1. INFERTILITY
Tariku Regea (BSc, MSC in CMw) July 2023

2. Objectives
At the end of these session, you will be able to
• Definition
• Causes
• Workup
• Principles of management

3. Introduction
• Pregnancy requires the effective function of at least
five systems or cell types:
A competent oocyte,
A competent sperm,
A favorable environment in which fertilization can
take place,
A transport system for passage of the fertilized oocyte to
uterus
A prepared endometrium that will accept the implantation
of the oocyte and nurture the growing embryo

4. Introduction
• Infertility affects both men and women with almost
equal frequency
• Women may bear the sole blame and lowers their social
status
• A socially acceptable basis for divorce in most of the
societies
• Public Health issue worldwide, including developed
countries

5. Introduction
• Fertility is defined as the capacity to conceive and
produce offspring.
• Since the fertility potential of the female partner decreases
after 35 years of age,
 Some recommend infertility evaluation after six
months of attempting conception in women 35–40
and
 Immediately in women over 40 years of age.

6. Definition and Terms
• Infertility is inability of a couple to conceive after 12 months
of regular intercourse without use of contraception in
women <35 years of age and
• After six months of regular intercourse without use of
contraception in 35 and more years of age.
• It is a common condition with important psychological,
economic, demographic, & medical implications.
• It is a unique medical condition because it involves a couple,
rather than a single individual.

7. • Subfertility to describe failure to conceive if the couple
has not been proven to be sterile.
• Fecund ability, the probability of achieving a
Pregnancy in one menstrual cycle,
 It is a more accurate descriptor because it recognizes
varying degrees of infertility.
• Infertility is reversible, but sterility is not.
Definition...

8. Types of infertility
• Primary infertility: A couple that has never conceived.
• Secondary infertility: occurs after previous pregnancy
regardless of its site & outcome.

9. CAUSES OF INFERTILITY
The cause may be present
• Male Infertility Factors
• Female Infertility Factors
• Male-Female Infertility factor
• Unexplained
9

10. Male Infertility Factors
Two defects: - Sperm production and delivery
1. Endocrine disorders
 Hypothalamic dysfunction
 Pituitary failure (tumor, radiation, surgery)
 Hyper-prolactinemia (drug, tumor) - Impotence
 Diabetes mellitus disease.
 Hypertrophy of the prostrate gland
10

11. 2. Structural Abnormalities
• Varicocele (most common), swollen veins surrounding the
testis w/c increases the temperature within the testes.
• Torsion, in which one testis is twisted
• Cryptorchidism - undescended testicles.
• Vas deferens may be blocked b/c of past infection or injury.
• Absence of vas deferens due to a congenital abnormality.
• Bilateral obstruction of epididymis or ducts
• Abnormal position of urethral orifice:- Hypospadias &
epispadias
11

12. 3. Sperm Abnormalities
• Low sperm count (oligospermia)- count < 20 million/mL
• Absence of living spermatozoa in the semen
(azoospermia)-due to obstruction in outflow tract.
• Poor motility will prevent sperm from swimming.
• Sperm that have structural deformity will also have
problems penetrating an egg.
• Male may produce antibodies to his own sperm- due to
damage blood testis barrier
• Chromosomal abnormalities- eg. klinefelter syndrome
(47,XX) 12

13. 4. Medical Disorders
• Infection – Usually childhood disease (Mumps orchids) or TB
orchids.
• STI- Sterility after infections like gonorrhea.
• Impotence- Erectile dysfunction.
• Ejaculatatory d/o – Retrograde and Premature ejaculation.
• Thyroid disorders- Hypothyroidism.
• Psychological factors like
 Job and financial stress, Fatigue, depression,
 Anxiety surrounding sexual intercourse,
• Illness, Trauma to the testes, Drug or alcohol abuse.
13

14. Diagnostic Evaluation
• History of both partners and separate private consultation.
• Age, Lifestyle – smoking, alcohol.
• History of too tight fitting pant for long time.
• Medical history (trauma, mumps, chronic medical illness).
• Occupation – excess heat, radiation, toxins
• Previous paternity
• Sexual history (technical difficulty), history of STI.
• Surgical history (mainly inguinal and scrotal).
14

15. Physical examination
 General appearance
 Testicular size and Epididymis, Scrotum
 Malformation of penis- Hypospadias and epispadias
 Varicocele
15
Diagnostic Evaluation...

