Female reproductive system & male and female infertility

LEARNING OBJECTIVES
1. PHYSIOLOGICAL ANATOMY.
2. THE MONTHLY OVARIAN CYCLE
3. HORMONES INFLUENCING THE
FEMALE REPRODUCTIVE SYSTEM
Dr. Misbah-ul-Qamar

FEMALE REPRODUCTIVE SYSTEM
• Female’s role in reproduction is more
complicated than the male’s. The essential
functions include:-
Production of ova, reception of sperm and their
transport to a common site for union
(fertilization)
Maintenance of the developing fetus (gestation
or pregnancy).
Formation of placenta that serves as the organ of
exchange between mother and fetus.
Parturition (delivering the baby)
Nourishing the infant after birthDr. Misbah-ul-Qamar

PHYSIOLOGICAL ANATOMY OF FEMALE
REPRODUCTIVE ORGANS
• Female Reproductive Organs Include the
Ovaries and Accessory Sex Organs.
Dr. Misbah-ul-Qamar

Function of Female Reproductive
System
• Produce sex hormones
• Produce functioning gametes [ova]
• Support & protect developing embryo.
Dr. Misbah-ul-Qamar

General Physical Changes
• Axillary & pubic hair growth
• Changes in body conformation [widening
of hips, development of breasts]
• Onset of first menstrual period [menarche]
• Mental changes
Dr. Misbah-ul-Qamar

Major Organs
• Ovaries [ gonads]
• Uterine tubes [ fallopian tubes]
• Uterus
• Vagina
• Accessory glands
• External genitalia
• Breasts
Dr. Misbah-ul-Qamar

OVARIES
• Each ovary is about the size and shape of an
almond.
• In young women the ovaries are about 1½ - 2
inches long, 1 inch wide & 1/3 inch thick.
After menopause they tend to shrink.
• They produce eggs (also called ova) - every
female is born with a lifetime supply of eggs.
• They also produce hormones:
Estrogen & Progesterone
Male Homolog = testesDr. Misbah-ul-Qamar

FALLOPIAN TUBES.
• Stretch from the uterus to the ovaries and measure
about 8 to 13 cm in length.
• Range in width from about one inch at the end next to
the ovary, to the diameter of a strand of thin spaghetti.
• The ends of the fallopian tubes lying next to the ovaries
feather into ends called fimbria.
Dr. Misbah-ul-Qamar

• Millions of tiny hair-like cilia line the fimbria
and interior of the fallopian tubes.
• The cilia beat in waves hundreds of times
a second catching the egg at ovulation
and moving it through the tube to the
uterine cavity.
• Fertilization typically occurs in the fallopian
tube
Dr. Misbah-ul-Qamar

UTERUS
• Pear-shaped muscular organ in the upper
female reproductive tract.
• The fundus is the upper portion of the uterus
where pregnancy occurs.
• The cervix is the lower portion of the uterus that
connects with the vagina and serves as a
sphincter to keep the uterus closed during
pregnancy until it is time to deliver a baby.
• The uterus expands considerably during the
reproductive process. the organ grows to from
10 to 20 times its normal size during pregnancy.
Dr. Misbah-ul-Qamar

UTERUS
• The main body consists of a firm outer coat of
muscle (myometrium) and an inner lining of
vascular, glandular material (endometrium).
• The endometrium thickens during the
menstrual cycle to allow implantation of a
fertilized egg.
• Pregnancy occurs when the fertilized egg
implants successfully into the endometrial
lining. If fertilization does not occur, the
endometrium sloughs off and is expelled as
menstrual flow.
Dr. Misbah-ul-Qamar

UTERUS
• Functional zone – layer closest to the
cavity – contains majority of glands.
Thicker portion – undergoes changes with
monthly cycle
• Basal zone – layer just under myometrium,
attaches functional layer to myometrial
tissue, has terminal ends of glands.
Remains constant
Dr. Misbah-ul-Qamar

UTERINE ARTERIES
• Arcuate arteries - encircle endometrium
• Radial arteries – connect arcuate to
straight
• Straight arteries – deliver blood to basilar
zone
• Spiral arteries – deliver blood to functional
zone
Dr. Misbah-ul-Qamar

CERVIX
• The lower portion or neck of the uterus.
• The cervix is lined with mucus, the quality and quantity of
which is governed by monthly fluctuations in the levels of
the estrogen and progesterone.
• When estrogen levels are low, the mucus tends to be
thick and sparse, hindering sperm from reaching the
fallopian tubes. But when an egg is ready for fertilization,
estrogen levels are high, the mucus then becomes thin
and slippery, offering a “friendly environment” to sperm
• At the end of pregnancy, the cervix acts as the passage
through which the baby exits the uterus into the vagina.
The cervical canal expands to roughly 50 times its
normal width in order to accommodate the passage of
the baby during birth
Dr. Misbah-ul-Qamar

