❖Causes of anovulation
➢Primary ovarian failure
• Premature ovarian failure. POF
• Genetic; Turners syndrome.
• Autoimmune.
• Iatrogenic
- Surgery
- Chemotherapy.
Female subfertility
➢Secondary ovarian disorders
• PCOS
• Excessive weight loss or exercise
• Hypopituitarism
- Tumor
- Trauma
- Surgery
• Kalman's syndrome
• Hyperprolactinemia
• Hypothyroidsm
Female subfertility
❖Tubal damage:
• Infection
• Endometriosis
❖Uterine factors;
• Infection
• Asherman's syndrome
• Submucous fibroids
• Congenital uterine anomalies.
❖Cervical:
• Stenosis or abnormalities of the mucus-sperm interaction
• Infection
• Female sperm antibodies
Evaluation of the
Infertile couple
• History taking (female)
• frequency of intercourse
• menstrual history: irregularities
• surgical history: abdominal / pelvic surgery
• history of weight changes,
• hirsutism and acne
• contraception :IUCDs
• cervical smear
• symptoms (past or present) : STD , galactorrhea, thyroid symptoms
• obstetric history
Evaluation of the
Infertile couple
• History taking (male)
• Genital tract infection : mumps. Orchitis, prostatitis
• History of impotence, premature ejaculation, change inlibido,
• Surgical history of testicular torsion, undescended or maldescended testis,
prostate surgery, hernia repair
• Trauma: genital or inguinal region
• Exposure to lead, cadmium, mercury
• Drug history: Sulphasalazine ’impairs spermatogenesis’
Phenothiazine/ antipsychotics/metoclopramide ‘increase prolactin levels’
Immunosuppresants
Medical history
• In both
• Smoking
• Alcohol intake
• Psychological factors
Evaluation of the
Infertile couple
• Examination for infertility (female)
• blood pressure, pulse, and temperature
• Body mass index BMI: <19 OR > 30
• Head and neck assessment:
• Exophthalmos (hyperthyroidism)
• Epicanthus, lower implantation of ears and hairline, and webbed
neck (chromosomal abnormalities)
• Exclude thyroid gland enlargement/nodules (thyroid dysfunction )
Examination for infertility (female) cont.
• Breast evaluation:
• Assess breast development
• abnormal masses or secretions, especially galactorrhea
• Abdominal evaluation:
• abnormal masses
• Speculum examination:
• Obtain a Papanicolaou test and cultures for gonorrhea, chlamydia.
• assess for cervical stenosis.
Examination for infertility (female) cont.
• Bimanual examination:
• Establish direction of the cervix + size/position of the uterus to
exclude the presence of uterine fibroids, adnexal masses Tenderness,
or pelvic nodules.
• Assess for defects (absence of vagina and uterus, vaginal septum)
• Extremities evaluation:
• Exclude malformation (cubitus valgus), which can indicate
chromosomal abnormalities and other congenital defects
• Dermatologic evaluation:
• Assess for the presence of acne or hirsutism.
Examination for infertility (male)
• General examination:
• Blood pressure, pulse, and temperature
• Body mass index BMI: > 30
• Secondary sexual character
• Local examination:
• Hypospadias
• Size and consistency of each testicle, epididymis and prostate
Presence of varicocele or hernia
• Gynaecomastia
Investigations for men
• Primary care
• Semen analysis
• Hormone testing
- testosterone
- LH FSH
- prolactine
• Secondary care
• Testicular ultrasound
• T. Biopsy
• Genetic testing : karyotype
Investigations for women
• Evidence of ovulation:
▪ serum progesterone in the mid-luteal phase of their cycle (day 21 of a 28-day cycle) even if they
have regular menstrual cycles.
▪ Serum gonadotrophins (follicle-stimulating hormone and luteinising hormone) on Day2-3
especially in irregular periods.
▪ (N.B.: No role for basal body temperature charts)
• Ovarian reserve
• -More important in >35 years old, suspected ovarian failure and to detect response to ovulation
induction.
• 1. Total antral follicle count.
• 2. Anti-Müllerian hormone of less than or equal to 5.4 pmol/l for a low response and greater than
or equal to 25.0 pmol/l for a high response
• 3. Follicle-stimulating hormone greater than 8.9 IU/l for a low response and less than 4 IU/l for a
high response.
Investigations for women
• Other Hormone testing:
• Prolactin
• Thyroid test
• Genetic testing
• Further investigations
• Pelvic ultrasound
• Laparoscopy
• Hystero-salpingography
Investigations for women
• Investigation of suspected tubal and uterine abnormalities:
• 1. Hystersalpingography (HSG):
• - usually after failed successive cycles of ovulation induction, and in
some centres after failed IUI.
Investigations for women
• 2. Hysterosalpingo-contrast-ultrasonography
• TVS scan during which air and saline or a solution of D-galactose is
• infused into the uterine cavity and observed to flow along the
fallopian tubes.
• Requires more expertise.
• Less invasive.
Investigations for women
• Laparoscopy:
• Invasive procedure.
• to check for pelvic disease; such as endometriosis
• check tubal patency.
• therapeutic as in laparoscpic myomectomy and ovarian drilling.
• Hysteroscopy:
• to evaluate uterine cavity.
• In case of repeated failed IVF cycles.
• therapeutic as in intrauterine septum.
Management
1. Counselling and waiting.
• Lifestyle changes
• Folic acid supplementation
• Rubella status
• Cervical screening
2. Treatment of the cause.
• Ovulation induction.
3. Artificial insemination (IUI/ICI)
4. IVF/ICSI
Treatment of the cause:
• Male Factor:
1. Medical management:
• Men with hypogonadotrophic hypogonadism should be offered
gonadotrophin drugs.
• Men with idiopathic semen abnormalities
should not be offered anti-oestrogens,
gonadotrophins, androgens, bromocriptine
or kinin-enhancing drugs.
Treatment of the cause:
• Surgical management:
• Surgical correction of epididymal block in obstructive azoospermia.
• No evidence for surgical treatment of varicocele in infertility.