Infertility

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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Chapter 10 Infertility

Anusch Yazdani

Definitions. Infertility is the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse. Primary infertility is no previous pregnancy, regardless of the outcome. Secondary infertility is previous pregnancy, regardless of the outcome. Fecundability is the probability of achieving a pregnancy per menstrual cycle. Fecundity is the probability of achieving a live birth per menstrual cycle.

Incidence. The overall incidence of primary infertility is 10%–15% of couples. Female fertility declines with age and the incidence of infertility increases: 5% under the age of 25; 10% under the age of 30; 15% under the age of 35; 30% under the age of 40; and 60% over the age of 40.

Conception

Conception requires:

• sperm∗

• adequate (quantity, quality)
• deposition (in vicinity of cervix, prior to/at ovulation, permeable cervical mucus)
• ovulation∗
• at least one patent fallopian tube to allow fertilisation∗
• transport to endometrial cavity
• implantation

Probability of conception

The probability of conception is time dependent:

• after 3 months: 60%
• after 6 months: 75%
• after 12 months: 85%
• after 24 months: 95%

Therefore, the majority of couples who have not conceived after 1 year are likely to conceive in the subsequent year.

Aetiology

The requirements for conception determine the aetiological factors that contribute to infertility:

• male factors: 40%

• pretesticular factors: hypothalamic–pituitary abnormalities
• testicular factors: primary testicular abnormalities, varicocoele, torsion, trauma, orchiditis, cytotoxic drug treatment, radiotherapy, undescended testes
• post-testicular factors: genital tract obstruction, may be congenital (congenital absence of vas deferens), inflammatory, Young’s syndrome, postvasectomy, vasectomy

• female factors: 50%

• tubal and pelvic pathology: 40%

— endometriosis, adhesions, hydrosalpinges, pelvic inflammatory disease, fibroids, congenital abnormalities

• ovulatory dysfunction: 40%

— primary ovarian abnormalities, polycystic ovary syndrome, obesity, age
— hypothalamic–pituitary disorders

• other: 20%

• unexplained: 10%

History

Female

• history of infertility

• primary or secondary infertility

— previous pregnancies: same or different partner, time to conceive, outcome of pregnancy

• duration of infertility

• sexual history

• history of contraception
• sexual function

— dyspareunia
— coital frequency, timing during cycle

• menstrual history

• regularity, frequency of cycles, evidence of ovulation (such as mucus changes)
• dysmenorrhoea

• evidence of endocrine disorder

• galactorrhoea, hirsutism, acne
• weight gain

• past medical history

• obesity
• hypertension, renal disease, gastrointestinal disease
• thyroid disease
• pelvic inflammatory disease
• peritonitis, appendicitis, ovarian or pelvic surgery
• endometriosis

• medications
• social history, including smoking, alcohol or other substance abuse
• family history, including birth defects, mental retardation or reproductive failure

Male

• history of infertility

• pregnancies to other partners

• sexual function

• erectile or ejaculatory dysfunction

• past medical history

• varicocoele, undescended testicle, mumps
• orchidopexy, inguinal hernia repair
• urinary tract infection, sexually transmitted disease
• testicular injury or infections

• medications
• social history, including smoking, alcohol or other substance abuse
• family history, including birth defects, mental retardation or reproductive failure

Examination

Female

• general

• pulse rate, blood pressure, body mass index (BMI)
• dysmorphic features, secondary sexual characteristics

• endocrine

• breast and thyroid, hirsutism, acne, galactorrhoea, striae, acanthosis

• reproductive

• vaginal examination

— cervical cytology, microbiological studies, including Chlamydia
— pelvic assessment (e.g. fixed retroversion of the uterus)

Male

• general

• pulse rate, blood pressure, BMI
• dysmorphic features, secondary sexual characteristics

• endocrine

• gynaecomastia, hair distribution

• reproductive

• phallus
• spermatic cord: presence of vas, varicocoele
• testicular size and consistency

Investigations

Initial investigations

Initial investigations focus on the three main factors causing infertility (ovulatory, pelvic and male factors) and assess the suitability for pregnancy (antenatal screening).

• ovulatory factor assessment

• a regular cycle with symptoms of ovulation is evidence of ovulation
• basal body temperature (BBT) chart

— progesterone is thermogenic and raises BBT after ovulation, which is maintained during the luteal phase
— 20% of ovulatory women have a monophasic BBT

• serum progesterone

— tested in the luteal phase on day 21 of an ideal 28-day cycle or 7 days prior to menses
— raised progesterone in the luteal range is evidence of ovulation in that cycle

• pelvic factor assessment

• ultrasound scan of pelvis: ovarian morphology, evidence of pelvic disease, such as fibroids

• antenatal screening tests (include cervical screening, rubella serology)
• male factor assessment

• seminal analysis

— requires 3 days abstinence before collection
— volume >2 mL
— density >20 million sperm/mL
— motility >50%
— morphology >15% normal

Extended investigations

Extended investigations are performed when the initial investigations have not identified a cause or when further elucidation is required.

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