16.  Semen analysis is a routine test that is the single most
important lab indicator for male infertility.
 Teach client how to collect specimen after a period of
abstinence.
 Better results if done after 2-3 days of abstinence.
 It should be analyzed within 1 hour of collection in the lab.
 If abnormal result repeat semen analysis in 3 months.
16
Laboratory Semen analysis

17. Normal Findings of seminal analysis
• Volume:- 2 mL or more
• PH :- 7.2-7.8
• Total sperm count :- more than 20 million/mL
• Liquefaction:- Complete in 1 hr.
• Motility:- 50% or more
• Morphology:- 30% or more normal forms.
• WBC:- Fewer than 1 million/ml
17

18. Laboratory tests
• A male with less than 5 million sperm per milliliter
warrants an endocrinology evaluation including:
• FSH and LH
• Testosterone
• Prolactine
• Thyroid function T3/T4 Extended
• Skull X-ray tests
• Sperm anti body testing
18

19. • Transurethral ultra-sonography, which detects ejaculatory
duct obstructions.
• Testicular biopsy –to determine if cancer cells.
• Once evaluation is complete, treatment of infertile couple is
directed by the findings.
19
Laboratory tests...

20. Treatment
 Eliminate alterations of thermoregulation.
 Hormonal manipulation to raise testicular testosterone
levels. Eg. GnRH – given in a pulsatile (to prevent down
regulation of receptors), hCG, testosterone.
 Clomiphene citrate is occasionally used for induction of
spermatogenesis-20% success.
 Artificial insemination.
 Medications to counter retrograde ejaculation.
20

21. Female Infertility Factors
• Structural Abnormality: the most common identifiable
female factors, w/c accounts for 81% of female infertility
• Ovulatory disorders (25%): Infrequent ovulation (oligo-
ovulation) or absent ovulation (anovulation)
• Oocyte aging — With advancing female age, there is an
increase in the percentage of infertility.
• The decrease in fecundability with aging is likely due to a
decline in both the quantity and quality of the oocytes.

22. Female Infertility...
• Endometriosis (15%): interfere with tubal transport
• Fallopian Tubal blockage (11%) / Pelvic Adhesions (12%):
• Prevent normal transport of the oocyte and sperm through
the fallopian tube.
• The primary cause of tubal factor infertility is pelvic
inflammatory disease (the most cause ).
• Ux D & C, previous Ux surgery and IUD complicated with
infection causes Pelvic Adhesions.

23. Female Infertility...
• Cervical factor: Congenital malformations and trauma to
the Cx (including surgery)
 May result in stenosis and inability of the Cx to produce
normal mucus, impairing fertility.
• In addition, other factors such as leiomyoma.
• A reduction in coital frequency with increasing age
• UNEXPLAINED: is the Dx given to couples after a thorough
evaluation has not revealed a cause.
• Many cases of unexplained infertility may be due to small
contributions from multiple factors.

24. Hormonal Imbalance
• Frequent cause of infertility in women is abnormal ovulation.
• Abnormal ovulation can be caused by a number of disorders
of the endocrine system:
• Problem to hypothalamus-pitutay-ovarian axes.
• Including thyroid disease- both hypothyroidism &
hyperthyroidism affects reproduction.
• Diabetes mellitus – affects ovulation, fertilization &
implantation.
• Polycystic ovarian syndrome- oligomenorrhea &
hyperandrogenism.
24

25. Other Factors
• Nutritional status:- being over or underweight.
• Functional abnormality of cervical mucus.
• The cervical mucus may be too thick for the sperm to
penetrate, or it may be chemically hostile to the sperm.
• Immunologic factor –development of antisperm antibodies
by the women or her partner.
25

26. Evaluation of female factors
• History- age, length of time with current partner,
• Menstrual history,
• Age at menarche,
• Menstrual cycle pattern
• Recent change in cycle
• Duration of flow
• Ovulation pain
• Dysmenorrhea
• Contraceptive hx (duration, type, date of last use)
26

27. Evaluation of female factors...
 Obstetric history:- abortion, ectopic Px, PPH.
 Sexual history- frequency, regularity, timing around mid
cycle, STI, PID
 Medical history-medical illness
 Surgical history-pelvic operation
 Drug history - (type, duration)
 Review history- diet, weight (b/c when over wt steroid
hormones increase in body fat), strenuous exercise.
27

28. Physical examination
• Routine PE is an essential component of general medical care.
• General appearance, thyroid, 20 sexual characteristics
• Abdominal scars, tenderness, adenexial masses.
• Uterine enlargement, position, motility.
• Vaginal exam: state of introitus, position /direction of Cx,
• Speculum exam: condition of cervix, cervical secretion in
relation to time in menstrual cycle.
• Basal body temperature (biphasic shift) for 3 cycle.
• Cervical mucus examination after expected time of ovulation-
thick, yellowish.
28

