Overview
Infertility is the inability of a couple to conceive with regular intercourse (3-4 times per week) and in the absence of contraception after 12 months in women < 35 years and 6 months in women > 35 years. Infertility is not the same as **recurrent pregnancy loss.
Definition of terms
| Term | Definition |
|---|---|
| Primary infertility | The couple meets the definition of infertility and has never been able to conceive. Prevalence increases with the age of the female partner |
| Secondary infertility | The couple meets the definition of infertility, but has conceived before |
| Fecundability | The probability of achieving pregnancy in one cycle. Around 0.20-0.25. Lowers with increasing age of the female partner |
Female Infertility
- Common causes of infertility in women
- Defective implantation due to endometrial dysfunction (fibroids, adhesions, polyps – 30%)
- Anovulation (25%)
- Tubal damage (20%)
- Cervical scarring or dysfunction (5%)
- Sexual dysfunction (5%)
Disorders of ovulation
| Group | Description |
|---|---|
| Group I – Hypothalamic failure | Hypogonadotropic hypogonadism caused by failure of the hypothalamus to produce sufficient FSH and LH, leading to no ovulation |
| Group II – Hypothalamic-pituitary-ovarian dysfunction | Commonly the result of PCOS. This is the most common cause of ovulation disorder. Excess androgens associated with PCOS inhibit ovulation |
| Group III – Ovarian failure | Hypergonadotropic hypogonadism due to insufficient follicles in the ovary |
Causes of infertility in women
| Causes | Examples |
|---|---|
| Ovulatory | Hypothyroidism, Hyperprolactinemia, PCOS, Premature ovarian failure, Diminished ovarian reserve (age, endometriosis), Wedge resection of the ovary, Functional hypothalamic amenorrhoea, Turner syndrome |
| Tubal | PID, Endometriosis, Pelvic adhesions/obstructions |
| Uterine | Uterine fibroids, Endometrial polyps, Bicornuate uterus, Septate uterus, Asherman syndrome, Mayer-Rokitansky-Kuster-Hauser syndrome |
Male Infertility
Causes of primary hypogonadism in men
| Causes | Examples |
|---|---|
| Testicular | Varicocele, Mumps, Gonorrhea, Torsion, Cryptorchidism |
| Genetic | Klinefelter syndrome, Y chromosome microdeletion |
Causes of secondary hypogonadism in men
| Cause | Examples |
|---|---|
| Secondary hypogonadism | Hyperprolactinemia, Hypothyroidism, Liver cirrhosis, Obesity, Spironolactone, Cimetidine, Anabolic steroids, Prolonged glucocorticoid therapy, Kallman syndrome |
Other causes of male infertility
| Causes | Examples |
|---|---|
| Psychosocial | Erectile dysfunction, impotence |
| Sperm abnormalities | Immotile cilia syndrome |
Evaluation of Infertility
- Questions on conception
- Has the couple been able to conceive before?
- Has either member of the couple conceived before (with another partner)?
- Menstrual history
- Has she ever had a period? (rule out primary amenorrhoea)
- Does she have regular periods?
- How long are her cycles?
- Does she have symptoms with her periods/ (e.g., cramping, bloating)
- Are her periods painful? (dysmenorrhea = endometriosis)
- Sexual history
- When and how often is the couple having sex?
- Is it painful?
