Fawaz Edris MD, ARDMS, AAACS, FRCSC, FACOG

Background

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

Background 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

Infertility

Time of Exposure % Pregnant

3 months 60%

6 months 70%

1 year 85%

18 months 90%

Approach to Infertility

DDX Hx Px Tests/Inv Dx Rx

Approach to Infertility

Production Storage Delivery

Male Infertility1. Production:

HypothalamusAnterior PituitaryTestes

Hypothalamic-Pituitary-Gonadal Axis

Male Infertility 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)○ XRT○ Drugs: marijuana,

Male Infertility 1. Production:

Pituitary○ Endocrine: thyroid, prolactin○ Tumors○ Inflammation: sarcoidosis, meningitis○ Infiltration○ Infarction○ Trauma/XRT○ Drugs: anabolic steroids

Male Infertility 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

Male Infertility

2. Storage:Temperature

○ Rise in scrotal temperature○ Occupation○ Varicocoele

Male Infertility

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

Male Infertility History:

Previous childrenInfections: prostatitis, STD, mumps orchitisTrauma to head or testiclesSurgery to testicles or herniaOccupation (sitting, bio hazards, XRT)Chemo or Radio therapyEthanol or SmokingMedicationMedical history (DM, HTN)Previous investigations

Male Infertility

PhysicalAnatomy (meatus)Testicular sizeVaricocele (valsalva)Rectal exam (protatitis, discharge)

Male Infertility

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

Male Infertility

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

Male Infertility

Tx / Interventions:Treat underlying causesIntrauterine Insemination (IUI)Intracytoplasmic Sperm Injection (ICSI)

Female Infertility

Fecundability: probability of achieving a pregnancy within 1 menstrual cycle (25%)

Fecundity: ability to achieve a live birth within 1 menstrual cycle (6%)

Female Infertility

Production Storage Delivery

Female Fertility Production:

HypothalamusPituitaryOvary

Hypothalamic-Pituitary-Gonadal Axis

Female Infertility 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

Female Infertility

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

Female Infertility

OvaryGonadal dysgenesis - Turner’s Syndrome

45XO or mosaics 46 XX/45 XOTesticular feminizationXRT / Chemo for childhood malignanciesPremature ovarian failure

Female Infertility

Storage (R.P.L. unless severe)Uterine abnormalitiesMullerian Agenesis: Mayer-Rokitansky-

Kuster-Hauser syndromeAsherman’s syndromeLeiomyoma Luteal phase deficiency

Female Infertility

Delivery:Uterine abnormalitiesVaginal septumTubal Disease

○ Infections/ STD/PID○ Ruptured appendix○ Septic abortion

Endometriosis

Female Infertility History:

AgeGTPALRegulatory of periodProlactin S/SThyroid S/SInfections, SurgeriesMedication, Smoking, EthanolMedical history Previous investigations

Female Infertility

Examination:ThyroidBreast (milk)Abdomen (masses, scars)Vaginal (abnormalities)Bimanual (Uterus, masses)

Investigations Blood work:

TSHPRLD3 FSHD3 LHLuteal phase Progesterone

Imaging:Pelvic UltrasoundHSG

DiagnosticLaparoscopy (later)

Treatment

Treat the underlying cause Medical Surgical

Treatment Anovulation:

Clomiphene induction IUIGonadotropin IUI

IVFBilateral tubal diseaseUnexplained infertility after Gonadotropin + IUI

failure.Failure of the above

ICSIMale factorUnexplained infertility

Take Home Points

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: SpermsFemale: Tubes (HSG) + Ovaries (FSH, LH,

PRL, TSH)

Thank you