VAGINA
• vagin = sheath
• a muscular, ridged sheath connecting the
external genitals to the uterus.
• Functions as a passageway for sperms
and serves as the birth canal.
Dr. Misbah-ul-Qamar

MAMMARY GLANDS
• Present in both sexes - normally only functional in
females.
• Developmentally they are derived from sweat glands.
• Contained within a rounded skin-covered breast anterior
to the pectoral muscles of the thorax.
• Slightly below center of each breast is a ring of
pigmented skin, the areola - this surrounds a central
protruding nipple.
• Internally - they consist of 15 to 25 lobes that radiate
around and open at the nipple.
• Each lobe is composed of smaller lobules- these contain
alveoli that produce milk when a women is lactating.
• Non-pregnant women - glandular structure is
undeveloped - hence breast size is largely due to the
amount of fat deposits.
Dr. Misbah-ul-Qamar

GLANDS
• Lesser Vestibular (Paraurethral, Skene's)
( Male Homolog = prostate) located on the upper
wall of the vagina, around the lower end of
the urethra. They drain into the urethra
and near the urethral opening
• Function - mucus production to aid
lubrication during intercourse
Dr. Misbah-ul-Qamar

GLANDS
• Greater Vestibular (Bartholin's) (Male
Homolog = bulbourethral glands) located slightly
below and to the left and right of the
opening of the vagina. They secrete
mucus to provide lubrication.
Dr. Misbah-ul-Qamar

PHYSIOLOGIC Anatomy OF FEMALE
REPRODUCTIVE SYSTEM
• The principle organs include:-
OVARIES:- lie within the pelvic cavity.
OVIDUCTS:- 2 oviduct (uterine or fallopian tubes)
lie in close association with the ovaries. It is the
site for fertilization.
UTERUS:- Thick walled hollow organ. Responsible
for maintaining the fetus during development
and expelling it out at the end of pregnancy.
VAGINA:- A muscular expandable tube that
connects uterus to external environment. .
Dr. Misbah-ul-Qamar

CERVIX:- The lowest portion of uterus. It
contains a small opening  CERVICAL CANAL.
Dr. Misbah-ul-Qamar

Oogenesis
• It is a series of steps through which a
developing egg differentiates into a mature
egg.
• The process completes itself in 2 phases:
– Phase I
– Phase II
Dr. Misbah-ul-Qamar

Phase I
• Phase I: Starts during early embryonic
development of female fetus & ends by the 5th
month of fetal development.
• What is achieved in phase I? formation of
primary oocyte & only 1st stage of meiosis!
• At birth: ovary contains about 1-2 million
primary oocytes
Dr. Misbah-ul-Qamar

Phase II
• Development of egg to maturity after puberty
• comprises of 2 divisions of meiosis.
• The phase starts with 1st meiotic division of
oocyte which occurs after puberty.
• In this division: each oocyte divides into 2 cells:
– A large ovum
– A small 1st polar body
• 2nd division: as a result of this division, sister
chromatids separate from each other in the same
cell
Dr. Misbah-ul-Qamar

Relation of oogenesis with ovulation
• Ovulation is the release of ovum from the ovary
• Before ovulation, the ovum is in an arrested state
of pause in meiosis
• After ovulation, If the ovum is fertilized, the final
step in meiosis occurs
• This final step dispatches the sister chromatids of
ovum to separate cells
– Half remain in fertilized ovum
– Other half are released in a 2nd polar body which then
disintegrates.
Dr. Misbah-ul-Qamar

Outcome of Oogenesis
• At puberty, only about 300,000 oocytes
remain in the ovaries.
• Only a small percentage of these oocytes
become mature.
• Many thousands of oocytes that do not
mature, degenerate.
Dr. Misbah-ul-Qamar

Female reproductive years
• Between about 13 and 46 years of age.
• During these years of adult life, 400-500 of
primordial follicles develop enough to expel
their ova
• Only one ovum is expelled each month
• Remainder of developing follicles become
acretic by degeneration
Dr. Misbah-ul-Qamar

Menopause
• It is the end of female reproductive capability.
• What happens at follicular level?
• Only a few primordial follicles remain in the
ovaries, and even these follicles degenerate
soon thereafter.
Dr. Misbah-ul-Qamar

FEMALE HORMONAL SYSTEM
• Normal reproduction in females is achieved through
monthly rhythmical changes in rates of secretion of
female hormones & corresponding physical changes in
ovaries & other sexual organs.
• Hormonal system consists of 3 hierarchies of
hormones:
1. GnRh (Gonadotropin-releasing hormone)
2. Anterior pituitary sex hormones (Gonadotropins)
3. Ovarian hormones
These various hormones are secreted at drastically
differing rates during different parts of monthly sexual
cycle.
Dr. Misbah-ul-Qamar

