Infertility - B. Pharma 2nd Semester Pathophysiology notes pdf
Infertility
Content
- Infertility
- Definition
- Causes
- Evaluation of the Infertile couple
- Abnormalities of Spermatogenesis
- Evaluation of Ovulation
- Diagnosis
Objectives
At the end of this PDF Notes, students will be able to -
• Define primary and secondary infertility
• Describe the causes of infertility
Infertility
• The inability to conceive following unprotected sexual intercourse
– 1 year (age < 35) or 6 months (age >35)
– Affects 15% of reproductive couples
• 6.1 million couples
– Men and women equally affected
• Reproductive age for women
– Generally 15-44 years of age
– Fertility is approximately halved between 37th and 45th year due to alterations in ovulation
– 20% of women have their first child after age 30
– 1/3 of couples over 35 have fertility problems
• Ovulation decreases
• Health of the egg declines
Primary infertility
– a couple that has never conceived
Secondary infertility
– infertility that occurs after previous pregnancy regardless of outcome
Requirements for Conception
• Production of healthy egg and sperm
• Unblocked tubes that allow sperm to reach the egg
• The sperms ability to penetrate and fertilize the egg
• Implantation of the embryo into the uterus
• Finally a healthy pregnancy
Causes for infertility
• Male
– ETOH
– Drugs
– Tobacco
– Health problems
– Radiation/Chemotherapy
– Age
– Enviromental factors
• Pesticides
• Lead
• Female
– Age
– Stress
– Poor diet
– Athletic training
– Over/underweight
– Tobacco
– ETOH
– STD’s
– Health problems
Causes of Infertility
• Anovulation (10-20%)
• Anatomic defects of the female genital tract (30%)
• Abnormal spermatogenesis (40%)
• Unexplained (10%-20%)
Evaluation of the Infertile couple
• History and Physical exam
• Semen analysis
• Thyroid and prolactin evaluation
• Determination of ovulation
– Basal body temperature record
– Serum progesterone
– Ovarian reserve testing
• Hysterosalpingogram
Abnormalities of Spermatogenesis
Male Factor
• 40% of the cause for infertility
• Sperm is constantly produced by the germinal epithelium of the testicle
– Sperm generation time 73 days
– Sperm production is thermoregulated
• 1° F less than body temperature
• Both men and women can produce anti-sperm antibodies which interfere with the penetration of the cervical mucus
Semen Analysis (SA)
• Obtained by masturbation
• Provides immediate information
– Quantity
– Quality
– Density of the sperm
• Abstain from coitus 2 to 3 days
• Collect all the ejaculate
• Analyze within 1 hour
• A normal semen analysis excludes male factor 90% of the time
Normal Values for SA
Volume - 2.0 ml or more
Sperm Concentration- 20 million/ml or more
Motility - 50% forward progression
25% rapid progression
Viscosity - Liquification in 30-60 min
Morphology - 30% or more normal forms
pH - 7.2-7.8
WBC - Fewer than 1 million/ml
Causes for male infertility
• 42% varicocele
– repair if there is a low count or decreased motility
• 22% idiopathic
• 14% obstruction
• 20% other (genetic abnormalities)
Abnormal Semen Analysis
• Azospermia
– Klinefelter’s (1 in 500)
– Hypogonadotropic-hypogonadism
– Ductal obstruction (absence of the Vas deferens)
• Oligospermia
– Anatomic defects
– Endocrinopathies
– Genetic factors
– Exogenous (e.g. heat)
• Abnormal volume
– Retrograde ejaculation
– Infection
– Ejaculatory failure
Evaluation of Ovulation
Menstruation
• Ovulation occurs 13-14 times per year
• Menstrual cycles on average are Q 28 days with ovulation around day 14
• Luteal phase
– dominated by the secretion of progesterone
– released by the corpus luteum
• Progesterone causes
– Thickening of the endocervical mucus
– Increases the basal body temperature (0.6° F)
• Involution of the corpus luteum causes a fall in progesterone and the onset of menses
Ovulation
• A history of regular menstruation suggests regular ovulation
• The majority of ovulatory women experience
– fullness of the breasts
– decreased vaginal secretions
– abdominal bloating
– mild peripheral edema
– slight weight gain
– depression
• Absence of PMS symptoms may suggest anovulation
Anovulation
Symptoms
• Irregular menstrual cycles
• Amenorrhea
• Hirsuitism
• Acne
• Galactorrhea
• Increased vaginal secretions
Evaluation*
• Follicle stimulating hormone
• Lutenizing hormone
• Thyroid stimulating hormone
• Prolactin
• Androstenedione
• Total testosterone
• DHEAS
*Order the appropriate tests based on the clinical indications
Anatomic Disorders of the Female Genital Tract
Sperm Transport, Fertilization, & Implantation
• The female genital tract is not just a conduit
– facilitates sperm transport
– cervical mucus traps the coagulated ejaculate
– the fallopian tube picks up the egg
• Fertilization must occur in the proximal portion of the tube
– the fertilized oocyte cleaves and forms a zygote
– enters the endometrial cavity at 3 to 5 days
• Implants into the secretory endometrium for growth and development
Congenital Anatomic Abnormalities
Unexplained infertility
• 10% of infertile couples will have a completely normal workup
• Pregnancy rates in unexplained infertility
– no treatment 1.3-4.1%
– clomid and intrauterine insemination 8.3%
– gonadotropins and intrauterine insemination 17.1%
Summary
• Infertility is the inability to conceive following unprotected sexual intercourse
• Infertility should be evaluated after one year of unprotected intercourse
• Primary infertility - a couple that has never conceived
• Secondary infertility - infertility that occurs after previous pregnancy regardless of outcome
• History and Physical examination usually will help to identify the etiology.
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