Infertility

Last updated 20.09.12

 

Index

 

Definition

-  Unable to conceive (pregnancy) after 12 months unprotected frequent (2-3+/week) intercourse

 

Features

-  Affects 10-15% couples

-  DDx sterility: absolute & irreversible inability to conceive

-  Conception Requires

-  Healthy egg, healthy sperm

-  Sperm transport to site of fertilization

-  Implanation in a receptive endometrium

-  Young couple: 20% chance/month of pregnancy

-  2 – 18 months to fall pregnant

-  Older couple: 10% chance/month of pregnancy

-  3 months – 4 years to fall pregnant

 

Causes

-  Possibly 50:50 male:female

-  Not uncommon to find path in both

-  15% causes non-identifiable

-  Malnutrition: coeliac disease

 

Hx

-  Children w current/past partners

-  Previous ART

-  Female

-  Infertility, menopause, contraception, amenorrhoea

-  Menstrual Hx

-  Irregular: PCOS

-  Prev pregnancies: ectopics, miscarriage, TOP (abortions)

-  Male

-  Trauma, testicular Ca

 

Mx

-  Intercourse during ovulatory period

-  BBT

-  Assisted Reproductive Technology (ART)

-  Clomid (Clomiphene)

-  Ovarian induction w Intrauterine insemination

-  Invitro Fertilation (IVF)

 

 

 

Male Infertility

<Infertility>

 

Mx

-   

 

Features

-  >80% men w infertility have low sperm counts, asthenozoospermia (decreased motility) w normal morphology on SFA

 

Causes

-  Hypothalamic pituitary disease (Secondary hypogonadism)

-  1-2% males w infertililty

-  Congenital

-   Congenital idiopathic hypogonadotropic hypogonadism (Kallmanns..)

-   Laurence-Moon-Biedl syndrome

-   Prader-Willi synrome

-   Familial cerebellar ataxia

-   Lowe oculocerebral sydrome

-  Acquired

-   Pituitary macroadenoma

-   Post surgery for macroadenomas or craniopharyngiomas

-   Infiltrative disease: sarcoidosis, histiocytosis, TB, fungal infection, haemochromatosis, transfusion siderosis

-   Vascular lesions: pituitary infarct, carotid aneurysm

-   Hormonal: hyperprolactinaemia, androgen excess, oestrogen excess, glucocorticoid excess

-  Systemic

-   Serious systemic illness

-   Chronic nutrional deficiency

-  Obesity

-  Testicular disease

-  30-40% males w infertililty

-  Primary Hypogonadism

-  Oligospermia

-  Azoospermia

-   Klinefelters syndrome (47XXY)

-  Y chromosome defects

-  Myotonic dystrophy

-  Cryptorchidism (undescended testis)

-  Varicocele (dilated pampiniform plexus): controversial

-  Occupational related (taix, truck driver..)

-  Acquired

-  Infection scarring: mumps orchitis

-  Chemotherapy, Ketoconazole, Cimetidine

-  Radiation

-  Toxins: dibromochlorpropane, lead, cadmium, mercury

-  Antisperm antibodies

-  Systemic illness: Coeliac disease, CRF, Cirrhosis, malnutrition

-  Post-testicular defects (sperm transport)

-  10-20% males w infertility

-  Epididymis

-  Absence, dysfunction or obstruction

-  Usually presents w isolated asthenospermia

-  Vas Deferens

-  Bilateral obstruction, ligation or altered peristalsis

-  Acquired

-   Infection: gonorrhoea, chlamydia, TB

-  Congenital

-    

-  Idiopathic

-  40-50% males w infertility

 

-  Male

-  Blockage of vas deferens or epididymis: CF (CBAVD)

-  Vasectomy reversal

-  Inadvertant Sx ligation during inguinal surgery (hernia repair..)

-  Retrograde ejaculation: bladder neck injury, lumbar SNS damage, MS

-  Inadequate hormonal stimulation of testis

-  (Ca)

-  Impotence & premature ejeculation

-  CF (CBAVD)

 

Ix

-  Physical exam

-  Testicle Ex

-  Vas deferens: CBAVD (CF)

-  SFA

 

 

 

Female Infertility

<Infertility>

 

Mx

-   

 

Causes

-  Production of healthy ovum: age

-  Sperm transport to site of fertilization

-  Implantation in a receptive endometrium

-  Immunological

-  Anti-sperm antibodies in cervical mucus, antiphospholipid antibodies

-  Hypothalamic

-  BMI, excess exercise, stress

-  Endocrine

-  Hyperprolactinaemia, hypothyroid

-  Ovarian

-  PCOS, premature ovarian failure

-  Anatomical

-  Tubal: PID (STI), rupture appendix, septic abortion, prev Sx, reverasal of tubal ligation

-  Endometriosis: inflammation, fibrosis, adhesions

-  Fibroid (Leiomyoma): distorted uterus, blocked tubes

 

Ix

-  Serum progesterone

-  7 days prior to expected date of period

-  Based on 14 day luteal phase

-  Ie: Day 21 on 28 day cycle or Day 25 on 32 day cycle

-  > 20-25nmol/L = ovulation

-  < 20nmol/L = anovulation or incorrect timing of test

-  TSH

-  Prolactin

-  BSL: DM

-  Ultrasound: septate uterus

-  +/- Hysterosalpingogram

-  +/- HyCoSy (Levovist)

-  +/- 17-OHPG: late onset CAH

 

 

 

References

 

Upto Date: Causes of Male Infertility, 05/02/2010

Australian Prescriber: Fertility Testing, 2002