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Infertility

Infertility is a common condition that affects many couples, with important psychological and medical implications. 


Presentation

The presentation will be as per the definition. There may be physical sign such as physical habitus that is suggestive of a genetic cause such as Turner syndrom or Klinefelter syndrome. Or vague abdominal symptoms in endometriosis. Most other causes are asymptomatic. There may be obvious complaints such as amenorrhea (primary or secondary) so a detailed sexual development history is required for both partners [6].

Plethora
  • Abstract A plethora of studies have examined the prevalence and severity of anxiety and depression in relation to infertility, while ignoring social and cultural factors.[ncbi.nlm.nih.gov]
Abdominal Mass
  • Here is discussed a challenging case of a 30-year-old woman with no living child and secondary infertility who presented with a large abdominal mass and severe abdominal pain, sequelae of previous obstructed labour.[ncbi.nlm.nih.gov]
Vomiting
  • After only six days of persisting vomiting acute renal failure was found. A complete recovery of renal function was obtained after 14 days. CONCLUSION: Acute renal failure was due to persistent vomiting leading to dehydration.[ncbi.nlm.nih.gov]
Short Arm
  • The CCR included five breakpoints and was caused by the inverted insertion of a chromosome 12 segment into the short arm of one chromosome 7 and a pericentric inversion of the structurally rearranged chromosome 12.[ncbi.nlm.nih.gov]

Workup

A comprehensive history and examination is key to the initial assessment for women:

  • Menstrual history
  • Any medical comorbidities or medications
  • Sexual history, use of lubricants, sexual dysfunction such as anorgasmia (male and female)
  • Physical exam, looking for signs of genetic diseases, breast exam, and abdominal exam and gynecologic exam and inspection of the cervix plus a PAP smear and bimanual examination.

Men

  • Ingunal hernia repair history 
  • Semen analysis 
  • Urologic exam
  • Testicular size
  • Urethral exam 

Treatment

The treatment is dependent on the identified cause of the infertility by various procedures and medications. In vitro fertilization may be of use or more advance techniques such as oocyte donation or surrogacy [8].

Prognosis

The prognosis depends on the cause of infertility. With the advent of in vitro fertilization may be aided. Other procedures such as oocyte donation of surrogacy may be required depending on the problem. There also has been uterine transplantation to aid infertility.

Etiology

With the increase in family planning and increased women career development, many women postpone child bearing to beyond 30 years of age, as a result their chances of conceiving are decreased because the fecundability rates are lower at these ages.

Reproduction requires that the male and female reproductive tracts be intact with normal oocyte and normal spermatozoa. The transport of the egg has to be adequate into the fallopian tube where fertilization occurs and then proper implantation into the endometrium [1] [2].

With infertility there are:

Male factors

  • Hypogonadism
  • Seminiferous tubule dysfunction 
  • Post-testicular defect

Female factors

  • Cervical factors 
  • Endometriosis 
  • Tubal damage
  • Coital problems
  • Ovulatory problem

Epidemiology

Up to 10% of couples of reproductive age are infertile. The prevalence increases with age with women between 15 and 34 having a prevalence of 8% and 35 to 39 being 25%. Male factors listed above account for 26% of the causes of infertility, cervical factors account for 3%, coital problems 6% and endometriosis 6% and tubal damage 14% [3] [4].

Sex distribution
Age distribution

Pathophysiology

Male factors

  • Hypogonadism may be congenital due to genetic causes such as Klinefelter syndrome. Other non-genetic factors include radiation, infections and trauma.
  • Seminiferous tubule dysfunction 
  • Post-testicular defect, these are factors that don’t allow the proper transport of sperm through the reproductive system and can be congenital (such as ductal obstruction) or acquired such as surgical procedures, infections and trauma.