29. Laboratory investigation
• VDRL
• T3/T4
• FSH, LH
• Vaginal pH
• Estradiol, Prolactin levels
• Fasting blood sugar
• Urinalysis
• Liver enzymes, renal function
• Progestrone mid luteal phase (>25mg/L)
29

30. Laboratory investigation...
 Post-coital test (day 12-14, sperm motility in cervical
mucus 2-6 hours after intercourse).
 A satisfactory result is finding of >10 motile
spermatozoa with good forward movement
 under high power field in the presence of adequate
cervical mucus.
 Determination of sperm anti bodies
 Laparascopy
 Hystrosalpingography (HSG)
30

31. TREATMENT
 Education - timing of intercourse
 Anovulation:- ovulation induction by clomiphene
citerate-via increased pituitary gonadotropins.
 Bromocriptine if increased prolactin.
 Tubal factor- surgical correction.
 Cervical factor- antibiotic Rx for infection
31

32. TREATMENT...
 If anovulatory cycle is a cause induce ovulation using
• Clomiphen citrate:
- It is indicated primarily in pts with adequate levels of
estrogen & normal levels of FSH & prolactin.
- It is generally ineffective in hypogonadotropic patients who
already have a poor estrogen supply
- Bromocriptine
• 1-2 mg BID in the first week then
• 2.5 mg BID for 01 month
- Thyroxine:- 0.2 mg/d until response 32

33. Month Dose of clomiphene
1 50mg/d for 5 days in the first cycle beginning on the
third to fifth day of menstrual or withdrawal bleeding.
2 100mg/d for 5 days
3 150 mg/d for 5 days
4 200 mg/d for 5 days
6, 7, 8 No treatment
9 Clomiphene 150 mg/day + HCG 5000 IU 7 days after
10 Clomiphene 150 mg/d + HCG 5000 IU 7 days after
TREATMENT...

34. • Ovulation induction with Clomiphene citrate – increase
pulse & amplitude of:
- GnRH
- Gonadotropins – FSH & LH
 Dexamethasone: reduction of level of androgen
 Bromocriptine: reduction of prolactin
 Substitution therapy for hypothyroidism
TREATMENT...

35. Assisted Reproductive Technology (ART)
• If a woman does not become pregnant after treatment
with medical and surgical techniques,
 she may choose to undergo more complex
procedures, called Assisted Reproductive Technology

36. 1. Intrauterine insemination(IUI)
 IUI- is the procedure in w/c processed & concentrated
motile sperm are placed directly into the uterine cavity
 using a long tube.
 IUI is particularly useful in couples with some types of
severe sexual dysfunction
 (e.g. severe veganism's, ejaculatory dysfunction) or
discordant for STIs carriage (eg, HIV, hepatitis).

37. SPERM COLLECTION AND PROCESSING
• IUI is usually performed with fresh sperm from the partner.
• Semen collection- a semen specimen in the morning after
two or three days of sexual abstinence.
• Masturbation or withdrawal, ideally in a private room
designated for this purpose in the laboratory/office.
• The entire ejaculate is collected in a sterile cup to minimize
the risk of uterine infection from contaminants.
• Avoid the lubricants, as most are toxic to sperm.
• If a lubricant is needed, instruct the client to prevent
contact b/n the lubricant and glans.

40. • Sperm processing - sperm preparation maximizes the
number of motile sperm for insemination, removes cellular
debris & concentrates the specimen.
• Stimulated cycles - Controlled ovarian hyper-stimulation
plus IUI for Rx of infertility in couples with unexplained
infertility.
• Clomiphene citrate - For most women, the first-line
approach for ovarian stimulation is clomiphene citrate (CC)
100 mg for 5consecutive days beginning on cycle day 3 or
5, depending on the woman's natural cycle length.
SPERM COLLECTION AND .....

41. • Gonadotropin and HCG -women with diminished ovarian
reserve, induce ovulation with injectable gonadotropins
rather than clomiphene or perform IVF.
• Injectable gonadotropins (recombinant FSH) are given per
provider dosing preference beginning on cycle day 2 or 3.
• It is the standard of care to follow serum estradiol levels
and ovarian follicle size with trans-vaginal ultrasounds.
SPERM COLLECTION AND .....

42. • When at least one follicle has a mean diameter:15-18 mm,
the patient self administers 5000 to 10,000 units of HCG
 as a subcutaneous or intramuscular injection to
trigger ovulation.
• The minimum size (15-23 mm) of the leading follicle before
HCG injection is controversial.
• One IUI is performed 36 hours after HCG injection.
SPERM COLLECTION AND .....

