• The inability to conceive after 12 months of unprotected sexual intercourse
• Affects 15 % of couples

There are two types :

• Primary infertility : Infertility in the absence of previous pregnancy
• Secondary infertility : Infertility after previous pregnancy

Female factors affecting infertility

Tubal diseases 20%, Anovulation 15%, Unexplained 10%, Multifactoral 40%

Infertility workup

Semen analysis

Performed after at least 48 hours of abstinence, with examination maximum 2 hours from time of ejaculation (for those who prefer to donate at home)

Characteristics of semen analysis

• Volume – normal , > 2ml
• Semen count – normal, >20 million/ml
• Motility – normal, > 50% with forward movement
• Morphology – normal, > 40% normal

Treatment for abnormal sperm findings

• Urology referral
• Quitting smoking
• Avoidance of lubricans
• Intrauterine insemination
• Intracytoplasmic injection
• Artificial insemination

If semen analysis normal, continue workup with analysis of ovulation

Methods of analyzing ovulation

• History of monthly menses is a strong indicator of normal ovulation
• Basal body temperature; rises about 0.5 to 1 F during the luteal phase due to the increase level of progesterone. Presence of basal body temperature increase is a good indicator that ovulation is occurring
• Measurement of luteal phase progesterone level
• Sonogram = determines normal or abnormal endometrial anatomy
• Endometrial biopsy – determines histologically the presence/absence ovulation

Possible causes and treatments of anovulation

• Pituitary insufficiency : treat with intramuscular luteinizing hormone / follicle stimulating hormone
• Hypotalamic disfunction  : treat with bromocriptine ( a dopamine antagonist)
• Polycsystic ovary syndrome : treat with clomiphene or human menopausal gonadotropin
• Other causes: Hyper/hypothyroid, androgen excess, obesity/starvation, galactorrhea

If ovulation analysis and semen analysis are normal, analysis of the internal architecture is performed to determine if there is an anatomical impediment to pregnancy.

Internal  architecture study

Hysterosalpingogram

• Performed during follicular phase
• Radio opaque dye is injected into cervix and uterus and shoul fill both fallopian tubes and spill into peritoneal cavity
• Allows visualization of uterus and fallopian tubes
• There is risk of salpingitis

Treatment for structural abnormalities

• Microsurgical tuboplasty
• Neosalpingostomy
• Tubal reimplantation for intramural obstruction

If findings of the semen analysis, ovulation analysis and hysterosalpingogram are normal, an exploratory laparoscopy can be done.

Exploratory laparoscopy

A laparoscope is inserted transabdominally to visualize the pelvis :

• Check for adhesions
• Check for endometriosis

Treatment

• Laparoscopic lysis of adhesions
• Laparoscopic endometriosis ablation
• Medical treatment of endometriosis

Assisted reproductive technologies

Definition

Directly retrieving eggs from ovary followed by manipulation and replacement. Generally employed for inadequate spermatogenesis. The following are examples.

In vitro fertilization and embryo transfer

Fertilization off eggs in a lab followed by uterine placement: Intracytoplasmic sperm injection is a subtype of IVF to aid severe male factors. Success rate of IVF is about 20%

Gamete intrafallopian transfer

Egg and sperm placement in an intact fallopian tube for fertilization: Success rate of this is about 25%.

Zygote intrafallopian transfer

Zygote (fertilized in vitro) is created and placed in fallopian tube, where it procceds to uterus for natural implantation: Success rate of this is about 30%