1. Infertility
Chapter 31

2. Definition
Strictly defined as the inability to conceive after one year of unprotected regular sexual intercourse
More workable definition: is any involuntary inability to conceive at the time desired

3. The definition expanded to include couples who conceive but repeatedly lose a pregnancy before the fetus is old enough to survive

4. Definitions Primary infertility Secondary infertility
Couples have never conceived
Secondary infertility
Couple may have conceived before but are unable to conceive again

5. Factors contributing to Infertility
Factors in man
1. Abnormalities of the sperm;
Twenty million sperm /milliliter of semen is considered minimum number adequate for fertilization
Abnormal structure or motility may reduce motility regardless of number
Some sperm look normal but unable to penetrate ovum

6. Factors impair function and # of sperm include
Abnormal hormonal stimulation of sperm production
Acute or chronic illness such as mumps,RF
Infection of genital tract
Anatomic abnormalities e.g. Varicocele or obstruction of ducts that carry sperm to penis
Exposure to toxins(lead, pesticides)

7. Therapeutic treatment (radiation ,antineoplastic)
Excessive alcohol intake
Use of illicit drug such as cocaine
Elevated scrotal temperature that may result for example from febrile illness, sauna , hot tub or prolonged sitting
Immunologic Factors by man or woman against sperm (autoantibodies)

8. 2. Abnormal Erections
Reduce man ability to deposit sperm,bearing seminal fluid in woman’s upper vagina near her cervix
Can be caused by physical and psychologic factors for example: CNS dysfunction caused by drugs, psychiatric disturbance or chronic illness.spinal cord disorders, peripheral vascular disease and drugs such as antihypertensive also reduce erections

9. 3. Abnormal Ejaculation
Prevent deposition of sperm in the ideal place to achieve pregnancy
Retrograde ejaculation such as with DM or nuerologic disorders Anatomic abnormalities such as hypospadias, Excessive alcohol
Premature ejaculation related to biological or psychologic disorders (Anxiety)

10. 4. Abnormalities of Seminal Fluids
Seminal fluid that is abnormal in amount (With each ejaculation during intercourse about million sperm are deposited in upper vagina and over cervix), consistency or chemical composition suggest obstruction, inflammation or infection
The PH of seminal fluids is slightly alkaline to protect sperm from acidic secretion of vagina
Adequate frouctose,citric acid and other nutrients must be present to provide energy for the sperm to move
Seminal fluid that remain thick impede sperm motility into cervix

11. Factors in the woman 1. Disorders of ovulation
Ovulation can be disrupted by
1. Dysfunction of hypothalamus or pituitary gland that alter secretion of GNRH,FSH,LH
2. Failure of ovaries to respond to FSH and LH stimulation
These two factors can be caused by many factors such as cranial tumors ,stress , obesity..etc
A few woman has a premature ovarian failure (early menopause)

12. Polycystic ovary Syndrome also affect fertility
Other factors include: Cancer chemptherapeutic agents, Excessive alcohol intake and cigarette smoking

13. 2.Abnormalities of fallopian tube
1. Tubal obstruction: scaring, adhesions, result from infection such as STD
2. Endometriosis
3. Congenital anomalies of the tube
4. Poor movement (motility of the distal end of the tube prevent ovum pickup and abnormal cilia actions prevent ovum transport)

14. 3. Abnormalities of Cervix
Low estrogen level prevent development of appropriate cervical mucus
Polyps or scaring from previous surgery may obstruct cervix
Surgical destruction of the mucus secreting gland and infection

15. Repeated pregnancy loss
1. Abnormalities of fetal chromosome
2. abnormalities of cervix or uterus may include
-Congenital malformation and stenosis
-Prenatelly exposure to DES: lead to uterine malformation or incopmetent cervix) -

16. -Uterine myomas or fibroid (may lead preterm birth)
Cervical or uterine abnormalities occurs after surgery
-Uterine myomas or fibroid (may lead preterm birth)