- What is his libido? (Low libido = androgen insensitivity)
- When did each start puberty? (Should be at Tanner stage V)
- History of STDs or genitourinary infections (PID)
- Past medical history
- Weight (extremes of BMI)
- Chronic illnesses
- Medications
- Past surgical history
- History of gynaecologic surgery (e.g., oophorectomy, dilation and curettage causing Asherman syndrome)
- Has he had any genitourinary or inguinal surgery? (Vasectomy, Orchidectomy, Herniorrhaphy)
- Social history
- Alcohol
- Drugs (including anabolic steroids)
- Stress
- Physical exam of the female partner
- General exam: Abnormal body habitus, lack of secondary sex characteristics (breast, hair distribution)
- Skin: Hirsutism, acne (PCOS)
- HEENT: abnormalities of the thyroid gland, male pattern balding (PCOS)
- Breast: underdeveloped, expressable milk from nipples
- Abdomen: abdominal striae, truncal obesity
- Pelvic exam
- External: lack of pubic hair
- Vaginal/cervical: lack of a patent cervix, double cervix
- Uterine/adenxal: Structural (Mullerian) abnormalities, leiomyomas, retroversion, tender nodules
- Physical exam of the male partner
- General exam: Eunuchoidal habitus (long arms and legs; upper/lower body ratio < 1); obesity and decreased muscle mass
- Skin: absence or loss of axillary and facial hair
- Breast: Gynecomastia
- Pelvic
- Inguinal: Direct inguinal hernia
- External/phallus: absence or loss of pubic hair; abnormally small phallus
- Scrotal/testicular: undescended or absent testicle; absence of vas deferens; epididymal thickening or cyst; varicocele; indirect inguinal hernia
Management of Infertility
- Investigations
- Semen analysis: always get a semen analysis after the patient has abstained from coitus for 3 – 4 days. The sample should be obtained via masturbation without a condom and delivered to the lab within 1 hour
- Azoospermia: absence of motile sperms
- Oligozoospermia < 15 million per mL
- Asthenozoospermia < 32% motile sperm
- Teratozoospermia < 4% normal forms
- Assess ovulatory function: Mid-luteal progesterone level or OTC urinary ovulation prediction kit
- Abnormal mid-luteal progesterone levels = amenorrhoea
- Serum prolactin
- FSH
- TSH
- Assessment of PCOS (ultrasound)
- Abnormal mid-luteal progesterone levels = amenorrhoea
- Assessment of ovarian reserve: Day 3 FSH and estradiol levels should be ≤ 10 mIU/L)
- Abnormal levels suggest menopause or premature ovarian failure
- Hysterosalpingogram (HSG): evaluate the anatomy of the uterus and fallopian tubes using a dye. Performed as part of the initial workup or postponed until normal semen analysis and ovulation are confirmed
- Tubal damage → Laparoscopy to further assess and attempt Tuboplasty
- Semen analysis: always get a semen analysis after the patient has abstained from coitus for 3 – 4 days. The sample should be obtained via masturbation without a condom and delivered to the lab within 1 hour
- Treatment if semen analysis is abnormal
- Assisted Reproductive Technology (ART)
- Intrauterine insemination (IUI) – mild to moderate decreased density
- Intracytoplasmic sperm injection followed by in vitro fertilization (ICSI + IVF) – severe abnormalities
- Artificial insemination with donor sperm (AID) – absence of viable sperm
- Assisted Reproductive Technology (ART)
- Treatment if the cause is anovulation
- Correct the underlying cause (Hypothyroidism, hyperprolactinemia, or PCOS)
- Ovarian Induction Therapy
- Clomiphene citrate to induce ovulation – idiopathic or due to menopause/ovarian dysfunction
- Human menopausal gonadotropin – second-line agent if Clomiphene fails. Carries a significant risk of multiple pregnancy
- Treatment if there is tubal damage
- Tuboplasty
- In Vitro Fertilisation
- Complications of Ovarian Induction Therapy
- Ovarian Hyperstimulation Syndrome (OHSS): Swollen ovaries, ascites (high risk with gonadotropins/high estradiol)Multiple Pregnancy: 5–12% twins, 1% triplets+ (strict monitoring reduces risk)Ectopic Pregnancy: Slightly increased risk
Semen Analysis parameters
| Parameter | Description | Normal value |
|---|---|---|
| Sperm count | Number of sperm in the ejaculate | ≥ 15 million/ml |
| Total motility | Proportion of sperm that can swim | ≥ 40% |
| Progressive motility | Proportion of sperm swimming in one direction | ≥ 32% |
| Morphology | Size and shape of sperm | ≥ 4% normal forms |
| Vitality | Proportion of sperm that are alive | ≥ 58% |
| Semen volume | Amount of semen produced | ≥ 1.5ml |
| White blood cells | Indicates infection | < 1 million/ml |