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INFERTILITY

Definitions

 Infertility: The inability to achieve conception (regardless of cause) despite one year
of frequent unprotected intercourse.
 Fertility: The capacity to reproduce or the state of being fertile
 Sterility: Implies an intrinsic inability to achieve pregnancy
 Primary infertility: Applies to those who have never conceived
 Secondary infertility: Designates those who have conceived at some time in the past.
 Fecundity: The probability of achieving a live birth in 1 menstrual cycle.
 Fecundability: The likelihood of conception per month of exposure.

Epidemiology

 Infertility affects approximately 10-15% of reproductive-aged couples.
 The fecundability rate in the general reproductive-aged population is fairly constant
and is approximately 22% per month.
 In normal fertile couples having frequent intercourse, the chances of pregnancy are
estimated to be approximately 20% per month.
 The estimated fecundity rate is 15-18 % per month, representing a cumulative
pregnancy rate of 90% per year
 Fecundability rates are higher in younger women and lower in older women

 The decline in fecundability begins in the early thirties and progresses rapidly in the
late thirties and early forties
 Therefore as a woman's age increases, the incidence of infertility also increases
 Sterility affects 1-2% of couples.
 In some cases the choice of prior contraceptive method may have contributed to
infertility, as with the use of some intrauterine devices (IUDs); having an increased
number of sexual partners leads to a greater potential for exposure to sexually
transmitted diseases, which may contribute to infertility
 A conscientious evaluation of the factors contributing to fertility usually indicates a
probable cause in 85-90% of couples
 In women older than 35 years, a complete evaluation after 4-6 months of trying to
conceive is prudent because their response to treatment may be suboptimal due to
diminished ovarian reserve

Etiology

 Reproduction requires the interaction and integrity of the female and male
reproductive tracts, which involves:
1) The release of a normal preovulatory oocyte
2) The production of adequate spermatozoa
3) The normal transport of the gametes to the ampullary portion of the fallopian
tube (where fertilization occurs)

4) The subsequent transport of the cleaving embryo into the endometrial cavity
for implantation and development
 Infertility is caused by male and/or female factors.
 Male and female factors each account for approximately 35% of cases.
 Often, there is more than one factor, with male and female factors combined
causing 20% of infertility.
 In the remaining 10% of cases, the etiology is unknown.
 Couples with unknown etiology can be categorized as unexplained infertility
or normal infertile couples (NICs), indicating that all findings from standard tests
used in the infertility workup are normal.
 In normal infertile couples, the actual cause for infertility cannot be detected; perhaps
there is dysfunctional interaction between the sperm and the oocyte, poor quality of
the embryo, or a disruption at the implantation site.
 Other lifestyle factors that have been associated with an increased risk of infertility
include environmental and occupational factors; toxic effects related to tobacco,
marijuana, or other drugs; excessive exercise; inadequate diet associated with extreme
weight loss or gain; and advanced age.

Female infertility

 Female factor infertility can be divided into several categories: cervical or uterine,
ovarian, tubal, and other

Cervical factor infertility

 Cervical factor infertility can be caused by stenosis or abnormalities of the mucussperm interaction.
 The uterine cervix plays a pivotal role in the transport and capacitation of the sperm
after intercourse.
 Cervical factors account for 5-10% of infertility.
 Cervical mucus production and characteristics change according to the estrogen
concentration during the late follicular phase.
 At the beginning of the menstrual cycle, cervical mucus is scanty, viscous, and very
cellular.
 The mucus forms a netlike structure that does not allow the passage of sperm.
 Mucus secretion increases during the mid follicular phase and reaches its maximum
approximately 24-48 hours before ovulation.
 The water and salt concentration increases, changing the physical characteristics of
the mucus.
 The mucus becomes thin, watery, alkaline, acellular, and elastic (spinnbarkheit)
because of the increased concentration of sodium chloride
 At this point, the mucus organizes itself, forming multiple microchannels so the
spermatozoa can travel through.
 During this journey, the spermatozoa simultaneously undergo activation and
capacitation.

 In addition, the mucus acts as a filter for abnormal spermatozoa and cellular debris
present in the semen
 Mucus secretion may be altered by hormonal changes and medications, especially
drugs like clomiphene citrate, which decrease the production.
 Hypoestrogenism may cause thickened cervical mucus, which impairs the passage of
sperm
 Cervical stenosis can cause infertility by blocking the passage of sperm from the
cervix to the intrauterine cavity.
 Cervical stenosis can be congenital or acquired in etiology, resulting from surgical
procedures, infections, hypoestrogenism, and radiation therapy

Uterine factor infertility

 Uterine factors can be congenital or acquired.
 They may affect the endometrium or myometrium and are responsible for 2-5% of
infertility cases
 Congenital defects: The full spectrum of congenital/müllerian abnormalities varies
from total absence of the uterus and vagina (Rokitansky-Küster-Hauser syndrome) to
minor defects such as arcuate uterus and vaginal septa (transverse or longitudinal).
 Acquired defects: Endometritis associated with a traumatic delivery, dilatation and
curettage, intrauterine device, or any instrumentation (e.g. myomectomy,
hysteroscopy) of the endometrial cavity may create intrauterine adhesions or

synechiae (i.e. Asherman syndrome), with partial or total obliteration of the
endometrial cavity
 Placental polyps may develop from placental remains
 Intrauterine and submucosal fibroids are very common, affecting 25-50% of women.
 They are more common in women of African descent and can cause distortion of the
cavity and compromise the blood supply.
 They may also be implicated in implantation failure, early miscarriages, premature
delivery, and abruptio placentae

Tubal factors

 Abnormalities or damage to the fallopian tube interferes with...