43. IUI PROCEDURE
• Equipment
• Prepared sperm specimen
• Speculum
• 1 cc sterile syringe with blunt cannula
• Disposable polyethylene insemination catheter
• IUI is most effective for treating:
– women who have scarring or defects of the cervix
– men who have low sperm counts
– men who have sperm with low mobility
– men who cannot get erections
– men who have retrograde ejaculation

44. 2. Invitro fertilization
• IVF refers to a procedure designed to overcome infertility
and produce a Px as a direct result of the intervention.
• In general, the ovaries are stimulated by a combination of
fertility medications and then one or more oocyte(s) are
aspirated from ovarian follicles.
• These are fertilized in the laboratory ("in vitro"), after
which, one or more embryo(s) are transferred into the Ux.
• These steps occur over about a two-week interval of time,
which is called an IVF cycle.

45. 2. Invitro fertilization...
• IVF is for women with other causes of infertility, including
one or more of the following:
 Tubal factor-completely blocked.
 Severe male factor infertility
 Diminished ovarian reserve (time to conception is critical)
 Failed Rx with less invasive therapies (eg, ovulatory
dysfunction, endometriosis, unexplained infertility).
 Ovarian failure (donor eggs must be used in this case).
 Uterine factor (Asherman syndrome or distortion of the
Ux cavity, gestational surrogacy in conjunction with IVF).

46. Thank you!

47. MENOPUASE AND
CLIMACTERIC

48. Learning Objectives
• To define climacteric and menopause
• To describe the physiologic changes of climacteric
• To describe the problems of climacteric
• To enumerate the causes of postmenopausal bleeding

49. Introduction
– A problem of developed countries because of increase
life expectancy and quality of life
– Hormone deficiency
– Associated with both gynecological and medical problems

50. Definitions
• Climacteric (critical life): is the phase of life for women that
marks transition
 from being able to reproduce to being non-reproductive.
• Menopause is cessation of physiologic uterine bleeding (the
last menstruation)
 It is diagnosed retrospectively.
 It is the most visible event marking climacteric.
 Average age at menopause is 51 years and is not
affected by
o race, number of pregnancies, contraceptive use, age
at menarche and physical characteristics. .

51. Definitions
• In practice these two terms are used interchangeably
• Pre-menopause is the period before menopause during
which the menstrual cycle is irregular and climacteric
symptoms are experienced.
• Post menopause is the period after menopause.
• Perimenoposal includes the premenopause and post
menopause and extends from 40-55years

52. Etiology
– Age = exhaustion of the stoke of primordial follicles
– Surgery ,radiation ,chemotherapy
– Premature ovarian failure
– Smoking =decrease by 1-2 years

53. Pathophysiology
• Atresia starts in utero at 20 weeks
• With each ovulation there is 1000 atresia
• As menopause nears, ovarian follicles get depleted and
become resistant to gonadothropin hormones.
↓
• Estradiol production diminishes which in turn results in
elevated FSH and later LH levels.
↓
• Oligoovulation/anovulation results in menstrual irregularity
and unopposed estrogen action on the endometrium.
↓
• Later, there will not be any follicles to be stimulated
resulting significant drop in estrogen not capable of
stimulating the endometrium causing menopause.
• The hypo estrogenic state that follows menopause results in
a number of medical conditions

54. Changes in menopause
I. Hormonal changes
• Change in FSH and LH levels is the most striking hormonal
change of climacteric.
– Both exceed 40 IU/liter and continue to rise for 2-3years
and thereafter remain stable or slightly decrease.
– FSH levels are higher than LH levels for the first time in
the woman’s life.

55. Changes in menopause...
• Changes in estrogen levels are the last hormonal change in
climacteric
– Estradiol levels become very low and levels of
<20pg/liter is diagnostic of climacteric.
– The predominant estrogen is estrone, a result of
peripheral conversion of androgens.
• Progesterone levels are very low in climacteric.
• Levels of androgen like dehydroepiandrosterone sulfate, and
rostendione and testosterone fall.

56. II. Reproductive organs
• Effect depends on the level of endogenous estrogen.
• In typical hypo estrogenic states of climacteric atrophic
changes occur.
– Atrophy of the vagina results in thinning of the epithelium
and flattening of the rugae which
• gives it the appearance of smooth, shiny pale surface.
• will be narrow
• Change of flora as there is no desquamated cells = infection
• Causes Sexual trauma as it is dry
Changes in menopause...