GnRH
• It is a releasing hormone from hypothalamus
• FSH & LH are secreted in response to its
release
• It is formed in the hypothalamus & then
transported to anterior pituitary gland by way
of hypothalamic-hypophysial portal system.
Dr. Misbah-ul-Qamar

• Secreted in short(5-25 minutes) pulses
averaging once every 90 minutes(1-2hours)
stimulate pulsatile release of LH
• The pulsatile nature of GnRH release is
essential to its functions
• If it is infused continuously, its ability to cause
the release of LH & FSH is lost
Dr. Misbah-ul-Qamar

Hypothalamic centers for GnRH
release
• Neuronal activity that causes its release occurs
primarily inarcuate nuclei of medio-basal
hypothalamus
• Additionally neurons in preoptic area of
anterior hypothalamus also secrete GnRH in
moderate amounts
Dr. Misbah-ul-Qamar

Psychic control of GnRH
• Multiple neuronal centers in higher brain’s
limbic system transmit signals into arcuate
nuclei modify both the intensity of GnRH
release & the frequency of pulses
• That’s how the psychic factors often modify
female sexual function.
Dr. Misbah-ul-Qamar

GONADOTROPINS
(female sex hormones)
• Ovarian changes during sexual cycle depend
completely on gonadotropins(FSH &LH)
• During childhood, almost no pituitary
gonadotropins are secreted ovaries remain
inactive
• At age 9-12, pituitary begins to secrete
progressively more FSH & LH onset of normal
monthly sexual cycle (menarche) beginning b/w
ages 11 & 15(puberty).
• During each cycle, there is a cyclical increase &
decrease of FSH & LH cyclical ovarian changes.
Dr. Misbah-ul-Qamar

Functions of gonadotropins
• Both FSH & LH have stimulatory effects on
target ovarian cells:
• Increase in cells’s rate of secretion
• Growth & proliferation of target cells
ovaries begin to grow
Dr. Misbah-ul-Qamar

Ovarian sex hormones
• CHEMISTRY: STEROID HORMONES.
ESTROGEN:
, ESTRIOL, ESTRONE.
PROGESTERONE:
PROGESTERONE, 17 OH
PROGESTERONE.
Dr. Misbah-ul-Qamar

FEMALE REPRODUCTIVE
HORMONES:
Dr. Misbah-ul-Qamar

SYNTHESIS
• from
– mainly Cholesterole (derived from blood)
– Acetyl coenzyme A (to a slight extent)
• PROGESTERONE AND androgens
FORMED BY THE OVARIES 
CONVERTED TO ESTROGEN BY THE
GRANULOSA CELLS (not theca cells) IN
THE FOLLICULAR PHASE (by action of
aromatase).
Dr. Misbah-ul-Qamar

Production of estrogens
Dr. Misbah-ul-Qamar

Transport of estrogens & progesterone
• Transported in blood bound with:
– Mainly albumin
– Specific estrogen & progesterone binding
globulins
• This binding is loose enough to release the
hormones to tissues over a period of 30
minutes or so.
Dr. Misbah-ul-Qamar

Fate of ovarian sex hormones
ESTROGEN & PROGESTERONE
ELIMINATED BY THE LIVER.
Dr. Misbah-ul-Qamar

Role of liver in ovarian hormone
degradation
• It conjugates the estrogens
– 1/5 of conjugated estrogen is excreted in bile,
remainder in urine
• Coverts potent estrogens (estradiol & estrone)
into almost totally impotent estrogen (estriol)
– Diminished liver function increased activity of
estrogens in body hyperestrinism
• It degrades progesterone to other steroids
with no progestational effect.
Dr. Misbah-ul-Qamar

FEMALE REPRODUCTIVE
HORMONES:
• FUNCTIONS OF THE ESTROGEN:
ON UTERUS AND EXTERNAL FEMALE
SEXUAL ORGANS.
ON THE FALLOPIAN TUBULES.
ON THE BREASTS.
ON THE SKELETON.
ON PROTEIN DEPOSITION.
Dr. Misbah-ul-Qamar

FEMALE REPRODUCTIVE
HORMONES
• ON BODY METABOLISM AND FAT
DEPOSITION
• ON HAIR DISTRIBUTION.
• ON SKIN.
• ON ELECTROLYTE BALANCE.
Dr. Misbah-ul-Qamar

FEMALE REPRODUCTIVE
HORMONES:
• FUNCTIONS OF PROGESTERONE:
ON UTERUS.
ON FALLOPIAN TUBULES.
ON THE BREASTS.
Dr. Misbah-ul-Qamar

Monthly ovarian cycle
(less accurately called menstrual
cycle)
Function of the gonadotropic
hormones
Dr. Misbah-ul-Qamar

Introduction to Ovarian cycle
• This cycle corresponds to physical changes in
ovaries & other sexual organs
• Duration: 28 days (average)
• Abnormal cycle length is frequently associated
with decreased fertility
• Gonadotropic hormones cause 8-12 follicles to
begin to grow in ovaries…….
Dr. Misbah-ul-Qamar