17. 3. Endocrine abnormalities
-inadequate progesterone secretion by corpus luteum
-hypothyroidism and hyperthyroidism
-poorly controlled diabetes
4. Immunologic factors
-rejection embryo
-SLE related to thrombosis

18. 5. Environmental agent
-Ionizing radiation,alcohol
-suspected toxins such as smoking ,mercury, lead, anesthetic gas, pesticides…..etc
6. Infections

19. Evaluation of Infertility
Preconception Counseling
Couples may be offered a preconception counseling to help them evaluate their risk of birth defects and reduce their risk of bearing child with serious birth defect
History and Physical Examination
General health history and extensive reproductive history which includes

20. Reproductive History
Woman's age at menarche and menstrual characteristics
Pattern of intercourse in relation to woman’s menstrual cycle
Contraceptive history
Previous pregnancies and their outcomes
Previous surgeries ,infection and serious illness or injuries
Previous fertility of the man or the woman with other partner

21. Reproductive history cont.
Length of time the couples has had unprotected intercourse
Exposure to potential toxins
Family history of multiple pregnancy losses ,birth defects ,mental retardation
Any home tests the couples has used ,such as ovulation predictor kits or BBT

22. Physical Examinations
Thorough physical examination of each partner may identify problems such as endocrine disorders ,infection or other chronic disease
Specific examination of reproductive organs may reveal structural defects ,infection ,or other conditions
Chromosomal analysis may be done for couple experiencing repeated pregnancy loss

23. Diagnostic Tests
Tests generally proceeds from simple to complex, and test is individualized according to each couple condition
Example of some tests done:
1.Basal body temperature Hormoneevaluation(estrogene,progestrone,LH,Fsh, and thyroid functions)
3.Ultra sound, Hystrosalpingograghy,endometrial biobsy,semen analysis,testicular biopsy

24. hysteroscopy

25. hysterosalpingogram

26. Therapies to Facilitate Pregnancy
Many Factors must be considered when identify therapy for treatment include couple’s history ,medical conditions, financial resources, age and time constrains,a and religious and cultural values
1. Medications
May be used for example to improve semen quality, reduce endometriosis, induce ovulation…..etc

27. 2. Ovulation induction
Used for woman who does not ovulate or who ovulate erratically
Also given to provide multiple ova if a woman plans to have intrauterine insemination,IVF,GIFT…
Clomide (Clomiphene citrate) is drug often used to stimulate follicles development
Complications
-Increase risk of multiple births (triplets or more)
-Ovarian hyperstimulating Syndrome syndrome(marked ovarian enlargement)

28. 3. Surgical procedures
Endoscopic procedures may be used to correct obstructions
Laparotomy may be needed to relieve pelvic adhesions and obstructions if not corrected by laparoscopy
Laser surgical techniques may be used to reduce adhesions
Correction of Varicocele by ligating or embolizing dilated vein, may improve sperm quality and quantity
Other measures may also used

29. 5. Therapeutic Insemination
Intrauterine inseminations (IUI), allows sperm to bypass cervical mucus and reduce immunologic incompatibility by injecting prepared sperm directly into uterus
Surrogate parenting and Egg donation( religiously not acceptable in our countries)

30. 5. Advanced Reproductive Techniques
1. Invitro Fertilization(IVF)
2. GIFT: Gamete Intrafallopian Tube Transfer
3. Zygote Intrafallopian tube transfer

31. Nur 342, Second Semestre
8/25/2018
Course coordinator : Khulod Barqawi

32. GIFT: Gamete Intrafallopian Tube Transfer
Nur 342, Second Semestre
8/25/2018
GIFT: Gamete Intrafallopian Tube Transfer
Course coordinator : Khulod Barqawi

33. Nur 342, Second Semestre
8/25/2018
Course coordinator : Khulod Barqawi