In this unit of gynaecology all of aspects of fertility and associated diseases are described.

1. FERTILITY & INFERTILITY
(UNIT III)
SR. SUSMITA HALDER
TUTOR
SCHOOL OF NURSING ASIA HEART FOUNDATION

2. INTRODUCTION
The term 'subfertility' may be preferable to
infertility, as many of the bars to conception are
relative rather than absolute and in about 30%
of cases no cause is found.

3. INTRODUCTION
 People who are concerned about their fertility should be informed that
over 80% of couples in the general population will conceive within one
year if:
 the woman is aged under 40 years; and
 they do not use contraception; and
 they have regular sexual intercourse (every two to three days).
 Of those who do not conceive in the first year, about half will do so in the
second year (cumulative pregnancy rate over 90%).

4. INTRODUCTION
 Infertility may be due to problems with one or both
partners. Natural female fertility declines with age
and increasing maternal age is also associated with
increased obstetric risks and risk of miscarriage.
This should be noted by women who choose to
delay their family.

5. TERMINOLOGY
 Fertility is defined as a failure to conceive within one or more years
of regular unprotected coitus
 Primary infertility denotes the patients who have never conceived
 Secondary infertility indicates previous pregnancy but failure to
conceive subsequently
 Fecundability is defined as the probability Of achieving pregnancy
within one menstrual cycle. In a healthy young couple it is 20%
 Fecundity is the probability of achieving a life worth within a single
cycle

6. INCIDENCE
 80% of couples achieve conception if they so desire
within one year of having regular intercourse with
adequate frequency
 Another 10% will achieve the objective by the end
of second year search 10% Raman infidel by the
end of second year

7. FACTORS ESSENTIAL FOR CONCEPTION
 Healthy spermatozoa should be deposited in the vagina or at near the cervix
 The spermatozoa should undergo changes or capacitation acrosome reaction and aquire motility
 The spermatozoa should go through the cervix into the uterine cavity and the fallopian tubes
 There should be ovulation
 The fallopian tube should be patent and the suicide should be picked up by the scenery at end of the tu
 The spermatozoa should fertilizer suicide at the ampulla of the tube
 The embryo should reach the uterine cavity after three to four days of fertilization
 The endometrium should be receptive by oestrogen progesterone cytokines integrins for implantation
and Corpus luteum should function adequately

8. PHYSIOLOGICAL CONSIDERATION
 Due to an ovulation infertility is the prior to puberty after menopause but it
should be remembered that the girl may be pregnant even before menarche
and pregnancy is possible within few months of menopause conception is not
possible during pregnancy as the pituitary gonadal axis is suppressed by
human chorionic gonadotropin hence no ovulation and
 during lactation Infertility is said to be relative despite the fact that the
patient is our memory but during lactation ovulation and conception can
occur however it is fully elected woman pregnancy is unlikely upto 10 weeks
postpartum. (Breastfeeding 5 to 6 times a day and spending 60 minutes in 24
hours)

10. FEMALE
INFERTILITY

11. ETIOLOGY
 Causes of female infertility
 Disorders of ovulation
 They may occur at the level of pituitary or
hypothalamus as well as at the level of the ovary. If
there is amenorrhoea it should be investigated as
such and oligomenorrhoea along similar lines.

12. CLASSIFICATION
 The World Health Organization (WHO) classifies
ovulation disorders into three groups:
 Group I: hypothalamic pituitary failure
(hypothalamic amenorrhoea or hypogonadotrophic
hypogonadism).

13. CLASSIFICATION
Group II: hypothalamic-pituitary-ovarian
dysfunction (predominately polycystic ovarian
syndrome).
Group III: ovarian failure.

14. CLASSIFICATION
 Women with WHO Group I ovulation disorders:
 Should be advised that they can improve their chance
of regular ovulation, conception and an uncomplicated
pregnancy by:
 Increasing their body weight if their BMI is <19.
 Moderating their exercise levels if they undertake high
levels of exercise.

15. CLASSIFICATION
 Women with WHO Group II ovulation disorders:
 Should be advised to lose weight if their BMI is >30, as this alone may
restore ovulation, improve their response to ovulation induction agents,
and have a positive impact on pregnancy outcomes
 Those women taking clomifene citrate should have an ultrasound
monitoring during at least the first cycle of treatment to ensure that they
are taking a dose that minimises the risk of multiple pregnancy.

16. ETIOLOGY
According to FIGO manual 1990 causes are
Tubal & peritoneal factors 25-50 %
Ovulatory dysfunctions 30- 40 %
Endometriosis 1- 10%

17. ETIOLOGY
 Causes of ovarian failure:
 Pituitary tumours can displace or destroy normal tissue
and the production of follicle-stimulating hormone
(FSH) and luteinising hormone (LH) is often the first to
be affected. Panhypopituitarism is also called
Simmonds' disease.

