Dr Atin SinghaiAssistant Professor

Department of PathologyKGMU, Lucknow

Definition:1 yr unprotected coitus without conception

10-15% couples affected Etiology

Couples:○ 35% Tubal and pelvic pathology○ 35 % Male problems○ 15% Ovulatory dysfunction○ 10% Unexplained○ 5% unusual causes

Etiology◦ Women:

40% Tubal and pelvic pathology 40% Ovulatory dysfunction 10% Unexplained Infertility 10% Unusual causes

Normal couple:◦ 25-30% chance of pregnancy per ovulatory

cycle Fertility decreases with age

Time of Exposure % Pregnant

3 months 60%6 months 70%1 year 85%18 months 90%

DDX Tests/Inv Dx Rx

Production Storage Delivery

1. Production:◦ Hypothalamus◦ Anterior Pituitary◦ Testes

1. Production◦ Hypothalamus

Congenital abnormalities of hypothalamus e.g. Kallman’s syndrome

Starvation, stress or severe illness Tumors (craniopharyngioma, metastatic tumor) Head injury Inflammation (sarcoidosis) Infection (tuberculosis) Drugs: marijuana

1. Production:◦ Pituitary

Endocrine: thyroid, prolactin Tumors Inflammation: sarcoidosis, meningitis Infiltration Infarction Trauma/XRT Drugs: anabolic steroids

Production:◦ Testes:

Congenital: Klinefelters (XYY), developmental disorders

Disorders of gonadal steroidgenesis Infection: chlamydia, prostatitis, mumps orchitis Autoimmune Cryptorchidism Tumors; chemo/XRT Drugs / alcohol Vascular: testicular torsion

2. Storage:◦ Temperature

Rise in scrotal temperature Occupation Varicocoele

3. Delivery:Impotence/Ejaculation○ Neurogenic: medications (α-blockers,

methyldopa)○ Endocrine: diabetes○ Congenital: absence vas deferens (CF)○ Genetic: cystic fibrosis○ Primary ciliary dyskinesia: Kartagener syndrome○ Hypospadia○ Vasectomy

History:Previous childrenInfections: prostatitis, STD, mumps orchitisTrauma to head or testiclesSurgery to testicles or herniaOccupation (sitting, bio hazards)Chemo or Radio therapyEthanol or SmokingMedicationMedical history (DM, HTN)Previous investigations

Physical◦ Anatomy (meatus)◦ Testicular size◦ Varicocele (valsalva)◦ Rectal exam (protatitis, discharge)

Investigations:◦ semen analysis

Abstain 2-4 days prior At least 2 samples over different period of time

◦ If abnormal: Blood work: FSH, LH, TSH, testosterone, PRL Testicular U/S Chromosomal analysis

Semen analysis:◦ WHO (1992)

Volume > 2.0 mL Sperm > 20 million/mL Motility > 50% forward progression or

> 25% rapid progression within 60 min

Morphology > 30% normal forms WBC < 1 million/mL

Tx / Interventions:◦ Treat underlying causes◦ Intrauterine Insemination (IUI)◦ Intracytoplasmic Sperm Injection (ICSI)

Fecundability: probability of achieving a pregnancy within 1 menstrual cycle (25%)

Fecundity: ability to achieve a live birth within 1 menstrual cycle (6%)

Production Storage Delivery

Production:◦ Hypothalamus◦ Pituitary◦ Ovary

Hypothalamus:◦ Stress◦ Exercise◦ Eating disorders◦ Psychogenic◦ Congenital/genetic: Kallman’s syndrome (hyposmia &

hypoplasia olfactory lobes of brain)◦ Starvation/stress or severe illness◦ Tumors (craniopharyngioma, metastatic tumor)◦ Head injury◦ Inflammation (sarcoidosis)◦ Infection (tuberculosis)◦ XRT◦ Drugs

Pituitary:Sheehan syndromeTumors: Pituitary adenoma, metastaticEmpty sella syndromeInappropriate gonadal steroid feedback:○ estrogen excess: obesity/ tumors○ estrogen deficiency: aromatase deficiency/ ER

gene mutation○ androgen excess: adrenal or ovarian○ PCOS

Testicular feminization (46 XY) - absence androgen receptors

Ovary◦ Gonadal dysgenesis - Turner’s Syndrome 45XO or

mosaics 46 XX/45 XO◦ Testicular feminization◦ XRT / Chemo for childhood malignancies◦ Premature ovarian failure

Storage (R.P.L. unless severe)◦ Uterine abnormalities◦ Mullerian Agenesis: Mayer-Rokitansky-Kuster-

Hauser syndrome◦ Leiomyoma ◦ Luteal phase deficiency

Delivery:◦ Uterine abnormalities◦ Vaginal septum◦ Tubal Disease

Infections/ STD/PID Ruptured appendix Septic abortion

◦ Endometriosis

History:AgeGTPALRegulatory of periodProlactin S/SThyroid S/SInfections, SurgeriesMedication, Smoking, EthanolMedical history Previous investigations

Examination:◦ Thyroid◦ Breast (milk)◦ Abdomen (masses, scars)◦ Vaginal (abnormalities)◦ Bimanual (Uterus, masses)

Blood work:TSHPRLD3 FSHD3 LHLuteal phase Progesterone

Imaging:Pelvic UltrasoundHSG

DiagnosticLaparoscopy (later)

Treat the underlying cause Medical Surgical

Anovulation:◦ Clomiphene induction IUI◦ Gonadotropin IUI

IVF◦ Bilateral tubal disease◦ Unexplained infertility after Gonadotropin + IUI

failure.◦ Failure of the above

ICSI◦ Male factor◦ Unexplained infertility

DDx – Hx – Px – Inv - Rx Age is important factor for female Hypothalamic-Pituitary-Gonadal axis central

in working up both male and female infertility

Investigations:◦ Male: Sperms◦ Female: Tubes (HSG) + Ovaries (FSH, LH, PRL,

TSH)

Infertility is defined as unprotected coitus for ___ months, without conception :

a.3b.6c. 9d.12

Spermatogenesis and sperm maturation is regulated by :

a.Leydig Cellsb.Sertoli Cellsc. Vas Deferensd. Intermediate Cells

Cause/s of male infertility is / are :a.Kallaman’s syndromeb.Craniopharyngiomac. Marijuana abused.All of the above

Normal semen count is ___ million / mla.≥ 15b.≥ 20c. ≥ 25d.≥ 30

Indication/s for semen analysis is / are :a. Investigation for infertilityb.to check effectiveness of vasectomyc. for selection of donor for artificial

inseminationd.All of the above

Thank you