DR. GAYATHIRI GANESAN RAMMS(O.G) , FELLOW IN REPRODUCTIVE

MEDICINE AND ANDROLOGY.CONSULTANT INFERTILITY SPECIALIST

ARC FERTILITY CENTRE.

AN OVERVIEW OF INFERTILITY

INTRODUCTION

INFERTILITY can be considered a disease when health is defined as” the state of physical mental and social well being”.[WHO]

Distribution of infertility.

Male factor 40%

Female Factor40%

Unexplained 10%

Both Partners10%

INTRODUCTION

Approximately 15% of couples are unable to conceive after 1 year of unprotected intercourse.

Male factor is solely responsible in about 20% of  infertile couples and contributory in another 30 -40% .

A PRACTICAL APPROACH TO INFERTILITY

Why to treat?Infertility is disease of the reproductive

system.Untreated infertility would lead to

depression and several other psychosomatic diseases.

A PRACTICAL APPROACH TO INFERTILITY

Untreated PCOD increases the risk of Endometrial cancer,breast cancer, diabetes mellitus, hypertension and hyperlipidemia..

Untreated, undescended testes increases the risk of testicular malignancy.

Untreated Infertility increases the risk of endometriosis

DEFINITION OF INFERTILITY

“…one year of well-timed and unprotected coitus without conception...”

Rein MS, Barbieri RL. 1999.

Rein MS, Barbieri RL

1999

MALE & FEMALE FACTORS ARE EQUAL

Nelson AL, Marshall JR. 2004.

Among couples with identifiable causes of infertility

40%

20%

40%Female Factors

MaleFactors

Unknown/Both

INFERTILITY NUMBERS ARE INCREASING

Greater number of older womenWomen delaying childbearing

Stephen EH, Chandra A. Fam Plan Perspect. 2000.Chandra A, Martinez GM, Mosher W, et al. 2005.

6.7 million5.5 million

1988 1995

7.3 million

2002

TYPICAL CONCEPTION TIMETABLES

Meldrum DR. Infertility. 1998

60%75%

90%

25%

1 month 6 months 9 months 18 months

PRIMARY AND SECONDARY INFERTILITY

Hatcher RA, Trussell J, Stewart F, et al. 1994Stewart GK. 1998

Secondary infertility

30%

Primary infertility

70%

Total Infertility Cases

Female: Has never conceivedMale: Has never impregnated a female

Despite having unprotected intercourse for at least 12 months:

Female: Has previously conceived but is subsequently unable to do so Male: Has previously impregnated a female but is subsequently unable to do so

EXCLUSION

Bilateral tubal blockageSevere tubal damage or diseaseDeclining ovarian function ( D2 FSH )Ovarian failure ( menopause )Severe male factor infertilityActive PID/ cervicitis/ vaginitis/ infection

in male partnerHIVSevere hypoplastic uterus

Infertility is a race against time.- Pandiyan 1997.

Time would indicate the age of the couple, particularly woman and the duration of infertilty.

FACTORS RELATED TO INFERTILITY

Reproductive knowledge Toxic agents

Coital timing, frequency Substance use

Douching, lubricants Medications

Age-related changes Surgery

Sexually transmitted diseases Radiation

Previous pregnancy Physical exertion/heat

Nutrition Uterine myomas

WHY PATIENT SELECTION IS IMPORTANT ?

Success rates depend on Age Duration of infertility Cause of infertility No. of quality of motile sperms Type of OHS

FREQUENCY & PROBABILITY OF CONCEPTION

Frequency of Intercourse

% Achieving PregnancyWithin 6 Months

<1x per week 17

1x per week 32

2x per week 46

3x per week 51

Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 1994.MacLeod J, Gold RZ. Fertil Steril. 1953.

COITAL FREQUENCY AND CONCEPTION (FROM MACLEOD).

Weekly frequency Conception within 6 months (%).

< 1 171 to 2 322 to 3 463 to 4 51> 4 83

MALE FERTILITY & AGEAge-related decline.

Increased problems with sexual function .

Decreased coital frequency.

Diminished sperm output, morphology, & vitalityEdge V, Miller M. Women's Health Care. 1994.Ng KK, et al. Hum Repro. 2004.

AGE AND FERTILITY

Most important factor influencing a woman’s fertility.

Influences to some extent a man’s fertility also.

Incidence of Infertility is very low in teenagers – 6%.

Infertility is about 50% in the 40s.

FEMALE FACTORS Over age 35.Irregular menses.Severe progressive dysmenorrhea or

dyspareunia.Past IUD use.Past pelvic infection.Past surgery on an ovary, tube or uterus .Suspected damage to pelvic organs.

