Chris Davies & Greg Handley

Chris Davies & Greg Handley

Contents Definition Epidemiology Aetiology Conditions for pregnancy Female Infertility Male Infertility Shared infertility Treatment

Definition Failure of a couple to conceive after 12 months of regular unprotected intercourse Primary: never been pregnant before Secondary: previous pregnancies

Epidemiology Infertility affects 1 in 7 couples. Prevalence; 3.5 million in the UK Following regular unprotected intercourse 84% conceive within 1 year 92% conceive within 2 years

Aetiology Contributing factors to infertility

Conditions for pregnancy 1. An egg must be produced 2. Adequate sperm must be released 3. The sperm must reach the egg 4. The fertilized egg (embryo) must implant

Female Infertility Conditions impacting fertility; Damaged fallopian tubes Ovulatory Problems Endometriosis Uterine conditions Contributing factors; Age (female fertility declines sharply after 35 years) Medical conditions (diabetes, epilepsy, thyroid disease) Lifestyle factors (stress, overweight or underweight, smoking)

Anatomy Fallopian tube Ovary Uterus Endometrium Cervix Vagina

Fallopian tubes Contributes 20% of infertility Causes include; Pelvic inflammatory disease (PID) (1 episode:12% infertility, 2 episodes:23%, 3 episodes:53%) Endometriosis resulting in occlusion Adhesions distorting tube Hysterosalpingogram can demonstrate lumen of tubes

Ovulatory Problems Contributes 25% of infertility Causes include; Hormone imbalance: LH, FSH, Oestrogen, Progesterone Polycystic ovary syndrome: reduced ovulation Structural problems General medical problems: high or low BMI, high exercise, metabolic conditions Cancer Treatment: chemo and radiotherapy

Endometriosis Not understood exactly how it reduces fertility Likely mechanisms; Distorted pelvic anatomy in severe disease Impaired oocyte and sperm movement Reduced fertilisation and implantation Proposed mechanisms; Inflammatory cytokines Incorrect gene expression

Anatomy Fallopian tube Ovary Uterus Endometriu m Cervix Vagina

Uterine Numerous mechanisms of subfertility; Uterine malformations (6.7% of population, 7.3% of those infertile) Fibroids: submucosal and intramural fibroids reduce fertility Asherman s Syndrome: adhesions of fibroids of the myometrium Implantation failure: abnormal hormones or cytokines

Anatomy Fallopian tube Ovary Uterus Endometrium Cervix Vagina

Contributing Factors Age fertility declines in the 30 s, by 40 years a woman has 5% chance of pregnancy per cycle. Medical conditions diabetes (PCOS), epilepsy (3x infertility levels), thyroid (hypo/hyper) Lifestyle factors Extremes in body weight, stress, alcohol, cocaine, caffeine.

Male Infertility Conditions impacting fertility; Testicular Pre testicular Post testicular Contributing factors

Anatomy Seminal vesicle Bladder Vas deferens Ampulla Prostate Urethra Ejaculatory duct Penis Bulbourethral gland Epididym is Testis

Anatomy Seminal vesicle Ampulla Bladder Prostate Vas deferens Urethra Ejaculatory duct Penis Bulbourethral gland Epididymis Testis

Testicular Production of sperm. Production of enough sperm. Low number of sperm in semen = a low sperm count. (<15million sperm per ml of semen) A low sperm count Lower chance of sperm fertilising egg. Sperm must be functional and able to move. If the movement (motility) or function of the sperm is abnormal, it may not be able to reach or penetrate the egg.

Definitions: Oligozoospermia low sperm count Azoospermia absence of sperm in ejaculate Teratozoospermia Abnormal morphology Asthenozoospermia reduced sperm motility

Testicular Varicocele Engorged pampiniform venous plexus. Thought to impair temperature regulation of testes. Most common cause of reversible infertility in men. Cryptorchidism undescended testicle(s) Hydrocele Fluid build up around testis Trauma Cancer

Pre testicular Obesity Obesity reduces sperm quality Being underweight BMI <18.5 Coeliac disease Reduced semen quality Can cause hypogonadism and hyperprolactinaemia, leading to impotence and loss of libido Smoking Tobacco smoking damages the testicles and is spermicidal Drugs Can affect sperm count chemotherapy, cimetidine, spironolactone Can affect sperm motility sulfasalazine and nitrofurantoin

Post testicular Congenital Absence of vas deferens (Cystic Fibrosis) Hypospadias Meatus isn't at the tip of the penis. Impairs semen delivery Post infection Inflammation and/ or scarring blocks the passage of sperm Trauma Retrograde ejaculation semen is redirected into the urinary bladder. Dysfunction of bladder sphincter Auto immune Anti sperm antibodies can be produced, which attack sperm cells Ejaculatory duct obstruction Vasectomy Vas deferens is tied and severed. Very low failure rate

Contributing factors Illicit Drug use Anabolic steroids can cause the testicles to shrink and sperm production to decrease Cocaine or marijuana may temporarily reduce the number and quality of your sperm Impotence Premature ejaculation Exposure to radiation or heat Alcohol Drinking alcohol can lower testosterone levels, cause erectile dysfunction and decrease sperm production

Shared Infertility Often find a combination of the factors mentioned previously Environmental factors (stress, BMI) worth considering

Treatment Eligibility Type of treatment and waiting list varies across country Referral via GP General advice Weight management Ovulatory cycle awareness Reduce risk factors Expensive treatments such as IVF have stringent criteria Infertility >1year Woman <42 (varies geographically) No previous IVF No living child BMI 19 29.9

Treatment Types Three areas of fertility treatment Medicines to assist fertility Surgical procedures Assisted contraception

Treatment medication Clomifene/Tamoxifen: encourages ovulation Metformin: beneficial in PCOS Luteal support: give progestin's to increase chance of implantation Gonadotropins: may stimulate ovulation and improve fertility in men However, ovulatory stimulation should not be given to women with unexplained infertility

Treatment surgery Tuboplasty: to restore patency of fallopian tubes (PID) Estimates of success vary (20 50%) Increased risk of ectopic pregnancy Laparoscopy to reduce endometriosis Ovarian drilling to destroy part of the ovary in PCOS Correct epididymal blockage Surgical extraction of sperm

Treatment assisted contraception Intrauterine insemination (IUI) Sperm is placed into the womb via a fine plastic tube Best quality sperm selected 15% success per treatment In vitro fertilisation (IVF) Eggs are removed and then fertilised outside the body Embryo implanted into womb 32% success per cycle Egg and Sperm donation

References http://www.who.int/reproductivehealth/topics/infertility/ definitions/en/ http://www.nhs.uk/conditions/infertility/pages/introducti on.aspx https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3786590/ http://www.bmj.com/content/338/bmj.b126 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3538128/ https://www.asrm.org/uploadedfiles/asrm_content/res ources/patient_resources/fact_sheets_and_info_booklets /agefertility.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3205530/