Effect of gonadotropins on ovaries
Follicular development in the ovaries
• Reproduction begins with formation of ova in
the ovaries.
• Every month a single ovum is expelled from
ovarian follicle, which passes through the
fallopian tubes into the uterus, if fertilization
occurs, it is implanted in the uterus, where it
develops into fetus, otherwise it undergoes
degeneration.
Dr. Misbah-ul-Qamar

Introduction to ovarian cycle
• About every 28 days, gonadotropic hormones cause 8-
12 new follicles to begin to grow in ovaries.
• During the growth,estrogen is secreted.
• One of follicles become mature & ovulates.
• After ovulation, corpus luteum is formed by secretory
cells of ovulating follicle
• CL secretes progesterone & estrogen for 2 weeks &
then degenerate
• Menstruation begins upon this degeneration & a new
cycle follows.
Dr. Misbah-ul-Qamar

Ovarian cycle
DEFINITION
• The normal cycle that includes development
of an ovarian follicle, rupture of the follicle,
release of the ovum, and formation and
regression of a corpus luteum
• PHASES OF OVARIAN CYCLE
1.Follicular phase
2.Luteal phase
Dr. Misbah-ul-Qamar

Follicular phase
“The phase of ovarian cycle dominated by the
presence of maturing follicles”
It shows the progressive stages of follicular
growth in ovaries.
Dr. Misbah-ul-Qamar

FOLLICULAR PHASE
A cohort of follicles begin to develop.
The others, lacking hormonal support
undergo atresia.
During this phase the primary oocyte is
synthesizing and storing material for future
use.
Dr. Misbah-ul-Qamar

When a female child is born
PRIMORDIAL FOLLICLE
Each ovum is surrounded by a thin layer of cells
the granulosa cells
The ovum with this granulosa cell layer is known as
PRIMORDIAL FOLLICLE.
At puberty pulsatile release of GnRH causes the
release of FSH & LH, under the effect of which
some ovarian follicles to grow.
Ovum increases twofold to threefold in diameter,
followed by additional layer of granulosa cells.
called as PRIMARY FOLLICLE
Dr. Misbah-ul-Qamar

At puberty
 pulsatile release of GnRH causes the
release of FSH & LH, under the effect of
which some ovarian follicles to grow.
Ovum increases twofold to threefold in
diameter, followed by additional layer of
granulosa cells. called as PRIMARY FOLLICLE
Dr. Misbah-ul-Qamar

The follicular phase includes:-
1.Proliferation of granulosa cells and formation
of zona pellucida
2.Proliferation of thecal cells and estrogen
secretion
3.Formation of antrum
4.Formation of a mature follicle
5.Ovulation
Dr. Misbah-ul-Qamar

1.PROLIFERATION OF GRANULOSA LAYER AND
FORMATION OF ZONA PELLUCIDA
• Single layer of granulosa cells proliferate to form
several layers that surround the oocyte and
separate it from the surrounding cells.
• This innervating membrane is known as ZONA
PELLUCIDA.
Dr. Misbah-ul-Qamar

PROLIFERATION OF THECAL CELLS AND
ESTROGEN SCRETION
• As oocyte enlarges and granulosa cells
proliferate, the ovarian connective tissue cells
in contact with granulosa cells proliferate and
differentiate to form an outer layer of thecal
cells.
• FOLLICULAR CELLS
• The thecal cells and granulosa cells are
collectively called follicular cells.
• They function as a unit to secrete estrogen.
Dr. Misbah-ul-Qamar

FORMATION OF ANTRUM
• The fluid filled cavity that forms in a developing
ovarian follicle.
• This stage is characterized by formation of a fluid
filled cavity in the middle of granulosa cells.
• The follicular fluid originates from two sources:-
1.Transudation of plasma (through capillary pores)
2.Partially from follicular cells secretion
• At the time of antrum formation the oocyte has
reached its maximum size and this is the period
of rapid follicular growth.Dr. Misbah-ul-Qamar

FORMATION OF MATURE FOLLICLE
• One of the follicle grows rapidly than the
others, developing into mature ( preovulatory,
tertiary, or Graffian) follicle within 14 days
after the onset of follicular development.
• The antrum occupies most of the space in
mature follicle.
• The oocyte surrounded by zona pellucida and
a single layer of granulosa cells, is displaced
asymmetrically at one side of growing follicle
Dr. Misbah-ul-Qamar

OVULATION
It is the release of a mature ovum form a mature
ovarian follicle.
• Rupture of follicular cells to release ovum is
facilitated by the enzymes released from
follicular cells that digest the connective tissue
in the wall.
• The ovum is swept out of the follicular cells by
the antral fluid into the abdominal cavity.
• The released ovum is quickly withdrawn into
the oviduct where fertilization may or may not
take place. Dr. Misbah-ul-Qamar

