Download Cervical factor infertility

INFERTILTY
BY HUSSEIN TALAL SABBAN
• Infertility:
is the failure to conceive (regardless of cause)
after 1 year of unprotected intercourse.
• Infertility affects approximately 10-15% of
reproductive-aged couples.
• Fertility :
is defined as the capacity to reproduce or the
state of being fertile.
• fecundability:
is the probability of achieving a pregnancy each
month
• Fecundity:
is the ability to achieve a live birth within 1
menstrual cycle
Etiology of Infertility
• Reproduction requires the interaction and
integrity of the female and male reproductive
tracts, which involves:
(1) the release of a normal preovulatory oocyte.
(2) the production of adequate spermatozoa.
(3) the normal transport of the gametes to the
ampullary portion of the fallopian tube (where
fertilization occurs)
(4) the subsequent transport of the cleaving
embryo into the endometrial cavity for
implantation and development.
• Infertility is caused by male and/or female
factors.
• Male and female factors each account for
approximately 35% of cases.
• Often, there is more than one factor, with male
and female factors combined causing 20% of
infertility.
• In the remaining 10% of cases, the etiology is
unknown.
Female Factor Infertility
• Female factor infertility can be divided into
several categories:
• cervical
• uterine
• ovarian
• tubal
• other
• Cervical factor infertility:
• Cervical factor infertility can be caused by stenosis or abnormalities of the
mucus-sperm interaction. The uterine cervix plays a pivotal role in the
transport and capacitation of the sperm after intercourse. Cervical factors
account for 5-10% of infertility
• Uterine factor infertility:
• The uterus is the final destination for the embryo and the place where the
fetus develops until delivery. Therefore, uterine factors may be associated
with primary infertility or with pregnancy wastage and premature delivery.
Uterine factors can be congenital or acquired. They may affect the
endometrium or myometrium and are responsible for 2-5% of infertility
cases.
• Ovarian factor infertility:
• Ovulatory dysfunction is defined as an alteration in the frequency
and duration of the menstrual cycle. A normal menstrual cycle lasts
25-35 days, with an average of 28 days. Failure to ovulate is the
most common infertility problem. Absence of ovulation can be
associated with primary amenorrhea, secondary amenorrhea, or
oligomenorrhea.
• Advanced age:
• The prevalence of infertility rises dramatically as age increases.7
Furthermore, fertility decreases with marriage duration because of
less frequent intercourse and/or the use of contraception.
• Tubal factors:
• Abnormalities or damage to the fallopian tube interferes
with fertility and is responsible for abnormal implantation
(eg, ectopic pregnancy). Obstruction of the distal end of the
fallopian tubes results in accumulation of the normally
secreted tubal fluid, creating distention of the tube with
subsequent damage of the epithelial cilia (hydrosalpinx).
• Other tubal factors associated with infertility are either
congenital or acquired. Congenital absence of the fallopian
tubes can be due to spontaneous torsion in utero followed
by necrosis and reabsorption. Elective tubal ligation and
salpingectomy are acquired causes.
• Peritoneal factors:
• The uterus, ovaries, and fallopian tubes share the same space within the
peritoneal cavity.
• Anatomical defects or physiologic dysfunctions of the peritoneal cavity,
including infection, adhesions, and adnexal masses, may cause infertility.
• Pelvic inflammatory disease, peritoneal adhesions secondary to previous
pelvic surgery, endometriosis, and ovarian cyst rupture all compromise the
motility of the fallopian tubes or produce blockage of the fimbriae with
development of hydrosalpinx.
• Large myomas, pelvic masses, or blockage of the cul-de-sac interferes with
the accumulation of peritoneal fluid and interferes with the normal oocyte
pickup mechanism.
• Peri-ovarian adhesions that encapsulate the ovary interfere with the
normal oocyte release at ovulation, becoming a mechanical factor for
infertility.
• Male Factor Infertility:
• Male factor infertility can be divided into pretesticular,
testicular, and posttesticular etiologies.
• Factors Affecting Both Sexes
• Environmental and occupational factors
• Concern regarding the impact of environmental factors
on fertility is increasing. Published semen analysis
reports from 1985 confirm a 20% decrease of sperm
concentration compared with reports published in the
1960s. Toxic effects related to tobacco, marijuana,
and other drugs
General Guidance on Evaluation of
Infertility
• History
• The couple should provide a copy of their previous medical records
and complete a medical history questionnaire
• Obtain a detailed medical history regarding the type of infertility
(primary or secondary) and its duration.
• Obtain a history of previous pregnancies and their outcomes;
interval between pregnancies; and detailed information about
pregnancy loss, duration of pregnancy, human chorionic
gonadotropin (hCG) level, ultrasonographic data, and the presence
or absence of a fetal heartbeat.
• During the history of previous infertility evaluation and treatment,
specific questions should address the issues of frequency of
intercourse, use of lubricants (eg, K-Y gel) that could be spermicidal,
use of vaginal douches after intercourse, and the presence of any
sexual dysfunction such as anorgasmia or dyspareunia.