18. ETIOLOGY
 Sheehan's disease is pituitary infarction following postpartum
haemorrhagic shock.
 Hyperprolactinaemia may present with galactorrhoea or
amenorrhoea. The control of prolactin (PRL) is unlike the other
releasing factors, in that it is controlled by an inhibiting rather than
a releasing factor from the hypothalamus into the hypothalamic-
pituitary portal circulation. It is also released in response to
thyrotropin-releasing factor, as is thyroid-stimulating hormone
(TSH), and so it is elevated if thyroxine is low.

19. ETIOLOGY
The pituitary gland may be responsible for
other disorders such as Cushing's syndrome.
A number of chromosomal disorders result in
inadequate ovarian function and usually
primary amenorrhoea.

20. ETIOLOGY
 Turner syndrome - There is a loss or abnormality of the
second X chromosome in at least one cell line in a
phenotypic female. The ovaries are usually just streaks.
This condition may be a mosaic.
 In testicular feminisation there is primary amenorrhoea.
The karyotype is XY but there is androgen insensitivity.
 XXY or Klinefelter's syndrome appears as a male.

21. ETIOLOGY
 The XXX karyotype - this is the most common
female chromosomal abnormality, occurring in
approximately 1 in 1,000 female births. While
fertility in women with trisomy X is generally
considered normal, there is an increased risk for
premature ovarian failure.

22. ETIOLOGY
Premature ovarian failure or premature
menopause (menopause that occurs <40
years, although many gynaecologists use <45
years) causes secondary amenorrhoea.
Premature ovarian failure occurs in about 1%
of women.

23. ETIOLOGY
Polycystic ovarian syndrome is usually,
but not always, associated with obesity.
Sclerocystic ovaries fail to ovulate but they
can be very sensitive to clomifene.

24. ETIOLOGY
 Luteal phase defect LPD
 In this condition there’s inadequate growth and function of
corpus luteum↪️ inadequate progesterone secretion ↪️hinders
implementation
 Decreased FSH LH elevated prolactin, subclinical
hypothyroidism, older women, dysfunctional uterine bleeding
↪️ defective folliculogenesis
 Luteinised unruptured Follicular syndrome or trapped ovum
is associated with pelvic endometriosis or with
hyperprolactinemia

25. ETIOLOGY
 Problems of tubes, uterus or cervix
 The Fallopian tubes are delicate structures whose
cilia waft the ovum, or even early embryo, to its
destination for implantation - more correctly called
nidation.

26. ETIOLOGY
 Damage to the tubes may occur as a result of infection:
 A history of pelvic inflammatory disease (PID) is highly suggestive of
damage to tubes.
 Severe pelvic infection following illegal abortion is rarely seen in this
country but still occurs in places where termination of pregnancy is
illegal or difficult to secure.
 Even a medical or spontaneous abortion can lead to infection of retained
products of conception.
 Postpartum infection can also affect fertility

27. ETIOLOGY
 Sexually transmitted diseases may cause infertility, largely
through associated PID:
 Chlamydia and gonorrhoea are the most important.
 Infection may be less direct, and spread from appendicitis
is possible, even without overt peritonitis.

28. ETIOLOGY
Female sterilisation operations involve
disruption of the tube and results of attempted
reversal are poor:
Laparoscopic proof of patency of the tubes is
not evidence that they function normally.

29. ETIOLOGY
Infection can also damage the uterus:
Adhesions in the uterus and cervix are called
Asherman's syndrome.

30. Deformity of the uterus, such as a septum or
bicornuate uterus, may be more likely to cause
recurrent abortion than failure to conceive:
Significant distortion of the uterine cavity by
fibroids can prevent implantation and hence
fertility, although the impact on fertility remains
a subject for debate.
ETIOLOGY

31. ETIOLOGY
 The cervix may have been shortened and damaged by a cone biopsy.
 There may be problems of cervical mucus, including hostility to sperm.
 Endometriosis may cause such inflammation, adhesion and distortion
in the pelvis that it causes tubal infertility:
 Even when it is much less severe than that, it is commonly associated
with subfertility.
 Whether or not minor degrees of endometriosis contribute to subfertility
is still debated.

33. SIGN & SYMPTOMS
 History
 Enquire about frequency of coitus (ideally two to
three times a week) and any prolonged or recurrent
absences of one of the partners.
 Ask about potential physical problems such as
inadequate penetration or dyspareunia.

34. SIGN & SYMPTOMS
 Medication history
 A thorough review of all medication is required with a view to both fertility and
possible adverse effects on pregnancy, including teratogenicity.