57. II. Reproductive organs...
– Atrophy of the cervix reduces its size creating shallow fornices.
– Vaginal dryness results from decreased cervical mucus production.
– Uterus decreases in size from reduction in myometrium thickness.
– The endometrium atrophies.
• Uterus atrophic = cervix to uterine ratio 1 : (1 – 1.5)
– The ovaries decrease in size
– Supporting structures and muscles lose their tone.
– The labia loosen fat and flatten
Changes in menopause...

58. III. Menstrual cycle
• Changes in menstrual cycle are the first clinical evidence of
climacteric.
• The usual pattern is gradual increase in cycle length and
reduction in amount and duration of flow.
• Heavy bleeding and abrupt cessation are unusual.
Changes in menopause...

59. IV. Other organs
• Bladder and urethral epithelium atrophy
• Breasts decrease in size
• Generalized thinning loss of elasticity of the skin results
in wrinkling
 that is prominent on light exposed areas (face, neck
and hands).
• Accentuated bone loss
Changes in menopause...

60. • Changes before menopause
– At 35 years, follicular development decreases
– An ovulatory cycle
– Menstrual irregularity
– Low estrogen and progesterone
– Increase FSH
• Changes at menopause
– Failure of follicular development = decrease estrogen =
no menses
– Cyclic release of FSH and LH changed to continuous
Changes in menopause...

61. • Changes after menopause
– Estradiol metabolized to estrone
– Decrease estrogen
– No/little progesterone
– Androgen =normal or increased
– Gonadothropin FSH increased 3x LH 3x
• After 5-10 years
– All androgen ,estrogen and gonadothropin decreases
Changes in menopause...

62. Problems of climacteric
• These are related mainly to estrogen deficiency and
 rarely to estrogen excess.

63. Problems of estrogen deficiency
• Hot flush is the most common and characteristic
symptom of climacteric.
– It is an episodic Vasomotor disturbance consisting of
sudden flushing feeling of heat or burning in the
o face, neck and chest immediately followed by
outbreak of sweating affecting the whole body.
– It is seen in 75 % of women in climacteric
– In 25-50% it may persist for more than 5 years.

64. Problems of estrogen deficiency ...
Hot flush...
• In severe cases it may come as frequently as 1 - 2hours.
– These women suffer from insomnia, fatigue, night
sweating ,
• For severe cases treatment with conjugated estrogens or
progestin is recommended.

65. • Osteoporosis is the most important health hazard of
climacteric.
– It affects the trabecular bone.
– 10% loss starting from 35 years as the estrogen effect
of inhibition of osteocytes activity decreased
• Decrease height
• pathologic Fracture of vertebrae, femur ,callus
– Treatment of needs estrogen replacement, exercise and
adequate calcium intake.
Problems of estrogen deficiency ...

66. • Atherosclerotic disease of the heart
– Increase LDH and VLDL with decrease of HDL
• Dyspareunia arises from vaginal dryness and atrophic
vaginitis.
– Local treatment with estrogen cream relieves this
problem.
• Psychological problems may arise from estrogen deficiency
or from the effects of other climacteric problems (hot flush
and dyspareunia).
– Symptoms include anxiety, Insomnia, depression,
dementia and mood changes.
• UI and UTI, UVP, Restrictive lung diseases
Problems of estrogen deficiency ...

67. • It is defined as vaginal bleeding after 6 months of
menopause.
• It is an abnormal condition that always needs proper
investigation
• It could arise from benign of serious malignant conditions
of the genital tract.
Postmenopausal bleeding

68. • The causes are
– Vulvar dystrophy =bleeding after itching
– Atrophic vaginitis
– Atrophic endometritis
– Cervical, Endometrial, Vulvar, and vaginal cancer
– Endometrial hyperplasia and polyps
– Sarcoma of the uterus
– Estrogen producing tumors
– Exogenous estrogen therapy
Note: All women with postmenopausal bleeding should be
referred for identification and appropriate treatment
Postmenopausal bleeding...

69. • Diagnosis
– History and P/E
– Investigation (for Dx and see complications )
• U/A, vaginal smear
• D and C
• FSH
• Estrogen level
• Cholesterol level
• FBG

70. • Management
– Nutrition, water
– Exercise and Ca treatment
• to decrease bone resorpsion
– Hormonal
• Rx is estrogen cream:- For atrophic vaginitis
• Progesterone containing estrogen
• Indication
– Vasomotor symptoms ,Atrophic vaginitis , Premature
menopause Hyper lipidemia , frequent UTI

71. • Management:- Hormonal...
• Pre requisite
– Rule out cancer of breast, uterus
 CLD
 Thromboembolism
 Porphria
• NB diabetes and hypertension are not contraindicated