INFERTILITY

MA. TERESA C. LITA, MD

MARCH 15, 2025
DEFINITION

- Inability of a couple to conceive after 1 year of trying

- After 6 months, if:
- > 35 years old
- oligo/amenorrhea
- known tubal obstruction
- uterine disease
- severe endometriosis
- known male factor
DEFINITION

- approximately only 50% of the couples will conceive in 3

months, 75% will conceive in 6 months, and by 1 year
approximately 90% will have conceived

fecundability: monthly conception rate (20% for “normal”

couples)
impaired fecundity: a more general term applying to all
women who have difficulty conceiving or carrying a pregnancy
to term
unexplained infertility: no specific diagnosed cause of
infertility
DEFINITION

- Data from both older and more recent studies have

indicated that the percentage of infertile couples increases
with increasing age of the female partner
CAUSES

- Ovulatory disorders : 27%

- Male factors: 25%
- Tubal disorders: 22%
- Endometriosis: 5%
- Other: 4%
- Unexplained Factors:17%.
DIAGNOSTIC EVALUATION
MENSTRUAL PHYSIOLOGY
COUPLE’S MEDICAL HISTORY

- Type of infertility (primary or secondary) and its duration

- History of previous pregnancies and their outcomes;
- History of previous infertility evaluation/treatment
- Female menstrual history
- Male medical history
COUPLE’S MEDICAL HISTORY

- Couple’s history of sexually transmitted diseases (STDs);

surgical contraception (eg, vasectomy, tubal ligation);
lifestyle; consumption of alcohol, tobacco, and recreational
drugs (amount and frequency); occupation; and physical
activities
- History of abdominal or pelvic surgery
- History of chemotherapy or radiation
COUPLE’S MEDICAL HISTORY

- Couple’s current medical treatment (if any), reason, and

any history of allergies
- Complete review of systems to identify any endocrinologic
or immunologic issue that may be associated with infertility
COUPLE’S PHYSICAL EXAMINATION

- Vital Signs
- Height/weight
- Head and neck assessment
- Breast evaluation
- Abdominal evaluation
- Dermatologic evaluation
COUPLE’S PHYSICAL EXAMINATION

- Thorough gynecologic evaluation

- Speculum examination
- Bimanual examination
- Extremities evaluation
COUPLE’S PHYSICAL EXAMINATION

- The urologist usually examines the male partner if the

patient's history of his semen analysis produces an
abnormal finding.
- Attention should be directed to congenital abnormalities of
the genital tract (eg, hypospadias, cryptorchid, congenital
absence of the vas deferens).
- Testicular size, urethral stenosis, and presence of
varicocele are also determined.
- A history of previous inguinal hernia repair can indicate an
accidental ligation of the spermatic artery
DOCUMENTATION OF OVULATION

- History of regular monthly cycles

- LH kits (“ovulation kits”)
- Mid luteal serum progesterone > 10 ng/ml (some books: 3
ng/ml)
- BBT (basal body temperature)
- Endometrial biopsy
- Ultrasound/ follicle monitoring
- Pregnancy – the best evidence of ovulation
BASAL BODY TEMPERATURE (BBT)

- Indirect evidence that

ovulation has taken place
- Provides information about
the approximate day of
ovulation and duration of the
luteal phase.
BASAL BODY TEMPERATURE (BBT)

- Temp should be taken

shortly after awakening, only
after at least 6 hours of
sleep and prior to
ambulating, with sublingual
placement of a special
thermometer with gradients
between 96oF and 100oF
URINARY LUTEINIZING HORMONE DETERMINATION/
“LH KITS”/”OVULATION KITS”
- Identifies midcycle LH
surge
- Provides indirect evdence
of ovulation
- Helps define interval of
greatest fertility: the day of
LH surge and the next day
- Best done using midday
urine specimen
ENDOMETRIAL BIOPSY

- Also called “endometrial

dating”
- Indirect evidence of
ovulation: secretory
endometrium
- NO LONGER
RECOMMENDED as part of
infertility evaluation!
ULTRASOUND/FOLLICLE MONITORING

- Direct evidence of
ovulation
- Corpus luteum: evidence of
ovulation
- Usually done every other
day from day 10/12
ULTRASOUND

- Can detect significant

pathology such as fibroids,
endometriosis, polycystic
ovaries and other pathology
that can possible affect
fertility.
- Can be used to determine
antral follicle count (AFC,
cycle days 2-4) in the
assessment of ovarian
reserve.
OVARIAN RESERVE TESTS

- Not be routinely done for infertility patients

- Done only for female patients who are/have:
1. 35 years old and above
2. History of pelvic or ovarian surgery
3. History of chemotherapy
4. Family history of early menopause/premature
ovarian failure
5. History of poor response to infertility treatment
6. Planning to undergo ART/IVF
OVARIAN RESERVE TESTS

a) Day 3 FSH (NV: < 10 IU/ml)

b) Day 3 Estradiol (NV < 80 pg/ml)
c) Clomiphene citrate challenge test
d) Antral follicle count/AFC
OVARIAN RESERVE TESTS

e) AntiMullerian Hormone/AMH

f) Inhibin
TUBAL PATENCY TESTS

- Chromotubation (thru exploratory lap/laparoscopy)