 Legal drugs taken for legitimate purposes may also cause problems:
 Phenothiazines and the older typical antipsychotics as well as
metoclopramide increase levels of PRL.
 Non-steroidal anti-inflammatory drug (NSAID) use is associated with
luteinised unruptured follicles.
 The patient may be taking drugs like immunosuppressants for autoimmune
disease or after transplantation.

35. SIGN & SYMPTOMS
 Past medical history
 Previous treatment for malignancy (chemotherapeutic agents, such as those used in
childhood leukaemia) may result in subsequent sterility. Surgery and radiotherapy
may be relevant if they involved the pelvic region.
 Systemic disease may impair fertility, probably by interference with the hypothalamic-
pituitary axis:
 This may include autoimmune disease such as rheumatoid disease or systemic lupus
erythematosus (SLE), although the latter - eg, antiphospholipid syndrome - may be
associated with recurrent abortion.
 Chronic kidney injury can impair fertility.
 Poorly controlled diabetes mellitus should be improved.

36. SIGN & SYMPTOMS
 General health
 Even in the absence of systemic illness, poor
general health will impair fertility. Enquire about
general lifestyle including smoking, alcohol and
drug use in addition to exercise and dietary intake.

37. EXAMINATION
 Look for signs of hirsutism:
 Facial hair may be more profuse than normal, although this should be
interpreted in the light of racial norms.
 Acne may also indicate high androgen levels.
 There may be a hint of male pattern alopecia with slight bitemporal
recession.
 The pubic hairline may extend up towards the umbilicus in a typical
male pattern

38. EXAMINATION
 Abdominal examination should be performed and it
must precede bimanual pelvic examination or it is
very easy to miss a large mass like a big ovarian
cyst.

39. EXAMINATION
 Gynaecological examination, especially vaginal examination,
may indicate undisclosed sexual difficulties - eg, vaginismus.

 Bimanual examination:
 May find an adnexal mass from an ovary of tubo-ovarian mass
or tenderness suggesting PID or endometriosis.
 Uterine fibroids can distort the uterus and interfere with
implantation.

46.  Aim for an ideal BMI:
 Women with a BMI of <19 and who have irregular menstruation or
are not menstruating should be advised that increasing body
weight is likely to improve their fertility.
 Women with a BMI of 30 should be informed that they are likely to
take longer to conceive and those who are not ovulating should be
informed that losing weight is likely to increase their chance of
conception.
PREVENTION

47.  Participating in a group programme involving exercise and
dietary advice, rather than receiving weight loss advice
alone, leads to more pregnancies.
 Smoking cigarettes impairs fertility and smoking in
pregnancy increases the risk of miscarriage, obstetric
complications, intrauterine growth restriction and even
delayed reading ability (at least to the age of 7).
PREVENTION

48.  Excessive alcohol consumption impairs fertility. Women who are
trying to become pregnant should be informed that drinking no
more than 1 or 2 units of alcohol once or twice per week and
avoiding episodes of intoxication reduce the risk of harming a
developing fetus.
 There is currently insufficient evidence for a strong association
between excessive caffeine consumption and poor pregnancy
outcomes, including infertility.
PREVENTION

49.  Illicit drugs should be avoided. Some have adverse effects
on fertility or the fetus or both and, for most, the question
of teratogenicity has not been adequately addressed.
Cannabis can impair ovulation and cocaine can cause
tubal infertility. There is also reason to be concerned about
the effect these drugs may have in pregnancy.
PREVENTION

50. Assisted conception
Assisted conception broadly refers to
procedures whereby treated or
manipulated sperm are brought into
proximity with oocytes
TREATMENT

51. TREATMENT
 It includes:
 Intrauterine insemination (IUI) with partner or donor
sperm (in natural or stimulated cycles)
 Gamete intrafallopian transfer (GIFT)
 In vitro fertilisation and embryo transfer (IVF-ET)
 Intracytoplasmic sperm injection (ICSI)

52. TREATMENT
 The Human Fertilisation and Embryology Authority (HFEA)
has published data showing that there are wide variations
in the success rates of IVF clinics. Success depends upon
numerous factors, including the woman's age, BMI,
previous pregnancy history and lifestyle factors. Around
25% of IVF treatments using a woman's own fresh eggs
result in a live birth.

53. TREATMENT
 Intrauterine insemination (IUI)
 IUI involves the introduction of prepared sperm into the uterine cavity around the time of
ovulation (spontaneous or induced).
 IUI can be considered as a treatment option in the following groups:
 People who are unable to, or would find it very difficult to, have vaginal intercourse because
of a clinically diagnosed physical disability or psychosexual problem, who are using partner or
donor sperm.
 People with conditions that require specific consideration in relation to methods of conception
(for example, after sperm washing where the man is HIV-positive).
 People in same-sex relationships.
 People with unexplained infertility, mild endometriosis or 'mild male factor infertility', who are
having regular unprotected sexual intercourse should no longer routinely be offered IUI, either
with or without ovarian stimulation. They should be considered for IVF if they have not
conceived after trying for two years.

