Clinical evaluation of infertility DR. FARIBA KHANIPOUYANI OBSTETRICIAN & GYNECOLOGIST PRENATOLOGIST
Definition: inability to achieve conception despite one year of frequent unprotected intercourse.
Male factor 23 percent Ovulatory dysfunction 18 percent Tubal damage 14 percent Endometriosis 9 percent Coital problems 5 percent Cervical factor 3 percent Unexplained 28 percent
causes of male infertility Primary hypogonadism 10-15 percent Seminiferous tubule dysfunction 60 to 80 percent including microdeletions of the Y chromosome Post-testicular defects (disorders of sperm transport) 10 to 20 percent Hypothalamic pituitary disease(secondary hypogonadism) -1-2 percent
assessment of male factor a specific etiology or treatment can be found in only a few descriptions of observed abnormalities, such as decreased sperm number, movement, or egg penetrating and fusion capabilities Even testicular biopsies have provided little insight; they simply indicated the extent of impaired germ cell maturation. Use of molecular biology techniques has allowed definition of gene deletions and mutations in male infertility
components of the evaluation of male infertility history Endocrine tests Physical examination Genetic tests Semen analysis
History Developmental history, including testicular descent, pubertal development, loss of body hair, or decrease in shaving frequency Chronic medical illness Infections, such as mumps orchitis, sinopulmonary symptoms, sexually transmitted infections, and genitourinary tract infections including prostatitis Surgical procedures involving the inguinal and scrotal areas such as vasectomy, orchiectomy, and herniorrhaphy Drugs and environmental exposures, including alcohol, radiation therapy, anabolic steroids, cytotoxic chemotherapy, drugs that cause hyperprolactinemia, and exposure to toxic chemicals (eg, pesticides, hormonal disrupters) Sexual history, including libido, frequency of intercourse, and previous fertility assessments of the man and his partner School performance, to determine if he has a history of learning disabilities suggestive of Klinefelter's syndrome
PHYSICAL EXAMINATION focus on finding evidence of androgen deficiency depends upon the age of onset early gestation: as ambiguous genitalia late gestation: as micropenisi childhood: as delayed pubertal development adulthood: as decreased sexual function, infertility,and loss of secondary sex charactristics
General appearance Eunuchoidal proportions (upper/lower body ratio <1 with an arm span 5 cm >standing height) increased body fat and decreased muscle mass : androgen deficiency. Skin Loss of pubic, axillary, and facial hair, decreased oiliness of the skin, and fine facial wrinkling suggest long-standing androgen deficiency. External genitalia : Incomplete sexual development ( Tanner stage ) Diseases that affect sperm maturation and transport: absence of the vas, epididymal thickening, varicocele, and hernia Decreased volume of the seminiferous tubules : testicular size ( testicular volume below 15 ml and testicular length below 3.6 cm are considered small) Breasts Gynecomastia suggests a decreased androgen to estrogen ratio.
STANDARD SEMEN ANALYSIS Measurement of semen volume and ph Microscopy for debris and agglutination Assessment of sperm concentration, motility, and morphology Sperm leukocyte count Search for immature germ cells
WHO lower reference limits Volum- 1.5 ml Sperm concentration 15 million spermatozoa / ml Total sperm number 39 million spermatozoa per ejaculate Morphology 4 percent normal forms Vitality 58 percent live Progressive motility 32 percent Total(progressive & nonprogressive motility) -40 percent
SPECIALIZED SEMEN ANALYSIS Human zona pellucida binding test Zona-free hamster oocyte penetration test Acrosome reaction Computer-aided sperm analysis Sperm function tests Sperm-cervical mucus interaction Semen culture Semen biochemistry Sperm autoantibodies Sperm biochemistry Sperm chromatin and DNA assay
GENETIC TESTS CFTR gene Sex chromosome & somatic mutation Anderogen receptor
ENDOCRINE TESTS Serum testosterone Serum LH & FSH Others (prolactin,inhibin B)
azoospermia Normal LH OSTRUCTIVE AZOOSPERMIA Normal FSH Normal TESTOSTRONE
AZOOSPERMIA NORMAL LH NORMAL FSH OBSTRUCTIVE AZOOSPERMIA: Bilateral congenital absence of the vas NORMAL TESTOSTERONE
Evaluation of female infertility
infertility evaluation after one year in women under age 35 year after six months in women age 35 years and older sooner in women with irregular menstrual cycles or known risk factors for infertility
History and physical examination
most important points in the history Duration of infertility and results of previous evaluation and therapy Menstrual history Medical, surgical, and gynecological history Obstetrical history Sexual history Family history Personal and lifestyle history
Physical examination as extremes of BMI are associated with reduced fertility and abdominal obesity is associated with insulin resistance. of secondary sexual characteristics is a sign of hypogonadotropic hypogonadism. thyroid gland, galactorrhea, hirsutism, acne, male pattern baldness, virilization Tenderness or masses in the adnexae or posterior cul-de-sac ( chronic pelvic inflammatory disease or endometriosis) Vaginal/cervical structural abnormalities or discharge Uterine enlargement, irregularity, or lack of mobility( uterine anomaly, leiomyoma, endometriosis, or pelvic adhesive disease).
Diagnostic tests Semen analysis tests of ovarian reserve ( cycle day 3 FSH or estradiol, clomiphene citrate challenge test, AMH, or antral follicle Documentation of normal ovulatory function rule out tubal occlusion and assess the uterine cavity (HSG, laparoscopy with hysteroscopy Preconception laboratory screening
Assessment of the uterine cavity saline infusion sonohysterography HyCoSy three-dimensional sonography hysteroscopy hysterosalpingogr aphy
Karyotype male partner if there is severe oligospermia Separate testing for Y chromosome microdeletions may also be offered women with very early premature menopause (prior to age 40) both partners if there have been recurrent pregnancy losses Karyotype may be useful in patients who have failed initial treatment approaches and plan to undergo IVF