2. DEFINITION
A woman of reproductive age who has not conceived after
1 year of unprotected vaginal sexual intercourse, in the
absence of any known cause of infertility (WHO)
earlier referral and assessment for
Woman aged 36 years or more
There is a known clinical cause of infertility or a history of
predisposing factors for infertility
Primary infertility : not pregnant before
Secondary infertility : pregnant before irrespective of
outcome
3. 84% of couples in the general population will conceive
within 1 year if they do not use contraception and have
regular sexual intercourse.
Of those who do not conceive in the first year, about half
will do so in the second year (cumulative pregnancy rate
92%)
4. CAUSES
Male infertility : 30%
Impaired sperm production
Impaired sperm transport
Impaired deposition
Female infertility : 55%
Ovulatory disorder (25%) – PCOS accounts for 70% of cases
Tubal damage (20%)
Uterine or peritoneal disorders (30%)
Combined : 10%
Unknown : 25%
5. Risk Factors
Age
peak fertility : early of the third decade of life.
beyond 35 years (and particularly after age 40 years), the
likelihood of becoming pregnant is getting less.
Dunson DB, Baird DD, Colombo B [2004]. Increased infertility with age
in men and women. Obstetrics and Gynecology 103: 51–6.
6. Smoking
reduce in fertility (active / passive smokers)
reduce in semen quality
Alcohol consumption
women : < 1 or 2 units of alcohol once or twice per week
men : < 3-4 units per day
Body weight
BMI > 29 or < 19, especially who are having irregular menses.
7. Sexually transmitted infections (STIs)
chlamydia can damage the fallopian tubes, as well as
making the man's scrotum become inflamed.
Occupation
Chemicals
exposure to some pesticides, herbicides, metals (lead) and
solvents have been linked to fertility problems in both men and
women
9. General
age & duration of infertility
fertility in previous relationship
previous investigations and treatments
type & duration of previous contraception used
whether either of the partner requires to be away due to
occupational requirement – may affect the frequency of coitus
Post obstetric history
number of previous pregnancy
time taken to achieve previous pregnancy
history of post abortal / postpartum sepsis
Past medical/surgical/gynaecological history
STD, PID, IUCD usage
history of previous pelvic / abdominal surgeries (eg.
Appendicectomy, tubal surgery)
Female Partner - History
10. Menstrual history
frequency & regularity of cycles, dysmenorrhea
regular cycles with spasmodic dysmenorrhoea : likely to be
ovulating
flow & duration
look for symptoms suggestive of endometriosis, PID or fibroid
Sexual history
sexual dysfunction : dyspareunia, vaginismus
frequency of coitus
knowledge regarding fertile period
Systemic review
weight changes, hirsutism, galactorrhoea
symptoms of thyroid disease
11. Family history
including family members with infertility, birth defects, genetic
mutations, or mental retardation.
Personal and lifestyle history
occupation, changes in weight, smoking, and alcohol use.
** Unilateral oophorectomy generally do not have reduced fertility
in young women, since young women have many primordial
follicles per ovary
** However, unilateral oophorectomy may impact fertility in older
women as they may develop diminished ovarian reserve sooner
than women with two ovaries.
12. BMI
Secondary sexual characteristic
incomplete development : sign of hypogonadotropic hypogonadism
Turner’s Syndrome (45XO): short, square-shaped chest
Abnormalities of the thyroid gland, galactorrhea, or signs of
androgen excess (hirsutism, acne, male pattern baldness, virilization)
Examination of perineum & pelvic area
assess vulva, hymen
speculum examination : evidence of vaginitis, cervicitis, polyps
perform Pap Smear if due
bimanual : uterine size, position, mobility, tenderness, adnexal mass
Tenderness or mass in the adnexa or POD : chronic PID or endometriosis.
Uterine enlargement, irregularity, or lack of mobility are signs of a uterine
anomaly, leiomyoma, endometriosis, or pelvic adhesive disease.