54. TREATMENT
Gamete intrafallopian transfer (GIFT)
There is insufficient evidence to recommend
the use of GIFT or zygote intrafallopian
transfer in preference to IVF in couples with
unexplained fertility problems or male factor
fertility problems.

55. TREATMENT
 In vitro fertilisation and embryo transfer (IVF-ET)
 When IVF-ET is used:
 Women aged under 40 years should be offered three cycles.
 Those women who reach 40 years during treatment should not be offered further cycles.
 Women aged over 40 years should be offered one cycle of IVF as long as these women:
 Have never had IVF in the past.
 Have no evidence of low ovarian reserve.
 Have had a discussion of the additional implications of IVF and pregnancy at this age.
 When IVF is used and a top-quality blastocyst is available, a single embryo transfer is now recommended.
Currently, double embryo transfer in IVF is the most commonly used strategy in the UK. The new National
Institute for Health and Clinical Excellence (NICE) guidelines will change this and, in doing so, will maximise the
chance of pregnancy while minimising the risk of a multiple pregnancy.

56. TREATMENT
 Intracytoplasmic sperm injection (ICSI)
 In ICSI, a single sperm is injected directly into an oocyte. It should be
considered for those with severe deficits in semen quality, obstructive
azoospermia or those with non-obstructive azoospermia. In addition,
treatment by ICSI should be considered for couples in whom a previous
IVF treatment cycle has resulted in failed or very poor fertilisation.
 Where the indication for ICSI is a severe deficit of semen quality or non-
obstructive azoospermia, the man's karyotype should be established
(after genetic counselling).

57. TREATMENT
 Ovulation disorder treatment
 World Health Organization (WHO) Group I ovulation disorder is due to
hypothalamic pituitary failure (hypothalamic amenorrhoea or
hypogonadotrophic hypogonadism). These women should be advised that
they can improve their chance of regular ovulation, conception and an
uncomplicated pregnancy by increasing their body weight (for those with a
BMI of <19) and/or moderating their exercise levels (if they undertake high
levels of exercise). These women should be offered pulsatile administration of
gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone
activity to induce ovulation.

58. TREATMENT
 WHO Group II ovulation disorder is due to hypothalamic-
pituitary-ovarian dysfunction (predominately due to
polycystic ovarian syndrome). Clomifene citrate (CC) - an
anti-oestrogen - is an initial treatment for the majority of
these. Metformin (or a combination of clomifene and
metformin) can be also considered. However, those
women with a BMI of >30 should be advised to lose
weight before starting treatment.

59. TREATMENT
 Women who are known to be resistant to CC should
consider one of the following second-line treatments,
depending on clinical circumstances and the woman's
preference:
 Laparoscopic ovarian drilling (by laser or by diathermy)
 Combined treatment with CC and metformin
 Gonadotrophins

60. TREATMENT
 WHO Group III ovulation disorder is due to ovarian
failure - hypothalamic-pituitary failure (hypothalamic
amenorrhoea or hypogonadotrophic
hypogonadism). Women with ovulatory disorders
due to hyperprolactinaemia should be offered
treatment with dopamine agonists such as
bromocriptine.

61. TREATMENT
 General care
 The couple needs support and reassurance. It can be a very
difficult time for them, especially if there is pressure from parents
or in-laws, that may be more prominent in some cultures, but can
occur in all. Pregnancy probably will occur even without
intervention but they must not feel neglected or that nothing can be
done. There are many stories of couples who conceive after giving
up hope

62. TREATMENT
 Couples who have fertility problems should be
informed that they might find it helpful to contact a
fertility support group. Counselling may be
appropriate for some couples, as fertility problems
can cause psychological stress

63. TREATMENT
 Women intending to become pregnant should be informed
that dietary supplementation with folic acid (0.4 mg a day)
before conception and up to 12 weeks of gestation,
reduces the risk of having a baby with neural tube defects.
The dose should be 5 mg a day in those women who have
previously had an infant with a neural tube defect or those
receiving anti-epileptic medication or who have diabetes.

64. TREATMENT
Ovulation predictor kits should be
discouraged. Not only do they appear to be
ineffective, but making love should be a
spontaneous and amorous act, not dictated by
a calendar or a kit.

65. TREATMENT
 Where conventional medicine offers no help,
patients are often tempted by alternative therapies.
However, what little evidence there is suggests that
they are of no benefit and that, as they have not
been properly tested, they may even be
teratogenic.

69. MALE INFERTILITY

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