Stewart GK. 1998.

INFECTION SCREENING

HIVHepatitis BHepatitis CRubella ( for females )Chlamydia or other causes of PID ( in

women considered at risk )

ENDOCRINE DISRUPTING CHEMICALS

Environmental oestrogens and anti androgens are endocrine disrupting chemicals with adverse effect on male reproductive health.

DNA alone is not destiny.Environmental Endocrine Disrupting

Chemicals contamination have more control over the development of the offspring of exposed adults than the genes off springs inherit.

EDC also adversely disrupt human ovarian function.

ENDOCRINE DISRUPTING CHEMICALS

Bisphenol A – BPA and Phthalate are the commonest Endocrine disrupting chemicals.

These substances are ubiquitous in small amounts in water air and food.

Prenatal exposure to these chemicals can lead to impairment of male fertility.

Diethyl stilboesterol is an Endocrine disrupting chemical – DES syndrome.

Contamination with persistent endocrine disrupters may be a global problem relevant also to humans.

DOUCHING, LUBRICANTSDouching:May interfere with sperm reaching ovumIncreased incidence of ectopic pregnancy

Lubricants:May contain spermicidal agentsMay lead to decreased sperm motility

Stewart GK. 1998.

MACRO ENVIRONMENT

Atmospheric (air) pollution.Water contamination.Food contamination – You are what you eat,

what your mother ate and what your grandmother ate.

Electro magnetic radiation- Cell phones; lap tops.

Atomic energy.

OBESITY AND FERTILITY

In women:Obesity in childhood

advances puberty.In adulthood impairs

fertilityIn Men:Obesity in childhood

delays puberty.In adulthood - severe

forms impair fertility.

Risk ofovulatoryinfertility

FEMALE BODY WEIGHT & INFERTILITY

Barbieri RL. Am J Obstet Gynecol. 2001 .Stewart GK. 1998.

=17 kg/m2

30 kg/m2

TOBACCO USE & INFERTILITY

Stewart GK. 1998.Bouyer J, et al. Am J Epidemiology. 2003.

• Sperm production

• Motility• Morphology• Fertilization

capacity

• Decreased rates of conception

• Increased rates of miscarriage

• Increased risk of ectopic pregnancy

• Increased risk of placenta previa

• Negative effects on fetus

MICRO ENVIRONMENT

Body weight- Obesity -Positive influence on puberty in girls. Negative influence on puberty in boys.

Adults- Negative influence in both sexes.

Tobacco Negative influence in both sexes.

Alcohol Negative influence in both sexes.

All drugs are potentially gonadotoxic.

“Infertility Is a Race Against Time” (Pandiyan).

Age & Infertility :Female Partner’s ( Also Male Partner’s)

Age Is a Very Important Deciding Factor in the Success Rate.

Optimal success – (F) <30 years.Ideal fertile age – 20 – 25 years.Decline starts bet. 30- 35 years.Poor results > 40 years.

ALCOHOL USE & INFERTILITY

Decreased rates of conceptionIncreased rates of miscarriageOvulatory infertilityNegative effects on fetus

Stewart GK. 1998.

• Lower testosterone levels

• Decreased sperm production

• Impotence

Drugs

Narcotics, barbiturates

Decreases regularity and effectiveness of ovulation

Cause impotence, affect sperm productionPrescription

medications

Increased risk of fetal defects, fetal wastage

Chemotherapy Ovarian failure Testicular failure

Calcium channel blockers

Inhibit sperm production

MEDICATION USE & INFERTILITY

RADIATION & INFERTILITY

Stewart GK. 1998.

MaleTesticular damage

or cancer

Chromosomal aberrations

FemaleOvarian failure

Fetal wastage

Fetal damage

EVIDENCE BASED MANAGEMENT OF MALE INFERTILITY

FERTILITY

A couple’s fertility is the joint fertility of the man and the woman.

No man or woman is 100% fertile.If the man is sub fertile,( as in

Oloigozoospermia) woman’s enhanced fertility may compensate for that.

A woman’s sub fertility ( as in endometriosis) may be compensated by a man’s enhanced fertility.

MANAGEMENT OF MALE INFERTILITY

History: Crucial.Surgery -hernia, hydrocele, undescended

testes.Smoking- affects all semen parameters.Alcohol- affects all semen parameters and

sexual function- Shakespeare said ‘Alcohol provokes the desire but takes away the performance.’

Obesity.Drug Intake.

EVIDENCE BASED MANAGEMENT OF MALE INFERTILITY

Coital history.History of use of lubricants.Age and male reproduction.Anti sperm antibody.?Sperm function tests.?Post coital tests.?