Female factors

  • Cervical factors may be stenosis or abnormalities of the mucus. The mucus has to thin out and be watery during ovulation. 
  • Endometriosis is still a very poorly understood disease that affects women in their reproductive age with unpredictable evolution. 
  • Tubal damage may be due to infections, such as gonorrhea, that may cause tubal blockage. Also accumulation of tubal secretions may cause hydrosalpinx leading to damage of the lining, which is important for transport.
  • Coital problems
  • Ovulatory, there are many causes of ovulatory problems. There may be genetic as in Turner syndrome. There may be associated amenorrhea (primary or secondary). This may be due to inadequate gonadotropin release hormone level abnormalities from the pituitary [5]. 

Prevention

For the genetic causes, there is little to prevent, but for the acquired causes such as infections causing infertility (usually sexually transmitted), protected sex is mandatory unless both partners have been cleared for possible infections.

Summary

Infertility is the failure to conceive after 1 year of frequent unprotected intercourse in women less than 35 years of age and for woman who are 35 years or older the time cut off is 6 months. The infertility may be due to a single cause or multiple factors. There have been many new developments that can improve chances of conceiving.

Other term that need to be defined include fecundability which the chance of getting pregnant each month and fecundity, which is the ability to achieve a live birth from one menstrual cycle. The general fecundability rate is about 0.22 to 0.25 and the fecundity rate is 0.15 to 0.18 per month.

Patient Information

  • Definition: Infertility is the inability to pregnant after one year of frequent and unprotected sex with your partner. The inability may be caused by problems with either the male or female and sometimes both. 
  • Cause: There are multiple causes, that you could have been born with or are acquired with time. Your doctor will try and figure these out. In men there may be problems with the sperm production of delivery of the sperm. In women there be problems with egg production or transportation. There may also be problems with her reproductive tract not allowing sperm to reach the egg to fertilize.
  • Symptoms: There are usually no symptoms of this, most couple appear healthy and feel fine. There may symptoms of the underlying cause such as an infection or irregular or no periods.
  • Diagnosis: For men, blood test may be done to check hormone levels. The doctor may order an ultrasound to see you reproductive organs to check if there are any problems. There may also be urine tests and analysis of sperm. For women, blood test to check hormone levels and ovulations tests are necessary. The doctor may also ask for ultrasound to see the uterus and ovaries. They may also use a scope to look inside the uterus.
  • Treatment: This will depend on the cause of the infertility. The may be drugs if its hormone levels, but in vitro fertilization (IVF) may be used, where an egg is removed from you, then the man’s sperm are used to fertilize the egg and the egg is then returned to the uterus.

References

Article

  1. Practice Committee of tAmerican Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss. Fertil Steril 2008; 90:S60.
  2. Guttmacher AF. Factors affecting normal expectancy of conception. J Am Med Assoc 1956; 161:855.
  3. Thoma ME, McLain AC, Louis JF, et al. Prevalence of infertility in the United States as estimated by the current duration approach and a traditional constructed approach. Fertil Steril 2013; 99:1324.
  4. Chandra A, Copen CE, Stephen EH. Infertility and impaired fecundity in the United States, 1982-2010: data from the National Survey of Family Growth. Natl Health Stat Report 2013; :1.
  5. Hull MG, Glazener CM, Kelly NJ, et al. Population study of causes, treatment, and outcome of infertility. Br Med J (Clin Res Ed) 1985; 291:1693.
  6. Kerr J, Brown C, Balen AH. The experiences of couples who have had infertility treatment in the United Kingdom: results of a survey performed in 1997. Hum Reprod 1999; 14:934.
  7. ractice Committee of American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril 2012; 98:302.
  8. Balasch J, Creus M, Fabregues F, et al. Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study. Hum Reprod. Feb 1996;11(2):387-91
  9. Robertson JN, Ward ME, Conway D, Caul EO. Chlamydial and gonococcal antibodies in sera of infertile women with tubal obstruction. J Clin Pathol. Apr 1987;40(4):377-83
  10. Ceballo R, Abbey A, Schooler D. Perceptions of women's infertility: what do physicians see? Fertil Steril 2010; 93:1066.

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Last updated: 2017-08-09 17:40