• Question female patients about their menstrual
history, frequency, and patterns since menarche.
A history of weight changes, hirsutism, frontal
balding, and acne should also be addressed.
• Ask male patients about previous semen
analysis results, history of impotence, premature
ejaculation, change in libido, history of testicular
trauma, previous relationships, history of any
previous pregnancy, and the existence of
offspring from previous partners.
• Ask the couple about their history of sexually
transmitted diseases (STDs); surgical contraception (eg,
vasectomy, tubal ligation); lifestyle; consumption of
alcohol, tobacco, and recreational drugs (amount and
frequency); occupation; and physical activities.
• Ask the couple whether they are currently under
medical treatment, the reason, and whether they have
a history of allergies.
• A complete review of systems may be helpful to
identify any endocrinological or immunological
problem that may be associated with infertility.
• Physical
• A physical examination should be completed if one has
not been recently performed by a gynecologist.
• Measure height and weight to calculate the body mass
index, and measure arm span when indicated.
• Perform an eye examination to establish the presence
of exophthalmos, which can be associated with
hyperthyroidism.
• The presence of epicanthus, lower implantation of the
ears and hairline, and webbed neck can be associated
with chromosomic abnormalities.
• Carefully evaluate the thyroid gland to exclude
gland enlargement or thyroid nodules.
• Perform a breast examination to evaluate
breast development and to seek abnormal
masses or secretions, especially galactorrhea
• The abdominal examination should be
directed to the presence of abnormal masses
at the hypogastrium level.
• A thorough gynecologic examination should
include an evaluation of hair distribution, clitoris
size, Bartholin glands, labia majora and minora,
and any condylomata acuminatum or other
lesions that could indicate the existence of
venereal disease.
– The inspection of the vaginal mucosa may indicate a
deficiency of estrogens or the presence of infection.
– The evaluation of the cervix should include a
Papanicolaou test and cultures for gonorrhea,
chlamydia, Ureaplasma urealyticum,
and Mycoplasma hominis.
• Bimanual examination should be performed to
establish the direction of the cervix and the size and
position of the uterus to exclude the presence of
uterine fibroids, adnexal masses, tenderness, or pelvic
nodules indicative of infection or endometriosis.
• The examination of the extremities is important to rule
out malformation, such as shortness of the fourth
finger or cubitus valgus, which can be associated with
chromosomal abnormalities and other congenital
defects. Examine the skin to establish the presence of
acne, hypertrichosis, and hirsutism.
• The urologist usually examines the male partner
if the patient's history of his semen analysis
produces an abnormal finding.
– Attention should be directed to congenital
abnormalities of the genital tract (eg, hypospadias,
cryptorchid, congenital absence of the vas deferens).
– Testicular size, urethral stenosis, and presence of
varicocele are also determined.
– A history of previous inguinal hernia repair can
indicate an accidental ligation of the spermatic artery.
Comprehensive Evaluation of
Infertility
• Evaluation of infertile couples should be organized and
thorough.
• Diagnostic tests should progress from the simplest (eg,
pelvic ultrasonography) to the more complex and
invasive (eg, laparoscopy).
• The couple may be stressed by their need to seek
medical intervention; therefore, to relieve anxiety,
emphasize that a complete infertility evaluation is
performed according to the woman's menstrual cycle
and may take up to 2 menstrual cycles before the
etiology is determined
Cervical factors
The postcoital test (PCT
Cervical stenosis can be diagnosed during a speculum
examination. Uterine factors
pelvic examination
HSG, pelvic ultrasonography, hysterosonogram, and MRI.
Operative procedures such as laparoscopy and hysteroscopy are
often necessary for confirmation of the final diagnosis.
Tubal and peritoneal factors
The 2 most frequent tests used for diagnosis of tubal pathology
are laparoscopy and hysterosalpingogram.
• Ovarian factors
Ovulation
– Ovulation is usually inferred when a woman reports regular cycles. If there is
doubt, a progesterone greater than 4 ng/mL is indicative of ovulation.
Sonographic confirmation of follicle rupture with serial ultrasonography can
also be performed.
– Basal body temperature charts can be used to predict ovulation
• Ovarian reserve
– The level of ovarian reserve and the age of the female partner are the most
important prognostic factors in the fertility workup.
– Ovarian reserve is most commonly evaluated by checking a cycle day 3 FSH
and estradiol level. Normal ovarian function is indicated when the FSH level is
less than 10 mIU/mL and the estradiol level is less than 65 pg/mL
• Since thyroid disease and hyperprolactinemia can cause menstrual
abnormalities and infertility, a serum TSH and prolactin should always be
checked and corrected prior to
• Evaluation of the Male Partner:
The male partner must submit a semen sample for a
comprehensive semen analysis. Previous paternity does not
guarantee current fertility status.
• Sperm function tests
(1) the acrosome reaction test with fluorescent lectins or
antibodies.
(2) computer assessment of the sperm head
(3) computer motility assessment
(4) hemizona-binding assay
(5) hamster penetration test
(6) human sperm-zona penetration assay