Necessary factor for ovulation---a
surge of luteinizing hormone
• LH is necessary for final follicular growth &
ovulation
• Without this hormone, even when large
quantities of FSH are available, the follicle will
not progress to the stage of ovulation.
• Mechanism responsible for LH surge:
• About 2 days before ovulation, rate of LH
secretion increases markedly (rising 6-10 fold
& peaking about 16 hours before ovulation)
Dr. Misbah-ul-Qamar

Causes of LH surge
1. Positive feedback effect of estrogen on LH (&
to lesser extent FSH) secretion.
1. This effect is in sharp contrast to normal –ve
feedback effect of estrogen during remainder of
cycle.
2. Increasing quantities of progesterone from
granulosa cells (a day or so before LH
surge) could possibly stimulates the excess
LH secretion
Dr. Misbah-ul-Qamar

How to assess if ovulation has occured
• Urine analysis in latter half of cycle
– Measurement for a surge in pregnanediol (end
product of progesterone metabolism)
– Lack of this substance indicates ovulation failure
• Charting of body temperature throughout the
cycle.
– Secretion of progesterone during latter half raises
body temperature about 0.5oF
Dr. Misbah-ul-Qamar

Initiation of ovulation
Dr. Misbah-ul-Qamar

LUTEAL PHASE OF OVARIAN CYCLE
• This phase of ovarian cycle dominated by the
presence of corpus luteum.
• The ruptured follicle left behind changes rapidly.
• The thecal and granulosa cells left behind
collapse into the emptied antrum that has been
partially filled up with blood vessels..
Dr. Misbah-ul-Qamar

The luteal phase includes
1.Formation of corpus luteum and secretion of
progesterone and estrogen
2.Degeneration of corpus luteum
Dr. Misbah-ul-Qamar

FORMATION OF CORPUS LUTEUM
• Corpus means body and luteum means yellow.
• It is an ovarian structure that develops from a
ruptured follicle following ovulation.
• The follicular cells are transformed into corpus
luteum
• The follicular turned luteal cells are converted
into very active steroidogenic tissue.
• The abundant presence of cholesterol, steroid
precursor molecule and lipid droplets within the
corpus luteum gives it a yellowish appearance.
Dr. Misbah-ul-Qamar

• Progesterone secretion followed by secretion
of estrogen in follicular phase makes the
uterus a suitable site for implantation of
fertilized ovum
Dr. Misbah-ul-Qamar

Results of female sexual cycle
1. Only a single ovum is normally released from
the ovaries each month only a single fetus
will begin to grow at a time.
2. The uterine endometrium is prepared in
advance for implantation of fertilized ovum
at the required time of month.
Dr. Misbah-ul-Qamar

DEGENERATION OF CORPUS LUTEUM
• If the released ovum is not fertilized the corpus
luteum degenerates within 14 days after its
formation.
• The luteal cells degenerate and are phagocytized.
• The blood supply is withdrawn and connective
tissue fills in to form a fibrous tissue mass known
as corpus albicans, white mass.
• The luteal phase is now over and one ovarian
cycle is complete.
• If fertilization and implantation do occur, the
corpus luteum is not degenerated , but itDr. Misbah-ul-Qamar

Cause of corpus luteum involution
Loss of feedback inhibition of pituitary
• How anterior pituitary gland is uninhibited?
– Sudden cessation of secretion of estrogen &
progesterone
– Inhibin by corpus luteum
• Pituitary inhibition causes it to begin secreting
increasing amounts of FSH & LH.
Dr. Misbah-ul-Qamar

Effects of involution
• The final involution occurs at end of 12 days of
corpus luteum life (26th day of cycle, 2 days
before menstruation.
1. Increasing FSH & LH initiate the growth of new
follicles beginning a new ovarian cycle.
2. Menstruation by uterus due to paucity of
progesterone, estrogen secretion.
Dr. Misbah-ul-Qamar

Uterine CYCLE OR MENSTURAL CYCLE
• “The cyclical changes in the uterus that
accompany the hormonal changes in the
ovarian cycle”.
• The cyclical changes in the uterus results in
the menstrual bleeding once during each
menstrual cycle (once a month).
• Bleeding lasts for about five to seven days
after degeneration of corpus luteum.
Dr. Misbah-ul-Qamar

Phases
• Menstrual cycle coincides in timing with the
early phase of ovarian follicular phase..
• It consists of the following phases:-
The menstrual phase
(menstruation)
The proliferative phase
The secretory/progestational
phase.
Dr. Misbah-ul-Qamar

THE MENSTURAL PHASE
• It is characterized by discharge of blood and
endometrial debris form vagina.
• It is considered to be the start of a new
OVARIAN CYCLE, as it coincides with the end
of LUTEAL PHASE and onset of the
FOLLICULAR PHASE.
• Cause: involution of corpus luteum in ovary.
Dr. Misbah-ul-Qamar

