Definition:
Inability to conceive despite unprotected sexual intercourse
over a period of one year of time.
Only 50% of couples failing to conceive during the first
year will conceive in the 2nd year which justifies to begin
investigation after one year.
Among the total number of couples with subfertility: 70%-
Primary subfertility
30% secondary subfertility
Primary subfertility:
subfertility in a women who has not
conceived previously
Secondary
subfertility: subfertility in a women who has conceived previously regardless of the
outcome of conception
Causes:
Female causes
1. Anovulation
-
Ovarian dysfunction (normal gonadotrophins)
Eg: PCOD
-
Hypogonadotrophins Hypogonadism
Eg: tumors destroying anterioir
pituitary gland
-Adenoma/ craniopharyngioma
Inflammation of the
pituitary gland
-TB
Ischemia of anterior pituitary
-Sheehan’s syndrome
Congenital
-Lawrence- Moon syndrome
- Kallmann Syndrome
- Prader wily syndrome
Irradiation/ surgery
Hypothalamus dysfunction
- Excessive exercise
- Stress
- Anorexia nervosa
Hypergonadotrophic
hypogonadism
Premature ovarian failure
Resistant ovarian syndrome
(Abnormalities in FSH receptors)
Endocrine
-Hyperprolactinemia
-Hypothyroidism
2. Tubal damage
PID
TB
Iatrogenic
Schistosomiasis
Viral infection
Crohn’s disease
3. Endometriosis
Mechanical damages by adhesions
4. Uterine factors
-Submucosal fibroids
-Congeniotal uiterine abnormalities
-Endometrial polyps
-Intra uterine adhesions
-Endometritis by TB
Male causes:
1. Primary testicular diseases
Micro deletions in genes y chromosomes
Testicular maldescent
Torsion
Trauma/ infection
Neoplasm
Chemotherapy
Haemosiderosis
Klinefilter syndrom
Mumps orchitis
Epididymoorchitis
2. Obstructive
Congenital
Inflammatory
Iatrognic causes
3.
Endocrine
Hypogonadotrophic hypogonadism
Thyroid dysfunction
Adrenal disorders
4. Autoimmune
Anti-sperm antibodies
5. Drugs
6. Environmental
Chemical
Radiation
7. Varicocoele
8. Ejaculatory disorders
Retrograde ejaculation
Psychological causes
History taking:
1.Couples age
2.Occupation:
-
Working away from home can reduce intercourse
-
Exposure of male to heat / radiation/chemicals
3.Menstrual history:
Irregular
cycle, oligomenorrhea
Causes:
anovulation
Amenorrhea- exclude other causes
such as menopausal symptoms, symptoms of hypothyroidism and hyperprolactinemia (galactorrhea)
3. Obstetric history:
Any
previous pregnancy and the outcome
Breastfeeding
and sustained galctorrhea
Previous
history of subfertility
4. Contraception:
IUCD- PID
Hormonal
– long effect
5. Sexual Hx-
Frequency
of sexual intercourse
Dyspareunia
Ejaculation
/ erection problem
6. FHx-
DM
Endometriosis
PCOS
Assessment and
investigations
1. Ovulation
Reqular periods
usually indicate ovulation.
Secondary marker of ovulation
1. Day 21
progesterone in 28 day cycle ( 7 days before next cycle)
30nmool/L is
diagnosis of ovulation
2. Urinary LH detection kits can detect LH surge
Ovarian reserve
test
3. Day 3 FSH
Estradiol
level
AMH
Ovarian
antral follicle count by ultra sound
2. Tubal patency test
Ultrasound with hydrotubation –HyCoSg
HSG
Laparascopy with dye hydrotubation
HyCoSg-
Ultrasound done after injection of ultrasonographic contrast
medium .
HSG
Simple, safe, inexpensive , X ray based study
1st line screening
Done in 1st 10 days of cycle
Causes period like pain
Occasionally leads to vasovagal attack
May cause flare up of PID
Routine screening for chlamydia in
any patient before intrauterine instrumentation is recommended.
Lap and dye
Done under GA
Has both diagnostic and therapeutic value .
Not recommended as 1st line
can cause visceral injury
If HSG is abnormal need verification by Laparascopy
Hysteroscopy – not done routinely
Only if uterine cause is suspected
Post coital test
Not recommended as it has no predictive value on pregnancy rate
Management
Councelling
-
Explain physiology of cycle and fertile period
-
Lifestyle modification
-
Stop smoking and alcohol
-
Weight reduction
-
Dietary advice
-
Exercise
Management of tubal
infertility
-
Tubal surgery
-
IVF and Embro transfer
Tubal surgery
Only recommended for less severe disease
If severe disease –
IVF is recommended
Anoulatory infertility
-
Depends on the cause
-
Ovarian failure and resistant ovarian syndrome –
oocyte donation
-
Normalization of weight of obese and underweight
Prolactinoma –
Bromocriptine
Carbogoline
Hypogonadotropic hypogonadism
Pulsatile administration of GnRh or daily gonadotropin
PCOS –
-
Weight reduction
-
Medical ovulation induction – clomiphene /gonodatropin
-
Surgical ovulation induction – ovarian diathermy
Management of
unexplained sub fertility
-
Conservative
-
Ovulation induction with or without IUI
-
IVF with embro transfer
