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Report on Infertility(Subfertility) Cause, evaluation,Diagnois, management.

A) Classificaton-
1) Infertility- failure to conceive after 1 year of unprotected sex. 2) Primary infert- Those who have never
conceived before. 3) 2 ry infertility- Those who have conceived before.

B) Requirements for fertility-Gametogenesis→gamete transport→sex→fertilization→zygote formation→

endometrial embedding of zygote.

C) Factors causing infertility- ♀ factors.

1) Age -♀ are able to reproduce between menarche & menopause. But severel cyclesb/f menarche & b/f
menopause are anovulatory/ In ♂ spermatogenesis ↓ by approx 60.

2) Ovulatory failure –

a) Hypothalamic- •Stress, severe weight loss, exercise, anorexia nervosa- ↓ pulsatile release of LHRH. •
Kallmanns syndrome- congenital absence of LHRH •Craniopharyngioma, chromophobe adenoma.- ↓
transport of LHRH. • Desire for pregnancy- altreration in dopamine & nor epinephrine transmission • Drugs-
methyldopa , phenothiazine, haloperidol.
b) Pitiutary- • Prolactin producing macro/micro adenoma- hyperprolactinaemia→ ↑dopamine→↓ LHRH( may
have nausea ,vomiting, visual disturbances if pressing on optic chiasma. Focal neurologicval signs,
amenorrhoea, galactorrhoea.
c) Thyroid-Hypo+hyper thyroidism.
d) Adrenal • cushings- central obsity, facial plethora, purple striae, buffalo hump, DM, hypertension,
amenorrhoea, hirsuitism, osteoperosis( do dexamethasone suppression & US of adrenals.) Addisons disease (
↓ of all adrenal cortical hormones) • Congenital adrenal hyperplasia. & adrenal tumors- both have signs of
virilization- voice changes, temporal balding, breast atrophy , clitoromegaly, acne, oily skin.
e) Ovarian-• ovarian resistence syndrome – FSH , LH ↑ but receptors for these in ovaries are absent. • Turnerš
syndrome( 45xo or 45xo/46xx) – short stature, cubitus vulgus, webbing of neck, widely spaced hypoplastic
breasts., amenorrhoea. • Idiopathic premature menopause • PCO- Hirsuitism, obesity, infertility,
oligomenorrhoea. ( LH;FSH= 3:1 , eswtrione ↑ androstenedione ↑, SHBG ↓ )
f) Pancreatic- uncontrolled DM.

3) Tubal blockage- may cause tubal ciliary damage → scarring→ adhesions. Caused by - • infections
following pregnancy • PID, STD – gonorrea , chlamidia, TBC , • IUCD • Abdominal surgery, peritonitis,
D&C , EUP, abortions.

4) Uterine-• endometriosis • fibromioma • abortions D& C – leading to ashermanns syndrome( adhesions)

5)Cervical - • stenosis • Chronic cervicitis.

♂ factors –
a) ↓ production of sperm- • Kleinfelter syndrome- tall stature, gynaecomastia, long extremities, absent
secondary sexual characteristics.( small penis, small testis, hypoazothemia, 47xxy/ 48 xxxy / 49xxxxy)
• undescended testes- scrotum is empty. • Varicocoele • Infections- mumps, fibrosis, TBC ,
epidydimitis. • hysical & chemical- exposure to heat ,trauma, alcohol, smoking.
b) ↓ transport of sperm- infections traumatic herniectomy.
c) ejaculatory problems-impotence, premature or retrograde ejaculation.

Couple- • timing of intercourse • using of lubricants , douches.

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Diagnosis
partner –
a)Diagnosis of ovulation- • BBT-↑ 0.5 c after ovulation. • ↑ of progesterone from 22nd till 23rd day of cycle. •
US – can see 2cm graafian follicle today but tommorow it wiill be smaller if ovulation. • Endometrial biopsy-
on 21-24 day of cycle. Due to progesterone will be secretions. • Laporoscpy can see graafian follicle. • Cervix-
mucus becomes thicker , cellular & ferning ↓ b/c of progesterone. • ↑ of intermediate cells.

b) Tests for tubal patency. • Methylene blue or indigo injected through the cervix & under laparoscopy seeing
if it comes through fimbria to pelvic cavity. • HCG.

♂ partner – semen analysis- 2-3 days abstinence→ ejaculation→ to lab in 30-60 minutes. N volume-2-5 ml.
Morphology> 30% normal Liquefaction- complete in 30 min. pH 7.2-7.8. sperm density . 20million per ml.
Mortality >50% motile.

Couple- post coital test- intercourse on 12-13 day of 28 d cycle. → report to clinic in 8-12 hrs after intercose →
cervical mucus sampling.→ looking for motile sperm & cervical change.

Treatment-
• Ovulatory failure- bromocriptineif hyperprolactinaemia. Clomiphene citrate 50mg for 5days starting on 2nd-5th
day of cycle.
• HHG,HCG
• GnRH agonist Tubal surgery- salpingolysis, salpingostoma, excision of blocked part & reanastomosis.
• IVF.

Report on Infertility (Subfertility) Cause, evaluation, Diagnois & management.

Report prepared by
1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom.
2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia.
3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania.

Contact: publications [at] infekcijas.eu