PROLIFERATIVE PHASE (estrogen phase)
• The proliferative phase is characterized by
repair and proliferation of endometrium.
• The endometrial surface is re-epitheliallized
within 4-7 days after beginning of
menstruation
Dr. Misbah-ul-Qamar

Why named estrogen phase
• Estrogen plays a key role by stimulating
endometrium to proliferate.
• Estrogen is secreted in increasing quantities by
ovary during 1st part of ovarian cycle
Dr. Misbah-ul-Qamar

Effects of estrogen in proliferative
phase
• Its stimulation causes the proliferation of
epithelial cells and blood vessels
• Stromal cells also proliferate rapidly
• during next week & a half (before ovulation),
endometrium increases greatly in thickness
resulting in a net thickness of 3 to 5mm of the
endometrium due to increase in:
– Stromal cells
– Growth of endometrial glands
– New endometrial BVs
Dr. Misbah-ul-Qamar

Proliferative phase
• It occurs before ovulation, coincides with the
last part of follicular phase.
Importance of endometrial proliferation:
• At the beginning of each monthly cycle, most
of endometrium has been desquamated by
menstruation
– Only a thin layer of endometrial stroma remains
– Only epithelial cells that are left are those located
in remaining deeper portions of glands/crypts
Dr. Misbah-ul-Qamar

There is an additional advantage also
• Endometrial glands (especially those of
cervical region) secrete thin stringy mucus
mucus strings align themselves along the
length of cervical canal forming channels
that help guide sperm in proper direction
from vagina to uterus.
Dr. Misbah-ul-Qamar

Secretory phase
• That makes the latter half of monthly cycle
• This coincides with the luteal phase of ovarian
cycle.
Dr. Misbah-ul-Qamar

SECRETORY OR PROGESTational phase
• After ovulation, when corpus luteum is
formed the uterus enters secretory or
progestational phase.
• Corpus luteum secretes progesterone (mainly)
& estrogen.
• Progesterone converts the thickened estrogen
primed endometrium into glycogen filled
tissue.
Dr. Misbah-ul-Qamar

Peak of secretory phase
• The peak occurs about 1 week after ovulation
• During this part of cycle, endometrium has a
thickness of 5-6mm due to:
• Progesterone induced effects
• Estrogen induced effects (slight additional
cellular proliferation)
Dr. Misbah-ul-Qamar

Progesterone induced effects
• Marked swelling of endometrium
• Endometrial secretory development
• Glands increase in tortuosity
• Accumulation of an excess of secretory
substances in glandular epithelial cells
• Cytoplasmic increase in stromal cells (not only
glycogen but lipids also deposit)
• Proportional (secretory activity) increase in blood
supply
• BVs become highly tortuous
Dr. Misbah-ul-Qamar

• This phase is called the secretory phase
because the endometrial glands are
secreting glycogen or the progestational
(before pregnancy), referring to the
development of an endometrial lining
capable of supporting an early embryo.
Dr. Misbah-ul-Qamar

Purpose of endometrial changes
• To produce a highly secretory endometrium
that contains large amounts of stored
nutrients
• To provide appropriate conditions for
implantation of fertilized ovum (in blastocyst
stage)
• Availability of great quantities of nutrients to
early implanting embryo
Dr. Misbah-ul-Qamar

Uterine milk
• A name given to the uterine secretions.
• It provides nutrition for the early dividing
ovum until it implants.
• After implantation (7-9 days after ovulation),
trophoblastic cells absorb endometrial stored
substances
Dr. Misbah-ul-Qamar

• If fertilization and implantation do not occur
the corpus luteum degenerates and new
follicular phase and menstrual cycle starts
Dr. Misbah-ul-Qamar

Menstruation
• It occurs if the ovum is not fertilized.
• Cause: low levels of ovarian hormones
(estrogen & progesterone)
Dr. Misbah-ul-Qamar

Changes occuring in menstrual phase
• Reduction in estrogens & progesterone
Decreased stimulation of endometrial cells by
ovarian hormones involution of
endometrium (to about 65% of its previous
thickness) vasospasm in mucosal layers of
endometrium by vasoconstrictor
prostaglandins (involution induced release)
necrosis of endometrium & its BVs.
Dr. Misbah-ul-Qamar

Causes of endometrial necrosis
– Vasospasm
– Decrease in nutrient supply
– Loss of hormonal stimulation
Dr. Misbah-ul-Qamar

Outcome of endometrial necrosis
• Due to this necrosis, blood seeps into vascular
endometrial layerhemorrhagic areas grow
rapidly (over a period of 24-36 hours) necrotic
outer layers of endometrium separate from the
uterus
• The separation occurs at the sites of
hemorrhages.
• As a result, the superficial layers of endometrium
are desquamated (about 48 hours after the onset
of menstruation.
Dr. Misbah-ul-Qamar

