• 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%

Alcohol

• Alcohol is teratogenic
• An occasional drink during pregnancy carries no known risk
• Fetal alcohol syndrome (FAS) may occur with chronic exposure to alcohol in the later stages of pregnancy. Features  may include :
  • Growth retardation
  • Central nervous disfunction :
    • Microcephaly
    • Mental retardation
    • Abnormal neurobehaviour (hyperactivity disorder)
• Facial anomalies :
  • Small palpebral  fissures
  • Indistinct / Absent philtrum
  • Epichantic folds
  • Flattened nasal bridge
  • Short length of nose
  • Thin upper lip
  • Low set, unparallel ears
  • Retarded midfacial development

Tobacco

• The leading preventable cause of low birth weight
• Smoking is associated with decreased birth weight and increased prematurity
• There is a positive association between sudden infant death syndrome and smoking
• Use of nicotine patch is controversial

Marijuana

• No evidence of significant teratogenesis in humans
• Metabolites detected in urine of users for days to weeks
• Commonly used by multiple substance abusers; thus. Its presence in urine may identify patients at high risk for being current users of substances as well

Cocaine

• Pregnancy does not increase one’s suspectibility to cocaine’s toxin effects
• Complication of pregnancy :
  • Spontaneous abortion and fetal death in utero
  • Preterm labor and delivery
  • Meconium stained amniotic fluid
  • Teratogenic effects of cocaine :
    • Growth retardation
    • Microcephaly
    • Neurobehavioral abnormalities ; impairment in orientation and motor function

Opiates

Heroin

• Three to sevenfold increase in incidence of stillbirth, fetal growth retardation, prematurity, and neonatal mortalitiy
• Signs of infant withdrawal occur 24 to 72 hours after birth
• Treatment with methadone improves pregnancy outcome

Newborn infants born to narcotic addicts are at risk for severe, potentially fatal narcotic withdrawal syndrome, characterized by :

• High pitched cry
• Poor feeding
• Hypertonicity or tremors
• Irritability
• Sneezing
• Sweating
• Vomiting
• Seizures

Hallucinogens

• No evidence that lysergic acid diethylamide or other hallucinogens cause chromosal damage or other deleterious effects on human pregnancy
• There have been no studies on the potential long term effects on neonatal neurodevelopment

Amphetamines

Crystal methamphetamine, a potent iv stimulant has been associated with :

Decreased fetal head circumference

• Placental abruption
• Intrauterine growth retardation
• Fetal death in utero

The majority of women have amenorrhea from the last menstrual period until after the birth of their baby.

Symptoms

Although not specific to pregnancy, these symptoms may alert the patient to the fact that she is pregnant :

• Breast enlargement and tenderness from about 6 weeks gestational age.
• Areolar enlargement and increased pigmentation after 6 weeks gestational age.
• Colustrum secretion may begin after 16 weeks gestational age.
• Nausea with or without vomiting, from about the date of the missed period.

• Urinary frequency, nocturia, and bladder irritability due to increased bladder circulation and pressure from the enlarging uterus.

Signs

Some clinical signs can be noted, but may difficult to quantify :

• Breast enlargement, tension, and venous distention
• Bimanual examination reveals a soft, cystic, globular uterus with enlargement consistent with the duration of pregnancy.
• Chadwick’s sign : Bluish discoloration of vagina and cervix, due to congestion of pelvic vasculature.

Pregnancy Testing

How ?

The beta subunit of human chorionic gonadotropin (hCG) is detected in maternal serum or urine.

• hCG is a glycoprotein produced by the developing placenta shortly after implantation.
• A monoclonal antibody to the hCG antigen is utilized.

When ?

• Blood levels become detectably elevated 8 to 10 days after fertilization ( 3 to 3.5 weeks after the LMP ).
• hCG rises in a geometric fashion during T1, producing diferent ranges for each weeks of gestation.

Fetal Heart Tones

The electronic Doppler device can detect fetal heart tones as early as 8 weeks gestational age

Ultrasonic scanning

When ?

• To confirm an intrauterine pregnancy.
• To confirm the presence of a fetal heartbeat in a patient with a history of miscarriage.
• To diagnose multiple pregnancy.
• To estimate gestational age.
• To screen for fetal structural anomalies.