Physical examination
13. General
duration of infertility
previous history of infertility with previous partner if any
Occupation
exposure to chemical/radiation/intense heat
Past medical history
infection e.g. mumps orchitis, epididymitis, STD
cryptorchidism (undescended testis)
Torsion
DM
Male Partner - History
14. Past surgical history
hernia repair (damage to the vas deferens or testicular blood
supply).
radical pelvic or retroperitoneal surgery (absent seminal emission
secondary to sympathetic nerve injury)
Drug history
alcohol/nicotine, chemotherapy, anabolic steroid, sulphasalazine
Sexual function
coital frequency, erection, ejaculation
knowledge regarding fertile period
15. BMIBMI
Evidence of hypoandrogenism & gynaecomastiaEvidence of hypoandrogenism & gynaecomastia
Groin & Genitalia :Groin & Genitalia :
Presence of inguinal herniaPresence of inguinal hernia
Palpate for normal position / volume( using an orchidometer) &Palpate for normal position / volume( using an orchidometer) &
tenderness of testestenderness of testes
Palpate epididymis for nodularity & tendernessPalpate epididymis for nodularity & tenderness
Check for varicoceleCheck for varicocele
Palpate for normality of VasPalpate for normality of Vas
Examine Penis for abnormalities : hypospadias etcExamine Penis for abnormalities : hypospadias etc
Physical examination
16.
17. Investigations
Seminal Fluid Analysis (SFA)Seminal Fluid Analysis (SFA)
exclude abnormalities in semenexclude abnormalities in semen
repeat after 3 months if abnormal.repeat after 3 months if abnormal.
How to collect semen for SFA ?How to collect semen for SFA ?
abstinence for 3-5 daysabstinence for 3-5 days
non-spermicidal condomnon-spermicidal condom
sterile containersterile container
kept at body temperaturekept at body temperature
sent to lab within 1 hour after ejaculationsent to lab within 1 hour after ejaculation
18. SFA normal range (WHO 2010):
pH : ≥7.2
liquefaction : complete in 60 minutes
sperm concentration : ≥ 15 million /ml
Sperm count : ≥ 39 million / ejaculation
Total motility : 40% or more; 32% progressive motility
Vitality : ≥ 58% live
Morphology : ≥ 4% normal
If SFA abnormal, to repeat confirmatory test 3
months after the initial analysis to allow time for the
cycle of spermatozoa formation to be completed
But if a gross spermatozoa deficiency has been
detected, to repeat test ASAP
19. Abnormal semen is responsible for about 75% of all cases ofis responsible for about 75% of all cases of
male infertility.male infertility.
Aspermia : No ejaculateAspermia : No ejaculate
Azoospermia: Absence of spermatozoa in the ejaculateAzoospermia: Absence of spermatozoa in the ejaculate
Oligospermia: < 15 millions/mlOligospermia: < 15 millions/ml
Severe oligospermia : <5 millionSevere oligospermia : <5 million
Asthenospermia :Slow motilityAsthenospermia :Slow motility
Teratospermia: Morphological abnormalitiesTeratospermia: Morphological abnormalities
Leucocytospemia: >1 million leucocyte /mlLeucocytospemia: >1 million leucocyte /ml
20.
21. Assess ovulatory functionAssess ovulatory function::
regular cycles : mid luteal phase Serum progesterone (D21)regular cycles : mid luteal phase Serum progesterone (D21)
irregular cyclesirregular cycles
Se progesterone measured based on timing of menstrual periods (7Se progesterone measured based on timing of menstrual periods (7
days before next cycles)days before next cycles)
FSH & LH (D2)FSH & LH (D2)
Se Prolactin - only if ovulatory disorder, galactorhoea, pituitarySe Prolactin - only if ovulatory disorder, galactorhoea, pituitary
tumourtumour
thyroid function test : only if sign / symptom of thyroid dysfunctionthyroid function test : only if sign / symptom of thyroid dysfunction
Investigations
22. Pelvic ultrasound
to detect uterine fibroids, endometrial polyps, ovarian cysts, andto detect uterine fibroids, endometrial polyps, ovarian cysts, and
other abnormalities in the pelvis.other abnormalities in the pelvis.