- Hysterosalpingogram (HSG)
- Sonohysterosalpingogram/saline infusion
sonohysterogram (SISH)
HYSTEROSALPINGOGRAM
POST COITAL TEST (PCT)

- “Sims-Huhner test”
- A normal PCT is one in
which at least five motile
sperm are visible in normal
cervical mucus obtained
from the upper canal just
prior to ovulation
- May be done as an
alternative to semenanalysis
SEMEN ANALYSIS

- The male partner should be advised to abstain from

ejaculation for 2 to 3 days before collection of the semen
sample, because frequent ejaculation lowers seminal
volume and possibly, the sperm count.
- It is important that the entire specimen be collected,
because the initial fraction contains the greatest density of
sperm.
- Parameters used to evaluate the semen include volume,
viscosity, sperm density, sperm morphology, and sperm
motility
SEMEN ANALYSIS
SEMEN ANALYSIS

In case of poor semen quality:

- it is best to repeat the test at least once if an
abnormality is found.
- if abnormalities persist, the male should have a
urologic exam.
- comprehensive evaluation should include:
1. a history and physical exam (occasionally with
ultrasound);
SEMEN ANALYSIS

2. hormonal evaluation (LH, follicle-stimulating

hormone, testosterone, estradiol, prolactin, and thyroid-
stimulating hormone);
3. genetic abnormalities (karyotype, and defects
such as cystic brosis mutations and Y-chromosome
microdeletions), particularly with severe sperm
abnormalities
CHLAMYDIA ANTIBODY TITERS (CAT)

- if elevated may signify the possibility of tubal disease.

- If the immunoglobulin G (IgG) antibody titer is greater than
1:32, 35% of patients have evidence of tubal damage
OTHER TESTS

The following additional laboratory procedures have been

advocated by some to assist in determining the cause of
the infertility:
(1) measurement of serum TSH and prolactin levels in
ovulatory women, if not already done;
(2) luteal phase endometrial biopsy;
(3) measurement of antisperm antibodies in the male
and female partner;
OTHER TESTS

(4) bacteriologic cultures of the cervical mucus and

semen;
(5) other sperm testing, such as hypoosmotic swelling,
hamster egg penetration test, and DNA fragmentation.
TREATMENT
ANOVULATION

Ovulatory drugs
1. Clomiphene citrate
2. Aromatase inhibitors
3. Gonadotropins
Laparoscopic ovarian drilling (LOD)
ANOVULATION

If with hypothyroidism: correct thyroid disorder

If with hyperprolactinemia: bromocriptine
CLOMIPHENE CITRATE AND AROMATASE INHIBITORS

CLOMIPHENE CITRATE AROMATASE INHIBITORS

GONADOTROPINS

- indicated for ovulation induction when estrogen levels are

low and when there is no response to CC or letrozole.
- Low serum E2 levels (usually <30 pg/mL) or lack of
withdrawal bleeding after progestogen administration
signifies a state that will be unresponsive to oral therapies
(CC, letrozole)
- use gonadotropins when there is resistance to CC or
letrozole.
GONADOTROPINS

- Gonadotropins have also been used when there has been

the inability to conceive after several (four to six) cycles of
CC or letrozole, although this indication is not as frequently
applied today.
LAPAROSCOPIC OVARIAN DRILLING/OVARIAN DIATHERMY

- a possible alternative to gonadotropin therapy in

clomiphene-resistant women with PCOS
- Laparoscopic electrical or laser_x0002_generated burn
holes through the ovarian cortex have been associated with
improving ovulation rates
- major advantage of this more invasive method of ovarian
electrocauterization is that it decreases the risk of
hyperstimulation and multiple pregnancies.
LAPAROSCOPIC OVARIAN DRILLING/OVARIAN DIATHERMY

- In addition to a concern of surgical complications,

excessive destruction of the ovarian cortex can lead to
premature ovarian failure.
- Only a limited number of burn holes (∼ 10) should be
made.
WEIGHT AND LIFESTYLE MANAGEMENT

- Particularly in women who

are clomiphene-resistant,
weight loss will often
ameliorate the situation.
- In overweight women, it is
important to ensure that
abnormalities in glucose and
lipid metabolism are
normalized as much as
possible, before induction of
ovulation.
WEIGHT AND LIFESTYLE MANAGEMENT

- lifestyle changes in diet

and exercise may improve
overall fitness and metabolic
parameters, as well as
ovulatory responses
TUBAL BLOCK

- Tubal surgery

- In vitro fertilization (IVF)

MALE FACTOR INFERTILITY
MALE FACTOR INFERTILITY
MALE FACTOR INFERTILITY

- Testicular surgery (?) – Urology

- Intrauterine insemination (IUI)
- IVF
UNEXPLAINED INFERTILITY

- Ovulation induction +/- IUI

- IVF
THANK YOU!