Dr Atin SinghaiAssistant Professor
Department of PathologyKGMU, Lucknow
Definition:1 yr unprotected coitus without conception
10-15% couples affected Etiology
Couples:○ 35% Tubal and pelvic pathology○ 35 % Male problems○ 15% Ovulatory dysfunction○ 10% Unexplained○ 5% unusual causes
Etiology◦ Women:
40% Tubal and pelvic pathology 40% Ovulatory dysfunction 10% Unexplained Infertility 10% Unusual causes
Normal couple:◦ 25-30% chance of pregnancy per ovulatory
cycle Fertility decreases with age
Time of Exposure % Pregnant
3 months 60%6 months 70%1 year 85%18 months 90%
DDX Tests/Inv Dx Rx
Production Storage Delivery
1. Production:◦ Hypothalamus◦ Anterior Pituitary◦ Testes
1. Production◦ Hypothalamus
Congenital abnormalities of hypothalamus e.g. Kallman’s syndrome
Starvation, stress or severe illness Tumors (craniopharyngioma, metastatic tumor) Head injury Inflammation (sarcoidosis) Infection (tuberculosis) Drugs: marijuana
1. Production:◦ Pituitary
Endocrine: thyroid, prolactin Tumors Inflammation: sarcoidosis, meningitis Infiltration Infarction Trauma/XRT Drugs: anabolic steroids
Production:◦ Testes:
Congenital: Klinefelters (XYY), developmental disorders
Disorders of gonadal steroidgenesis Infection: chlamydia, prostatitis, mumps orchitis Autoimmune Cryptorchidism Tumors; chemo/XRT Drugs / alcohol Vascular: testicular torsion
2. Storage:◦ Temperature
Rise in scrotal temperature Occupation Varicocoele
3. Delivery:Impotence/Ejaculation○ Neurogenic: medications (α-blockers,
methyldopa)○ Endocrine: diabetes○ Congenital: absence vas deferens (CF)○ Genetic: cystic fibrosis○ Primary ciliary dyskinesia: Kartagener syndrome○ Hypospadia○ Vasectomy
History:Previous childrenInfections: prostatitis, STD, mumps orchitisTrauma to head or testiclesSurgery to testicles or herniaOccupation (sitting, bio hazards)Chemo or Radio therapyEthanol or SmokingMedicationMedical history (DM, HTN)Previous investigations
Physical◦ Anatomy (meatus)◦ Testicular size◦ Varicocele (valsalva)◦ Rectal exam (protatitis, discharge)
Investigations:◦ semen analysis
Abstain 2-4 days prior At least 2 samples over different period of time
◦ If abnormal: Blood work: FSH, LH, TSH, testosterone, PRL Testicular U/S Chromosomal analysis
Semen analysis:◦ WHO (1992)
Volume > 2.0 mL Sperm > 20 million/mL Motility > 50% forward progression or
> 25% rapid progression within 60 min
Morphology > 30% normal forms WBC < 1 million/mL
Tx / Interventions:◦ Treat underlying causes◦ Intrauterine Insemination (IUI)◦ Intracytoplasmic Sperm Injection (ICSI)
Fecundability: probability of achieving a pregnancy within 1 menstrual cycle (25%)
Fecundity: ability to achieve a live birth within 1 menstrual cycle (6%)
Production Storage Delivery
Production:◦ Hypothalamus◦ Pituitary◦ Ovary
Hypothalamus:◦ Stress◦ Exercise◦ Eating disorders◦ Psychogenic◦ Congenital/genetic: Kallman’s syndrome (hyposmia &
hypoplasia olfactory lobes of brain)◦ Starvation/stress or severe illness◦ Tumors (craniopharyngioma, metastatic tumor)◦ Head injury◦ Inflammation (sarcoidosis)◦ Infection (tuberculosis)◦ XRT◦ Drugs
Pituitary:Sheehan syndromeTumors: Pituitary adenoma, metastaticEmpty sella syndromeInappropriate gonadal steroid feedback:○ estrogen excess: obesity/ tumors○ estrogen deficiency: aromatase deficiency/ ER
gene mutation○ androgen excess: adrenal or ovarian○ PCOS
Testicular feminization (46 XY) - absence androgen receptors
Ovary◦ Gonadal dysgenesis - Turner’s Syndrome 45XO or
mosaics 46 XX/45 XO◦ Testicular feminization◦ XRT / Chemo for childhood malignancies◦ Premature ovarian failure
Storage (R.P.L. unless severe)◦ Uterine abnormalities◦ Mullerian Agenesis: Mayer-Rokitansky-Kuster-
Hauser syndrome◦ Leiomyoma ◦ Luteal phase deficiency
Delivery:◦ Uterine abnormalities◦ Vaginal septum◦ Tubal Disease
Infections/ STD/PID Ruptured appendix Septic abortion
◦ Endometriosis
History:AgeGTPALRegulatory of periodProlactin S/SThyroid S/SInfections, SurgeriesMedication, Smoking, EthanolMedical history Previous investigations
Examination:◦ Thyroid◦ Breast (milk)◦ Abdomen (masses, scars)◦ Vaginal (abnormalities)◦ Bimanual (Uterus, masses)
Blood work:TSHPRLD3 FSHD3 LHLuteal phase Progesterone
Imaging:Pelvic UltrasoundHSG
DiagnosticLaparoscopy (later)
Treat the underlying cause Medical Surgical
Anovulation:◦ Clomiphene induction IUI◦ Gonadotropin IUI
IVF◦ Bilateral tubal disease◦ Unexplained infertility after Gonadotropin + IUI
failure.◦ Failure of the above
ICSI◦ Male factor◦ Unexplained infertility
DDx – Hx – Px – Inv - Rx Age is important factor for female Hypothalamic-Pituitary-Gonadal axis central
in working up both male and female infertility
Investigations:◦ Male: Sperms◦ Female: Tubes (HSG) + Ovaries (FSH, LH, PRL,
TSH)
Infertility is defined as unprotected coitus for ___ months, without conception :
a.3b.6c. 9d.12
Spermatogenesis and sperm maturation is regulated by :
a.Leydig Cellsb.Sertoli Cellsc. Vas Deferensd. Intermediate Cells
Cause/s of male infertility is / are :a.Kallaman’s syndromeb.Craniopharyngiomac. Marijuana abused.All of the above
Normal semen count is ___ million / mla.≥ 15b.≥ 20c. ≥ 25d.≥ 30
Indication/s for semen analysis is / are :a. Investigation for infertilityb.to check effectiveness of vasectomyc. for selection of donor for artificial
inseminationd.All of the above
Thank you