Assess tubal patencyAssess tubal patency::
screen for chlamydia before instrumental testing for tubalscreen for chlamydia before instrumental testing for tubal
patencypatency
hysterosalphingography (without comorbidities, eg. PID,(without comorbidities, eg. PID,
endometriosis, previous ectopic pregnancy)endometriosis, previous ectopic pregnancy)
laparoscopy & dye insufflation (with comorbidities, or if HSG(with comorbidities, or if HSG
shows tubal disease that can be repaired)shows tubal disease that can be repaired)
23. Assess uterine cavity:
not generally recommended unless clinically indicated
Genetic testing
find out whether a genetic abnormality is interfering with the
woman's fertility.
Endometrial biopsy
not recommended to evaluate the luteal phase
Screening of viral status
25. Management
Non pharmacological therapy
Including conservative management
Pharmacological therapy
Surgical treatment
Assisted Reproductive Technology (ART)
Treatment for Male Infertility
26. Non Pharmacological Therapy
Couple educationCouple education
- Sexual intercourse 2-3 times per week may improve fertility.- Sexual intercourse 2-3 times per week may improve fertility.
Smoking cessationSmoking cessation
Limit alcohol intakeLimit alcohol intake
Preconceptional advicePreconceptional advice
- check Rubella status- check Rubella status
- Folic acid supplementation.- Folic acid supplementation.
Maintain BMI 19-29kg/m²Maintain BMI 19-29kg/m²
Stress managementStress management
Educate regarding fertile periodEducate regarding fertile period
27. Pharmacological
treatment
WHO Group I ovulation disorders
Pulsatile administration of gonadotrophin-releasing
hormone or gonadotrophins with luteinising hormone
activity
WHO Group II ovulation disorders
1st
line treatment
Clomifene citrate
block estrogen receptors in hypothalamus, interfereblock estrogen receptors in hypothalamus, interfere
normal feedback, then trigger FSH/LH releasenormal feedback, then trigger FSH/LH release
70% of anovulatory women ovulate after treatment70% of anovulatory women ovulate after treatment
failure to ovulate at dose of 150mg is consideredfailure to ovulate at dose of 150mg is considered
clomiphene-resistantclomiphene-resistant
Metformin or
Combination of both
28. 2nd
line treatment (clomiphene resistant)
Laparoscopic ovarian drilling
Combined treatment with clomiphene and metformin
if not already offered
Gonadotrophins
Human menopausal gonadotrophin – FSH + LH
FSH alone
Hyperprolactinaemic amenorrhea
Dopamine agonist – bromocriptine, carbegoline
29. Surgical Treatment
Laparoscopic ovarian drilling – clomiphene resistant PCOSLaparoscopic ovarian drilling – clomiphene resistant PCOS
destroy ovarian androgen-producing tissue and reduce thedestroy ovarian androgen-producing tissue and reduce the
peripheral conversion of androgens to estrogens.peripheral conversion of androgens to estrogens.
A fall in the serum levels of androgens and LH and an increase inA fall in the serum levels of androgens and LH and an increase in
FSH levels have been demonstrated after ovarian drillingFSH levels have been demonstrated after ovarian drilling
Disadvantage of destroying ovarian reserve and formation ofDisadvantage of destroying ovarian reserve and formation of
adhesionadhesion
30. Tubal surgeries
Tubal microsurgery & laparoscopic tubal surgeryTubal microsurgery & laparoscopic tubal surgery
For mild tubal diseaseFor mild tubal disease
adhesiolysisadhesiolysis
Tubal catheterization / cannulationTubal catheterization / cannulation
selective salphingography with tubal catheterizationselective salphingography with tubal catheterization
or hysteroscopic tubal cannulation for proximal tubalor hysteroscopic tubal cannulation for proximal tubal
obstructionobstruction
SalpingectomySalpingectomy
For hydrosalpinges before IVF treatmentFor hydrosalpinges before IVF treatment
31. Uterine surgery
Hysteroscopic adhesiolysis for intrauterine
adhesions – improve chance of pregnancy
Endometriosis
Medical treatment does not enhance fertility
Surgical ablation or resection; adhesiolysis
Cystectomy
33. Intrauterine Insemination
Insemination of sperm into uterusInsemination of sperm into uterus
Indication :Indication :
Physical disabilities or psychosexual problem causing vaginalPhysical disabilities or psychosexual problem causing vaginal
