Dr. Alexandru Radu Pintilie

INFERTILITY (male and female) FEMALE INFERTILITY Infertility is defined as 1 year of unprotected intercourse without pregnancy 10-15% of reproductive –age couples. Statistically, conception rate ( monthly fecundability) is about 20%( age dependent). More than 60% of normal couples will conceive within 6 months, about 90% within 1 year and the remainder by the end of the second year. Classification: -primary infertility -secondary infertility

FEMALE INFERTILITY Primary infertility- if conception has never occured. Secondary infertility- if there has been at least one pregnancy before. Sterility- the conception is impossible and the etiologic factor is irremediable. The phyisician’s initial encounter with the infertile couple (”biologic unit”) is the most important one …(history of illness, complete phisical examination of the female…)…

FEMALE INFERTILITY Causes of infertility - male factor25-40% - female factor40-55% - both10% - unexplained infertility 10% Causes of female infertility - Ovarian factor % -Tubal/peritoneal factor % -Miscellaneus factors (cervical, uterin,immunologic) % -Unexplained infertility %

FEMALE INFERTILITY Ovarian factor Etiology: - complete absence of ovarian function (gonadal dysgenesis, premature ovarian failure, tumors, radiation) - can be considered sterile. - polycystic ovarian syndrome (PCO)-80% - luteinised unruptured follicle (LUF) - luteal phase defect (LPD) Diagnosis (Ovulation detection): midluteal serum progesterone, serum LH, endometrial biopsy, ultrasound monitoring, basal body temperature( BBT), tests of the cervical mucus.

FEMALE INFERTILITY Diagnosis ( Luteal phase defect) : luteal duration, BBT charts, serum progesterone and metabolites, serum prolactin, ovarian ultrasonography, endometrial biopsy. Treatment- a). medical induction of ovulation - b). Surgical treatment for polycystic ovaries. a). – Clomiphene citrate - HMG ( Human Menopausal Gonadotropin) - R.a. = ovarian hyperstimulation and multiple gestation - purified FSH

FEMALE INFERTILITY a).- LPD treatement : - luteal phase progesteron supplementation - clomiphane citrate b).- ovarian wedge resection - ovarian electrocautery - ovarian diathermy - ovarian laser vaporisation

FEMALE INFERTILITY Tubal - peritoneal factor Phisiology… Etiology : - tubal factors= damage or obstruction of fallopian tubes ( PID, pelvic surgery, endometriosis, tubal malformations); - peritoneal factors= peritubal and periovarian adhesions( PID, surgery, endometriosis, subclinical chlamydial infections). Diagnosis : clinical examination, HSG, histeroscopy, laparoscopy, laparascopy-salpingoscopy,

FEMALE INFERTILITY Treatment - correction of periadnexal disease; - correction of proximal, distal or combined tubal disease; - correction of iatrogenic tubal abnormalities ( e.g. tubal sterilization).

FEMALE INFERTILITY Cervical factor Phisiology… Etiology : - phisical blockage - interference with mucus production - immunological factors Diagnosis : postcoital test ( hormonal abnormalities, anatomic factors, infections, medication-e.g. clomiphene,antisperm antibodies). Treatment : antibiotherapy, ovulation induction- HMG or pure FSH.

FEMALE INFERTILITY Uterine factor Phisiology… Etiology : malformation, uterine fibroids, Asherman’s syndrome ( intrauterine adhesions). Diagnosis : HSG, histeroscopy. Treatment : surgery ( myomectomy, resection of septate uteri, curetage, etc).

FEMALE INFERTILITY Unexplained infertility it is, by definition, a diagnosis of exclusion. Etiology : mild forms of POD, LPD, cornual polips, endometrial abnormalities, poor mucus production, morfological abnormalities of the sperm, retrograde ejaculation. Treatment : empirical - ovulation induction - assisted reproductive technologies ( in vitro fertilisation, gamete intrauterine or intrafallopian transfer ).

MALE INFERTILITY Male factor is involved in 40% of the cases and in about 10% it reprezents the cause together with the female. Male fertility peaks at about 35 years of age and declines sharply after 45. Etiology : a) - genetic - developmental abnormalities – all are accompanied by azoospermia : cryptorchidism ( late or no testes descent), Klinefelter’s syndrome, XX- syndrome,… b) - defective steroidogenesis in the testicles ( e.g. in adrenal hyperplasia);

MALE INFERTILITY c) - infections : mumps orchitis ; d) - vascular abnormalities : varicocele ( about 10-15%) or local raised temperature ; e) - immunological factors : serum antibodies against spermatozoal surface antigens ; f) - neurological causes : medullar lesions ( e.g. paraplegia ) ; g) - environmental toxins and drug exposure :radiations, raised temperature, cigarette smoching, heavy coffee, marijuana, cocaine, anabolic steroids… h) - endocrine disorders : diabetes mellitus,… i) - anatomical abnormalities : hypospadias, prostatic surgery, distrophy.

MALE INFERTILITY Diagnosis - Complete history - Physical examination - Investigations : seminal analysis ( eventualy repeated two times at 2-3 weeks intervals ), postcoital test, in vitro sperm penetration test, plasma FSH, LH, testosterone, Clomiphene stimulation test, testicular biopsy, tests of fertilising capacity of spermatozoa, semiography, antispermatozoal antibodies, ultrasound examination of the testicles, tyroid and adrenal investigations.

MALE INFERTILITY Treatment Medical therapy : - Gn-RH – used in hypogonadotropic hypogonadal males, hypotalamic dysfunction, panhypopituitarism; - Antibiotics in infection; - Reduced consumption of alcohol, cigarettes… Surgical therapy : - varicocele-corrective procedures ; - artificial insemination.