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INFERTILITY
DEFINITION of Infertility
What is Infertility?
Infertility is defined two years of unprotected
intercourse without pregnancy.
(WHO, one year)
Primary Infertility : no previous pregnancies
have occurred;
Secondary Infertility: a prior pregnancy has
occurred;
Causes
Causes
Female factors
Male factors
Both male and
female factors
unexplained factors
Percentage
40-55 %
25-40 %
10 %
10 %
Female Factors
Ovulatory dysfunction:
1. Hypothalamic dysfunction;
2. Pituitary Insufficiency;
3. Ovarian factor (peripheral defect);
4. Others: thyroid or adrenal dysfunction;
Pelvic factorsP:
1. Tubal factors: injury, blockage, adhesion;
2. Uterine factors;
3. Cervical factors;
4. Extra-genital tract factors;
Female Factors
Hypothalamus
Pituitary
Follopian tube
Uterine
ovary
oocyte
Cervix
Extra-genital tract
sperm
Thyroid Adrenal
Male Factors
1. Abnormal spermatogenesis
congenital;
chronic diseases;
infectious factors;
2. Obstructive;
3. Immunologic factors;
4. Endocrine disorders;
5. Sexual dysfunction;
Both Male and Female Factors
1. No demonstrable cause;
2. Psychological factors;
3. Immunologic factors;
count for 10%;
autoimmune response;
auto-antibodies;
Initial Visit
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The initial visit is the most important;
The infertility is a problem of couple;
The male partner should be present;
History: both male and female;
The guide to diagnostic and treatment plans;
Examinations
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Physical examination;
Bimanual examination
Rectal-Vaginal-examination
Laboratory;
Assistant imaging;
Examinations
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Laboratory:
semen analysis
hormone measurement;
sperm penetration assay (SPA)
postcoital examinition of cervical mucus
immunologic examination;
Assistant imaging :
Unltrasound
Hysterosalpingogram
Hysteroscopy
Laparoscopy
Examination and Diagnoses
Initial evaluation
History
Physical exam
Irregular menses
No ovulation
HSG
Tubal blockage
anovulation
Tubal factor
Normal
evaluation
unexplained
HSG or
Hysteroscopy
Abnormal of
uterine
Uterine factor
Further Investigate and Treatment
Abnormal
Semen
analysis
Male factor
Normal Values for Semen Analysis
Volume
Sperm concentration
Motility
morphology
Data from WHO, 1992
> 2.0 mL
> 20 million/mL
>50 %
>30 % normal
Methods to monitor ovulation
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Luteinizing Hormone monitoring:
LH surge;
after 34-36 hr occur ovulation;
Basal Body Temperature: simple, cheap,
biphasic pattern;
Mid-luteal serum progesterone: > 3ng/mL, peak;
Premenstrual molimina: 95% presence;
Mucus change: thick and cellular, no crystalline fern;
Ultrasound monitoring: follicle size 21-23 mm,
fluid in the cul-de-sac.
Treatment-female factor
Causes
anovulation
Tubal factor
Anatomic factor
immunologic
azoospermia
genetic disease
after surgery
unexplained
Treatment
induction of ovulation；
tuboplasty,
microsurgery；
medication or surgery；
immune inhibition；
Assisted Reproductive Technologies
(ART)
Induction of ovulation
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1. Clomiphen ：ER binding GnRH ,FSH/LH
dosage：50 mg, period day 5th， 5days；
2. Gonadotropin therapy ：
Indications:
Hypogonadotropic hypogonadism;
Pituitary dysfunction;
COH (controlled ovarian hyperstimulation) in IVF;
HMG: human menopausal gonadotropins;
FSH 75 IU/LH 75 IU, IM or SC;
Recombinant FSH: 75 IU, SC;
3. HCG: 5000-10000 IU;
Induction of ovulation
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4. Gonadotropin releasing hormone agonist
(GnRH-a)：hypothalamic factor, as COH;
protocol: according the every GnRH-a
component and feature, the time of
start and discontinuation are different;
zoladex; decapeptyl, dipherenline,
enantone;
5. GnRH antagonist;
6. Bromocriptine 溴隐停: high PRL;
Assisted Reproductive
Technologies (ART)
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Intrauterine insemination ( IUI)
In vitro fertilization and embryo
transfer
(IVF-ET) Intracytoplasmic sperm
injection (ICSI);
Gamete intrafallopian transfer
(GIFT)
Intrauterine insemination
( IUI)
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Indications:
1. as treatment of male factor infertility;
2. psychological factors;
3. unexplained infertility;
4. genetic defects;
Types:
1. artificial insemination with husband’s sperm (AIH);
2. artificial insemination by donor (AID);
Method:
placement of about 0.3 ml of washed, processed
and concentrated sperm into the intrauterine cavity
by trans-cervical catheterizaion.
In vitro fertilization and embryo
transfer (IVF-ET)
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Indications:
1. tubal factor;
2. endometriosis;
3. unexplained infertility;
4. IUI failure;
5. Immunologic factors;
Method:
1. Superovulation: COH, GnRH-a/FSH(HMG)/HCG;
2. Aspiration of eggs;
3. Fertilization with capacitated sperm;
4. Culture of fertilized egg in the lab;
5. Replacement of fertilized egg into the uterus;
Gamete intrafallopian
transfer (GIFT)
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Indications:
1. unexplained infertility;
2. endometriosis;
3. IUI failure;
4. Premature ovarian failure (POF);
5. Immunologic factors;
Method:
1. Superovulation is induced as IVF-ET;
2. HCG injection is given;
3. Follicle are aspirated via laparoscopy;
4. Sperm mixed with egg;
5. Replacement of fertilized egg into fallopian tube;
ART Complications
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Multiple gestations
Pre-eclampsia
Ovarian hyperstimulation syndrome
(OHSS)
Premature birth
Low birth weight
Long term emotional, social and
psychological impact