intercourse to be difficult or impossibleintercourse to be difficult or impossible
Discordant HIV positive coupleDiscordant HIV positive couple
Same sex relationshipSame sex relationship
Stimulated or non-stimulatedStimulated or non-stimulated
Multiple pregnancy is the major risk is ovarian stimulation is usedMultiple pregnancy is the major risk is ovarian stimulation is used
Cycle is terminated if >3 developing folliclesCycle is terminated if >3 developing follicles
Not routinely offered to couple withNot routinely offered to couple with
Unexplained infertilityUnexplained infertility
Mild endometriosisMild endometriosis
Mild male factor infertilityMild male factor infertility
34. In-vitro Fertilisation
Indication:Indication:
Severe tubal dysfunctionSevere tubal dysfunction
Endometriosis failed medical & surgical RxEndometriosis failed medical & surgical Rx
Unexplained infertilityUnexplained infertility
35. In-vitro Fertilisation
Factors affecting the outcome of IVF :Factors affecting the outcome of IVF :
Female ageFemale age
Number of previous treatment cyclesNumber of previous treatment cycles
Previous pregnancy historyPrevious pregnancy history
BMIBMI
Lifestyles factorsLifestyles factors
Alcohol, smoking, caffeineAlcohol, smoking, caffeine
38. ))
A single sperm is injected into an ovum to achieveA single sperm is injected into an ovum to achieve
fertilization. Then the embryo is transferred to the uterus orfertilization. Then the embryo is transferred to the uterus or
Fallopian tube. The likelihood of fertilization improvesFallopian tube. The likelihood of fertilization improves
significantly.significantly.
Indications :Indications :
severe deficits in semen qualitysevere deficits in semen quality
azoospermia.azoospermia.
Failed IVFFailed IVF
Intracytoplasmic spermIntracytoplasmic sperm
injection (ICSIinjection (ICSI
39. Indications :Indications :
- azoospermia- azoospermia
- infectious disease in the male partner (such as HIV)- infectious disease in the male partner (such as HIV)
- severe rhesus isoimmunisation- severe rhesus isoimmunisation
- severe deficits in semen quality in couples who do not wish- severe deficits in semen quality in couples who do not wish
to undergo intracytoplasmic sperm injection.to undergo intracytoplasmic sperm injection.
- cases where there is a high risk of transmitting a genetic- cases where there is a high risk of transmitting a genetic
disorder to the offspring.disorder to the offspring.
Donor inseminationDonor insemination
40. Indications :Indications :
- premature ovarian failure- premature ovarian failure
- gonadal dysgenesis including Turner syndrome- gonadal dysgenesis including Turner syndrome
- bilateral oophorectomy- bilateral oophorectomy
- ovarian failure following chemotherapy or radiotherapy- ovarian failure following chemotherapy or radiotherapy
- certain cases of IVF treatment failure.- certain cases of IVF treatment failure.
- cases where there is a high risk of transmitting a genetic- cases where there is a high risk of transmitting a genetic
disorder to the offspring.disorder to the offspring.
Oocyte donationOocyte donation
42. Erectile dysfunction or premature ejaculationErectile dysfunction or premature ejaculation
Medication and/or behavioral approaches can help men withMedication and/or behavioral approaches can help men with
general sexual problems, resulting in possibly improved fertility.general sexual problems, resulting in possibly improved fertility.
VaricoceleVaricocele
Surgical treatment of varicocele as a form of infertility treatmentSurgical treatment of varicocele as a form of infertility treatment
should not be offered as it does not improve pregnancy ratesshould not be offered as it does not improve pregnancy rates
Blockage of the ejaculatory ductBlockage of the ejaculatory duct
sperm can be extracted directly from the testicles and injectedsperm can be extracted directly from the testicles and injected
into an egg in the laboratory.into an egg in the laboratory.
Obstructive azoospermiaObstructive azoospermia
Surgery for epididymal blockageSurgery for epididymal blockage
Retrograde ejaculationRetrograde ejaculation
sperm can be taken directly from the bladder and injected intosperm can be taken directly from the bladder and injected into
an ovum in the laboratory.an ovum in the laboratory.
Treatment for male infertilityTreatment for male infertility
