Infertility – Structured Essay
Definition
Infertility is defined as the failure to conceive after 1 year of regular unprotected sexual intercourse.
- Primary infertility → couple has never conceived.
- Secondary infertility → inability to conceive after a previous pregnancy.
Causes of Infertility
Infertility may be due to:
- Female factors → 40%
- Male factors → 40%
- Combined → 10%
- Unexplained → 10%
Female Causes
1. Ovulatory Disorders
- Polycystic ovarian syndrome (PCOS)
- Hypothalamic dysfunction
- Hyperprolactinemia
- Premature ovarian failure
- Thyroid disorders
2. Tubal Factors
- Pelvic inflammatory disease
- Tuberculosis
- Endometriosis
- Previous pelvic surgery
3. Uterine Factors
- Fibroids
- Congenital anomalies
- Asherman syndrome
- Endometrial polyps
4. Cervical Factors
- Cervical stenosis
- Hostile cervical mucus
5. Vaginal/Coital Factors
- Dyspareunia
- Vaginismus
Male Causes
1. Sperm Abnormalities
- Oligospermia
- Azoospermia
- Asthenospermia
- Teratospermia
2. Testicular Disorders
- Varicocele
- Mumps orchitis
- Undescended testes
3. Endocrine Causes
- Hypogonadism
4. Obstructive Causes
- Vas deferens obstruction
5. Sexual Dysfunction
- Erectile dysfunction
- Premature ejaculation
Evaluation of Infertile Couple
Both partners must be evaluated simultaneously.
History
Female History
- Duration of infertility
- Menstrual history
- Coital frequency
- Previous pregnancies
- History of PID/TB
- Dysmenorrhea
- Galactorrhea
- Medical illnesses
Male History
- Sexual history
- Previous fertility
- Mumps orchitis
- Trauma/surgery
- Drug history
- Smoking/alcohol
Examination
Female Examination
- BMI
- Secondary sexual characters
- Thyroid examination
- Signs of hyperandrogenism
- Pelvic examination
Male Examination
- Secondary sexual characters
- Testicular size
- Varicocele
- Penile abnormalities
Investigations
Female Investigations
1. Assessment of Ovulation
- Basal body temperature
- Mid-luteal serum progesterone
- Follicular study by ultrasonography
2. Tubal Patency Tests
- Hysterosalpingography (HSG)
- Sonosalpingography
- Laparoscopy with chromopertubation (gold standard)
3. Ovarian Reserve Tests
- AMH
- Antral follicle count
4. Hormonal Assays
- FSH, LH
- Prolactin
- TSH
5. Pelvic Ultrasound
To detect:
- PCOS
- Fibroids
- Endometriosis
Male Investigations
Semen Analysis (Most Important)
Normal semen parameters:
- Volume: >1.5 mL
- Count: >15 million/mL
- Motility: >40%
- Normal morphology: >4%
Other tests:
- Hormonal assay
- Scrotal ultrasound
- Testicular biopsy
Management
Management depends on the cause.
General Measures
- Weight reduction
- Stop smoking/alcohol
- Timed intercourse
- Treat systemic illness
Medical Treatment
Ovulation Induction
Drugs:
- Clomiphene citrate
- Letrozole
- Gonadotropins
Treatment of Infections
- Antibiotics
Hormonal Treatment
- Thyroid disorders
- Hyperprolactinemia
Surgical Treatment
Female
- Laparoscopic adhesiolysis
- Ovarian drilling
- Myomectomy
- Tubal surgery
Male
- Varicocelectomy
- Vasovasostomy
Assisted Reproductive Techniques (ART)
1. Intrauterine Insemination (IUI)
Processed semen introduced into uterus.
2. In Vitro Fertilization (IVF)
Fertilization outside body.
3. Intracytoplasmic Sperm Injection (ICSI)
Single sperm injected into ovum.
4. Donor Programs and Surrogacy
Complications/Psychological Impact
- Anxiety
- Depression
- Marital stress
- Social stigma
Prognostic Factors
- Age of woman
- Duration of infertility
- Cause of infertility
- Ovarian reserve
Conclusion
Infertility is a common reproductive problem involving both partners. Proper evaluation of male and female factors, early diagnosis, and appropriate treatment including ART can help many couples achieve pregnancy.