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AZRA NAHEED MEDICAL COLLEGE DEPARTMENT OF PHYSIOLOGY MALE AND FEMALE INFERTILITY • Infertility is “inability to conceive after one year of conjugal life without use of contraceptive methods.” • The term "primary infertility" is applied to “the couple who has never achieved a pregnancy.” • "secondary infertility" implies that “at least one previous conception has taken place.” ORIGIN OF PROBLEM : • 35% female • 35% male • 20% both partners • 10% unexplained MALE EITIOLOGY • • • • • • • Idiopathic Infection – genito-urinary tract,mumps Genetic/systemic disease Endocrine Immunologic Obstruction Developmental FEMALE ETIOLOGY • Unexplained • DEVELOPMENT • Cervical • Endometrial/uterine • Pelvic • Tubal • Genetic APPROACH TO INFERTILITY • Production • Storage • Delivery MALE INFERTILITY Production: • Hypothalamus • Anterior Pituitary • Testes HYPOTHALAMIC-PITUITARY-GONADAL AXIS HYPOTHALAMUS • 1Congenital abnormalities of hypothalamus e.g. Kallman’s syndrome • Starvation, stress or severe illness • Tumors (craniopharyngioma, metastatic tumor) • Head injury • Inflammation • Infection • XRT • Drugs: marijuana, PITUITARY • . Endocrine: prolactin • Tumors • Inflammation: meningitis • Trauma/XRT • Drugs: anabolic steroids TESTES • Congenital: Klinefelters (XYY), developmental disorders • Infection: chlamydia, prostatitis. • Autoimmune • Tumors; chemo/XRT 2.STORAGE • Temperature • Rise in scrotal temperature • Varicocoele . DELIVERY: Impotence/Ejaculation ○Neurogenic: medications (α-blockers, methyldopa) ○Congenital: absence vas deferens (CF) ○Genetic ○Vasectomy HISTORY Infections: prostatitis, STD Trauma to testicles Surgery to testicles or hernia Chemo or Radio therapy Ethanol or Smoking Medication Previous investigations INVESTIGATIONS • semen analysis • At least 2 samples over different period of time • If abnormal: • Blood work: testosterone • Testicular U/S • Chromosomal analysis SEMEN ANALYSIS (WHO) • Volume > 2.0 mL • Sperm > 20 million/mL • Motility > 50% forward progression or > 25% rapid progression within 60 min • Morphology > 30% normal forms FEMALE INFERTILITY • Production • Storage • Delivery PRODUCTION • Hypothalamus • Pituitary • Ovary HYPO-PITUITARY GONADAL AXIS HYPOTHALAMUS • Stress • Congenital/genetic • Tumors (craniopharyngioma, metastatic tumor) • Head injury • Infection • XRT • Drugs PITUITARY Tumors: Pituitary adenoma, metastatic Inappropriate gonadal feedback ○estrogen excess: obesity/ tumors ○estrogen deficiency OVARY • XRT / Chemo for childhood malignancies • Premature ovarian failure STORAGE • Uterine abnormalities • Leiomyoma • Luteal phase deficiency DELIVERY • Uterine abnormalities • Tubal Disease • Infections/ STD/PID HISTORY Age Regulation of period Infections, Surgeries Medication, Smoking, Ethanol Medical history Previous investigations EXAMINATION • Abdomen (masses, scars) • Vaginal (abnormalities) • Bimanual (Uterus, masses) Blood work: FSH LH Luteal phase Progesterone Imaging: Pelvic Ultrasound (to ensure presence of organs) HSG (hysterosalpingography) Diagnostic Laparoscopy (later)