How uterine contractions start during
menstruation
• These contractions are responsible for the
expulsion of uterine contents which are:
• Mass of desquamated tissue
• Blood in uterine cavity
• These contents & certain contractile
substances cause the contraction
Dr. Misbah-ul-Qamar

Degeneration of corpus luteum
Decreased level of estrogen and
progesterone
Decreased level of ovarian hormone
stimulates release of prostaglandin
prostaglandin causes vasoconstriction of
endometrial vessels, disrupting the blood supply
to endometrium
Dr. Misbah-ul-Qamar

reduced O2 supply to endometrium causes
its death including the blood vessels
This resulting bleeding alongwith
endometrial debris from the uterine cavity is
known as Menstrual flow.
Dr. Misbah-ul-Qamar

Menstrual fluid
• Approximately 40ml of blood & an additional
35ml of serous fluid are lost normally.
• Menstrual fluid is non-clotting.
Dr. Misbah-ul-Qamar

After Menstruation
• Within 4-7 days, loss of blood ceases.
• Reason: by this time, endometrium has
become re-epithelialized.
Dr. Misbah-ul-Qamar

Leukorrhea During Menstruation
Dr. Misbah-ul-Qamar

Regulation of females????
• Females have got a monthly rhythm which
causes certain cyclical variations
• The mechanism responsible for these
variations is the interplay b/w ovarian &
hypothalamic-pituitary hormones.
Dr. Misbah-ul-Qamar

OVERALL MECHANISM
① the hypothalamus secretes GnRH, which
causes the anterior pituitary gland to secrete
LH & FSH.
②Negative feedback effects of estrogen &
progesterone to decrease LH & FSH secretion
③Positive feedback effect of estrogen before
ovulation the preovulatory luteinizing
hormone surge
Dr. Misbah-ul-Qamar

MONTHLY OVARIAN CYCLE
Dr. Misbah-ul-Qamar

Anovulatory cycles
• When does this occur?
– The 1st few cycles after the onset of puberty
– Cycles occuring several months to years before
menopause
Cause
• LH surge is not potent enough.
Dr. Misbah-ul-Qamar

How does an anovulatory cycle
proceeds?
The phases of cycle continue but they are
altered in following ways:
1. Lack of ovulation causes failure of
development of corpus luteum
2. Cycle is shortened by several days, but the
rhythm continues
Dr. Misbah-ul-Qamar

Abnormalities of ovarian secretion
Dr. Misbah-ul-Qamar

Hypogonadism
Irregular menses
Hypersecretion by ovaries
Dr. Misbah-ul-Qamar

Abnormal ovarian cycle
• The quantity of estrogens must rise above a
critical value to cause rhythmical cycles
• Irregularity occurs when the gonads are
secreting small quantities of estrogens.
• This could be a result of:
– Menopause
– Other factors causing hypogonadism, such as
hypothyroidism
Dr. Misbah-ul-Qamar

Effects of irregular cycle
• Several months may elapse b/w menstrual
periods
• Menstruation may cease altogether
(amenorrhea)
• Failure of ovulation (insufficient LH for
preovulatory surge)
Dr. Misbah-ul-Qamar

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.”
Dr. Misbah-ul-Qamar

origin of problem:
–35% female
–35% male
–20% both partners
–10% unexplained
Dr. Misbah-ul-Qamar

MALE EITIOLOGY
• Idiopathic
• Infection – genito-urinary tract,mumps
• Genetic/systemic disease
• Endocrine
• Immunologic
• Obstruction
• Developmental
Dr. Misbah-ul-Qamar

FEMALE ETIOLOGY
• Unexplained
• DEVELOPMENT
• Cervical
• Endometrial/uterine
• Pelvic
• Tubal
• Genetic
Dr. Misbah-ul-Qamar

Approach to infertility
• Production
• Storage
• Delivery
Dr. Misbah-ul-Qamar

Production:
–Hypothalamus
–Anterior Pituitary
–Testes
Dr. Misbah-ul-Qamar

Hypothalamic-Pituitary-Gonadal Axis
Dr. Misbah-ul-Qamar

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, Dr. Misbah-ul-Qamar

PITUITARY
• . Endocrine: prolactin
• Tumors
• Inflammation: meningitis
• Trauma/XRT
• Drugs: anabolic steroids
Dr. Misbah-ul-Qamar

TESTES
• Congenital: Klinefelters (XYY),
developmental disorders
• Infection: chlamydia, prostatitis.
• Autoimmune
• Tumors; chemo/XRT
Dr. Misbah-ul-Qamar

2.STORAGE
–Temperature
• Rise in scrotal temperature
• Varicocoele
Dr. Misbah-ul-Qamar

. Delivery:
Impotence/Ejaculation
○Neurogenic: medications (α-blockers,
methyldopa)
○Congenital: absence vas deferens (CF)
○Genetic
○Vasectomy
Dr. Misbah-ul-Qamar

