Makindo Medical Notes

About Infertility

Infertility is defined as the inability to conceive after 12 months of regular, unprotected sexual intercourse. It affects both men and women and can be classified as primary or secondary infertility based on the patient's reproductive history. Infertility can have significant psychological, social, and emotional impacts on individuals and couples.

Aetiology

The causes of infertility are diverse and can be attributed to factors related to either partner or a combination of both. Understanding the underlying cause is essential for appropriate management and treatment.

• Primary Infertility: Infertility without a previous pregnancy or live birth.
• Secondary Infertility: Failure to conceive after one or more pregnancies, whether successful or ending in miscarriage, ectopic pregnancy, or voluntary termination.

Risks

Certain factors increase the risk of developing infertility. These include:

• Age: Women over 35 and men older than 40 may experience reduced fertility due to declining reproductive capabilities.
• Male Factors: Older men may have sperm abnormalities and increased DNA fragmentation, affecting fertility.
• Lifestyle Factors: Excessive alcohol consumption, smoking, and obesity can negatively impact fertility in both genders.
• Chronic Health Conditions: Conditions such as diabetes, thyroid disorders, and autoimmune diseases can affect reproductive health.

Causes

Infertility can result from a variety of factors affecting either partner. Key causes include:

• Ovulatory Problems: Irregular or absent ovulation can prevent the release of eggs. Diagnostic tests include measuring LH (Luteinizing Hormone), FSH (Follicle-Stimulating Hormone), and prolactin (PRL) levels.
• Sperm Quality: Low sperm count, poor motility, or abnormal morphology can impede fertilization.
• Endometriosis: A condition where endometrial tissue grows outside the uterus, affecting fertility.
• Blocked Fallopian Tubes: Previous infections, surgeries, or congenital abnormalities can lead to blockages preventing sperm from reaching the egg.
• Unexplained Infertility: When no specific cause is identified despite thorough evaluation.
• Other Causes: Including hormonal imbalances, uterine fibroids, polycystic ovary syndrome (PCOS), and genetic factors.

Clinical Presentation

The evaluation of infertility involves a comprehensive clinical assessment of both partners. Key aspects include:

• Joint Consultation: Examine both partners together to assess potential combined factors contributing to infertility.
• Demographics: Determine age, occupation, and educational background, as these can influence fertility and access to care.
• Reproductive History: Review previous conceptions, pregnancies, and any complications such as miscarriages, ectopic pregnancies, or voluntary terminations.
• Gynecological History: Assess for past gynecological issues, surgeries, and any history of pelvic inflammatory disease (PID).
• Sexual History: Evaluate frequency of intercourse, sexual satisfaction, presence of pain during intercourse, abnormal discharge, or bleeding.
• Male Health Assessment: Review overall health, substance use (alcohol, smoking), and conduct a physical examination including assessment of testes.
• Previous Infections: Screen for sexually transmitted diseases (STDs) and history of pelvic inflammatory disease (PID) in women.

Differentials

Differential diagnoses to consider when evaluating infertility include:

• Polycystic Ovary Syndrome (PCOS): A hormonal disorder causing irregular menstrual periods and excess androgen levels.
• Premature Ovarian Insufficiency (POI): Reduced function of the ovaries before the age of 40.
• Hypogonadotropic Hypogonadism: Insufficient production of gonadotropins leading to reduced sex hormone levels.
• Genetic Disorders: Such as Kallmann syndrome or Y chromosome microdeletions affecting sperm production.
• Structural Uterine Anomalies: Including septate uterus or uterine synechiae affecting implantation.
• Immunological Infertility: Presence of anti-sperm antibodies preventing sperm from fertilizing the egg.

Investigations

A systematic approach is essential for diagnosing the underlying cause of infertility. Investigations may include:

For Women:

• Ovulation Assessment:
  • Basal body temperature charting.
  • Serum progesterone levels during the luteal phase.
  • Ultrasound monitoring of ovarian follicles.
• Hormonal Evaluation:
  • LH, FSH, PRL, thyroid function tests, and androgen levels.
• Imaging Studies:
  • Transvaginal ultrasound to assess uterine and ovarian structures.
  • Hysterosalpingography (HSG) to evaluate fallopian tube patency.
  • Laparoscopy to diagnose endometriosis or pelvic adhesions.
• Other Tests:
  • Endometrial biopsy to assess uterine receptivity.

For Men:

• Sperm Analysis: Evaluates sperm count, motility, morphology, and volume.
• Hormonal Profile: LH, FSH, testosterone levels.
• Genetic Testing: For cases of azoospermia or severe oligospermia.
• Imaging:
  • Scrotal ultrasound to detect varicocele or testicular abnormalities.

Management

Management of infertility depends on the underlying cause and may involve medical, surgical, or assisted reproductive techniques:

• Ovulation Induction:
  • Clomiphene citrate or letrozole to stimulate ovulation in women with ovulatory disorders.
  • Gonadotropins for more severe cases.
• Sperm Retrieval and Enhancement:
  • Varicocele repair in men with varicocele.
  • Intracytoplasmic sperm injection (ICSI) for male factor infertility.
• Surgical Interventions:
  • Correction of tubal blockages via laparoscopic surgery.
  • Removal of uterine fibroids or septa.
  • Treatment of endometriosis.
• Assisted Reproductive Technologies (ART):
  • In Vitro Fertilization (IVF).
  • Intracytoplasmic Sperm Injection (ICSI).
  • Use of donor eggs or sperm if necessary.
• Lifestyle Modifications:
  • Weight management, smoking cessation, and reduction of alcohol intake.
  • Improvement of diet and exercise habits.
• Psychological Support:
  • Counseling and support groups to help manage the emotional impact of infertility.
• Alternative Therapies:
  • Acupuncture and other complementary therapies may be considered adjunctively.

Prognosis

The prognosis for infertility varies based on the underlying cause and the timeliness of intervention. Many couples achieve successful pregnancies with appropriate treatment:

• Ovulatory Disorders: High success rates with ovulation induction medications.
• Male Factor Infertility: Good prognosis with treatments like ICSI and varicocele repair.
• Fallopian Tube Obstructions: Successful pregnancies following surgical correction or ART.
• Endometriosis: Variable outcomes; may require surgical intervention and ART for best results.
• Unexplained Infertility: Couples may conceive spontaneously or require ART for conception.

Conclusion

Infertility is a complex condition with multifactorial causes affecting both men and women. Comprehensive evaluation and targeted management are essential for improving fertility outcomes. Advances in medical and surgical treatments, along with assisted reproductive technologies, have significantly enhanced the prospects for couples struggling with infertility. Early intervention and a multidisciplinary approach can optimize the chances of successful conception and pregnancy.

References

• American Society for Reproductive Medicine. Guidelines for the Evaluation and Treatment of Infertility. 2015.
• Practice Committee of the American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. 2015;104(3):e26-41.
• Practice Committee of the American Society for Reproductive Medicine. Diagnostic evaluation of the infertile male: a committee opinion. Fertil Steril. 2015;103(3):e18-25.
• Morales L, et al. Male infertility: an overview. In: StatPearls [Internet]. StatPearls Publishing; 2023.
• Fauser BCJ, et al. Consensus on women's health aspects of polycystic ovary syndrome (PCOS). Hum Reprod. 2012;27(3):1146-1165.
• Jain S, et al. Endometriosis and infertility. Fertil Steril. 2010;93(1):S48-52.
• Legro RS, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2013;98(12):4565-4592.
• Dhillo WS, et al. Male infertility: evaluation and management. BMJ. 2015;351:h3687.