies: aetiology unclear ? testicular infection or injury Systemic disorders: cancer, organ failure

Disorders of sperm transport Epididymal (sperm maturation) abnormalities: Absence, obstruction o Chemical induced fungicides & herbicides Vas deferens abnormalities o Obstruction, altered peristalsis (infection, surgery) o Congenital: Can be assoc with mutations in the cystic fibrosis transmembrane conductance regulator gene Can be assoc with defect in cilia function: assoc with pulmonary infections Defective ejaculation: erectile dysfunction, premature ejaculation, o SC disease / trauma, ANS disease: diabetes Retrograde ejaculation Incompetence of the urethra-bladder junction diabetes, MS

Evaluation of male infertility History Developmental history o Testicular descent, pubertal development, loss of body hair or decrease in shaving o School performance evidence of intellectual impairment (assoc with Klinefelters) Medical / surgical history o Chronic illness o Infections: STD, mumps, genitourinary infection including prostatitis o Surgery to inguinal / scrotal areas i.e. vasectomy Drugs / social o Environmental drug exposures o Radiation o Cytotoxic chemotherapy Sexual history o Libido o Frequency of intercourse o Past fertility assessments Examination General: o Androgen deficiency: Early gestation: ambiguous genitalia Late gestation: micropenis Childhood: delayed onset puberty, Arm span > 2 cm greater than height, heel-pubis > 5cm greater than pubis-crown Adulthood: decreased sexual function, loss of secondary sex characteristics General appearance o Body proportions, hair distribution, fat distribution Signs of androgen deficiency External genitalia o Incomplete sexual development (Tanner stage other than 5 normal adult) o Diseases of scrotum that affect sperm maturation and transport Presence of vas deferens Varicocoele Hernia o Testicular size as per Prader orchidometer or callipers (vol < 15ml or length < 3.6 cm is small) Semen analysis Method o Collect after 2-7 days abstinence o Submit within 1 hr of collection o Two samples 1-2 weeks apart Elements o Semen volume and pH (1.5ml) o Microscopy for agglutination o Sperm concentration (15 million / ml), motility (32% progressive motility), vitality (58% alive) and morphology (4% normal forms)

o Sperm leukocyte count o Immature germ cell count Specialised analysis o Sperm autoantibodies Agglutination suggests sperm autoimmunity, this needs confirmation o Sperm cervical mucus interaction: identifies if there is a problem in Post coital test: 9-24 hrs after vaginal intercourse In vitro tests i.e. crossed tests performed on sperm and cervical mucus from infertile couple and from a fertile couple Further specialised testing indicated if semen analysis is normal o Computer aided sperm analysis Detailed sperm kinematics: useful in predicting in vivo and in vitro fertilising capacity o Acrosome reaction analysis Timing of acrosome reaction (fusion of acrosome and plasma membrane, leading to release of acrosomal enzymes and exposure of sperm head. Must occur after sperm binding to zona pellucida as this contains recognition site for sperm) o Zona-free hamster oocyte penetration test Tests sperm ability to capacitate, undergo acrosome reaction, penetrate oocyte membrane and fuse with oocyte Technically demanding and often inaccurate! o Human zona pellucida binding test: numbers of sperm bound to zona from test compared with control. Technically demanding and not often used (difficult to obtain human oocytes!) Hemizona assay Human zona pellucida is bisected, half incubated with test sample, half with control sperm. Competitive zona binding assay Test and control sperm are labelled with different fluorochromes Genetic tests: i.e. present in men with azoospermia considering ICSI (Intracytoplasmic sperm injection) o CFTR gene o ICSI impossible with some Y chromosome abnormalities Endocrine testing o Testosterone o FSH/LH If high + testosterone low primary hypogonadism If low + low testosterone secondary hypogonadism o Serum prolactin

Treatment of female infertility Lifestyle interventions to improve fertility: o Smoking cessation o Appropriate BMI o Reduce excessive caffeine o Reduce excessive alcohol o Appropriate timing and frequency of coitus: every 1-2 days around expected time of ovulation or according to an ovulation prediction kit Ovulatory disorders o Ovulation induction (for those without ovarian failure) Weight modulation and lifestyle changes If BMI > 27 or < 17 Clomiphene citrate and other selective oestrogen receptor modulators (stop oestrogens ve feedback at hypothalamic level) Often not effective in hypothalamic disorders or primary ovarian failure Metformin and other insulin sensitisers PCOS GnRH therapy Aromatase inhibitor: reduce serum oestrogen release hypoT from neg inhibition In PCOS: excessive androgens are converted to oestrogen in brain suppress FSH o Aromatase inhibitors suppress oestrogen production in ovaries and brain Laparoscopic partial ovarian ablation Reduces androgen production Bromocriptine (or other bromocriptine agonist for hyperprolactinaemia) Assisted reproductive technology Tubal factors o Surgical reconstruction o ART Endometriosis o Surgical resection o Ovulation induction + intrauterine insemination o ART Uterine factors o Leiomyomas / polyps imposing on intrauterine cavity: resection. Not all are associated with infertility o Septae: correction o Irreparable uterine defects require a gestational carrier Treatment male infertility ART Limited treatment for conditions associated with no sperm in semen unless problem is with transport o Irreversible damage to seminiferous tubules i.e. Klinefelters syndrome, Hypogonadotropic hypogonadism o Treat cause i.e. hyperprolactinaemia or GnRH therapy Treatment of genital infections as evidenced by leukocytes in sperm (uncertain significance of leukocytes in sperm) GCS for presence of autoantibodies to sperm Obstructive azooperermia: ART ART Intrauterine insemination o Ejaculate purified to give concentrated sperm. This is injected into uterus preovulation IVF o Ovarian stimulation GnRH agonist Administered until hypoT GnRH production is downregulated for max cycle control

During stimulation phase: FSH given to stimulate follicle growth and GnRH continued to prevent LH surge (that would trigger ovulation. It is suppression of GnRH secretion by increasing oestrogen levels that triggers ovulation) GnRH antagonist Administered when follicles are large Prevents further LH and FSH secretion causing further development allowing harvest Intracytoplasmic sperm injection o Direct injection of a single sperm into cytoplasm of oocyte o Sperm obtained from ejaculate or biopsy Artificial insemination with donor semen