HISTORY
• Previous children
Infections: prostatitis, STD
Trauma to testicles
Surgery to testicles or hernia
 Chemo or Radio therapy
Ethanol or Smoking
Medication
Previous investigations
Dr. Misbah-ul-Qamar

• Physical
–Morphology
–Testes having normal head, neck and tail
Dr. Misbah-ul-Qamar

INVESTIGATIONS
–semen analysis
–At least 2 samples over different period of
time
–If abnormal:
• Blood work: testosterone
• Testicular U/S
• Chromosomal analysis
Dr. Misbah-ul-Qamar

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
Dr. Misbah-ul-Qamar

Female sterility
About 5-10% of women are infertile!
Dr. Misbah-ul-Qamar

Cause of female infertility
• Abnormality in genital tract
• Abnormal physiological function of genital
system
• Abnormal genetic development of ova
• Ovulation failure is the most common cause
Dr. Misbah-ul-Qamar

Classification of causes of FEMALE INFERTILITY
• Production
• Storage
• Delivery
Dr. Misbah-ul-Qamar

PRODUCTION
–Hypothalamus
–Pituitary (hyposecretion of gonadotropic
hormones failure to ovulate due to
insufficient hormonal stimuli)
–Ovary
Dr. Misbah-ul-Qamar

HYPOTHALAMUS
• Stress
–Congenital/genetic
–Tumors (craniopharyngioma, metastatic
tumor)
–Head injury
–Infection
–XRT
–Drugs
Dr. Misbah-ul-Qamar

PITUITARY
Tumors: Pituitary adenoma, metastatic
Inappropriate gonadal feedback
○estrogen excess: obesity/ tumors
○estrogen deficiency
○Pituitary hyposecretion can be treated
by appropriately timed administration
of hCG.
Dr. Misbah-ul-Qamar

OVARY
–XRT / Chemo for childhood malignancies
–Premature ovarian failure
–Thick ovarian capsules occasionally exist on
the outside of ovaries, making ovulation
difficult.
Dr. Misbah-ul-Qamar

STORAGE
–Uterine abnormalities
–Leiomyoma
–Luteal phase deficiency
Dr. Misbah-ul-Qamar

DELIVERY
–Uterine abnormalities (most common is
endometriosis)
–Tubal Disease (common cause is salpingitis)
–Infections/ STD/PID
Dr. Misbah-ul-Qamar

Endometriosis
• Endometrial tissue almost identical to that of
normal uterine endometrium grows (& even
menstruate) in the pelvic cavity.
• Common sites for the development of
endometriosis are surrounding the uterus,
fallopian tubes & ovaries.
Dr. Misbah-ul-Qamar

Effects of endometriosis
• This situation causes fibrosis throughout the
pelvis which sometimes so enshrouds the
ovaries that an ovum cannot be released in
abdominal cavity
• Endometriosis also occludes the fallopian
tubes, either at fimbriated ends or elsewhere
along their extent.
Dr. Misbah-ul-Qamar

How salpingitis could cause infertility
• It is inflammation of fallopian tubes which
causes fibrosis occlusion
• Gonococcal infection used to lead to
salpingitis in past but it has become less
prevelent due to modern therapy.
Dr. Misbah-ul-Qamar

Mucus related infertility
• Still another cause of infertility is secretion of
abnormal mucus by uterine cervix
• In this case, failure of fertilization occurs due
to a viscous mucus plug
• Formation of such abnormal consistency of
mucous could result due to:
– Low grade infection /inflammation of cervix
– Abnormal hormonal stimulation of cervix
Dr. Misbah-ul-Qamar

• Ordinarily, at the time of ovulation, the
hormonal environment of estrogen causes the
secretion of mucus with special characteristics
that allow rapid mobility of sperm into uterus.
• This environment actually guides the sperm
up along mucous threads
Dr. Misbah-ul-Qamar

HISTORY
Age
Regulatory of period
Infections, Surgeries
Medication, Smoking, Ethanol
Medical history
Previous investigations
Dr. Misbah-ul-Qamar

EXAMINATION
–Abdomen (masses, scars)
–Vaginal (abnormalities)
–Bimanual (Uterus, masses)
Dr. Misbah-ul-Qamar

Blood work:
FSH
 LH
Luteal phase Progesterone
Imaging:
Pelvic Ultrasound (to ensure presence of
organs)
HSG (hysterosalpingography)
Diagnostic
Laparoscopy (later)Dr. Misbah-ul-Qamar

PREGNANCY TEST
• Beta HCG
• LH
• FSH
Dr. Misbah-ul-Qamar

Female reproductive system & male and female infertility

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Female reproductive system & male and female infertility

Similar to Female reproductive system & male and female infertility (20)

More from DrMisba

More from DrMisba (10)

Recently uploaded

Recently uploaded (20)