Infertility

Infertility & Fertility
Essentials
Infertility & fertility in Males & Females of
Reproductives Ages
Instructor: Dr. Ezekwu Precious K., MLS, OHS
Date：17th - 18th April, 2020

contents
INTRODUCTION01
INFERTILITY IN MALES02
INFERTILITY IN FEMALES03
INFERTILITY TREATMENT04

When a couple experiences problems with fertility, the cause(s) can be
multiple and overlapping. Problems in the male are just as likely as
problems in the female, and it is equally likely that the cause is a
combination from both partners.
In many cases, the exact cause of the infertility remains unknown or
unexplained—a situation called idiopathic infertility.
In some cases, these causes or factors overlap and occur at the same time,
compounding their effects on fertility.

Infertility Definitions and Terminology
• Infertility is “a disease of the reproductive system defined by the failure
to achieve a clinical pregnancy after 12 months or more of regular
unprotected sexual intercourse.”… (WHO-ICMART glossary1).
• Infertility is the inability of a sexually active, non-contracepting couple
to achieve pregnancy in one year. The male partner can be evaluated for
infertility or subfertility using a variety of clinical interventions, and also
from a laboratory evaluation of semen.” (Semen manual, 5th Edition).
Demographic Definitions of Infertility
• Infertility: An inability of those of reproductive age (15-49 years) to
become or remain pregnant within five years of exposure to pregnancy.
(DHS2)
• Infertility: An inability to become pregnant with a live birth, within five
years of exposure based upon a consistent union status, lack of
contraceptive use, non-lactating and maintaining a desire for a child.
(Trends in prevalence).
Clinical Definitions

Epidemiological Definition of Infertility
(for monitoring and surveillance) Women of reproductive age (15–
49 years) at risk of becoming pregnant (not pregnant, sexually
active, not using contraception and not lactating) who report trying
unsuccessfully for a pregnancy for two years or more.
(Reproductive Health Indicators)
Infertility as a Disability
Disability: Infertility generates disability (an impairment of
function), and thus access to health care falls under the Convention
on the Rights of Persons with Disability. An estimated 34 million
women, predominantly from developing countries, have infertility
which resulted from maternal sepsis and unsafe abortion (long term
maternal morbidity resulting in a disability). Infertility in women
was ranked the 5th highest serious global disability (among
populations under the age of 60).

Primary Infertility
When a woman is unable to ever bear a child, either due to the
inability to become pregnant or the inability to carry a pregnancy to
a live birth she would be classified as having primary infertility.
Thus women whose pregnancy spontaneously miscarries, or whose
pregnancy results in a still born child, without ever having had a
live birth would present with primarily infertility. (Trends in prevalence).
Secondary Infertility
When a woman is unable to bear a child, either due to the inability
to become pregnant or the inability to carry a pregnancy to a live
birth following either a previous pregnancy or a previous ability to
carry a pregnancy to a live birth, she would be classified as having
secondary infertility. Thus those who repeatedly spontaneously
miscarry or whose pregnancy results in a stillbirth, or following a
previous pregnancy or a previous ability to do so, are then not
unable to carry a pregnancy to a live birth would present with
secondarily infertile. (Trends in prevalence)

Global infertility prevalence rates are
difficult to determine, due to the
presence of both male and female
factors which complicate any estimate
which may only address the woman
and an outcome of a pregnancy
diagnosis or live birth.
Global prevalence of infertility, infecundity and childlessness

New infertility prevalence calculation
One in every four couples in
developing countries had been found
to be affected by infertility,When an
evaluation of responses from women in
Demographic and Health Surveys from
1990 was completed in collaboration
with WHO in 2004.
The burden remains high. A WHO
study, published at the end of 2012, has
shown that the overall burden of
infertility in women from 190 countries
has remained similar in estimated
levels and trends from 1990 to 2010.

INFERTILITY IN MALES
Men also contribute to infertility in a couple. In fact, men are
found to be the only cause or a contributing cause of infertility
problems in couples in about 40% of cases.
• To conceive a child, a male's sperm must combine with a
female's egg. The testicles make and store sperm, which are
ejaculated by the penis to deliver sperm to the female
reproductive tract during sexual intercourse.
• The most common issues are problems that affect how the
testicles work. Other problems are hormone imbalances or
blockages or absence of some of the ducts in the male
reproductive organs.
Lifestyle factors and age-related factors also play a role in
male infertility.

1) Conditions That affects Sperm Formation
Many different issues can affect the formation of sperm in the
testicles. These conditions can lead to sperm that is abnormally
shaped or malformed or to low amounts of sperm.
Common issues includes;
• Chromosome defects
• Diabetes
• Hyperprolactinemia (pronounced hi-purr-proh-lak-tih-NEE-
mee-ah), which is overproduction of a hormone called
prolactin made by the pituitary gland
• Injury to the testicle
• Insensitivity to hormones called androgens, which include
testosterone
• Swelling of the testicles from infections such as mumps,
gonorrhea, or chlamydia
• Chromosome disorder called Klinefelter syndrome
• Thyroid problems

Conditions That affects Sperm Formation
Cont.
Common issues includes;
• Cryptorchidism (pronounced krip-TAWR-ki-diz-uhm), which occurs when one or both
testicles are not descended
• Varicocele, which is the enlargement of veins in the scrotum; enlarged veins disrupt the blood
flow in the testicle and cause an increase in temperature, which negatively affects sperm
production. This condition is present in about 40% of men with fertility problems.5
• Remember that lifestyle, environmental, and age-related factors can also play a role in male
infertility.

2) Conditions That affects Sperm Transport
Even if the male's body produces enough viable sperm, sometimes
factors and conditions that affect how or whether the sperm moves can
also contribute to infertility.
• Sperm may move too slowly or not at all and thus die before they can
reach the egg. Sometimes the seminal fluid, which contains the
sperm, is too thick for the sperm to move around properly.
• An inability to transport sperm from the testicles to the penis causes
about 10% to 20% of the cases of male infertility. The inability can
be caused by natural blockages in the tubes that transport sperm from
the testicles to the penis or from vasectomy, a surgical procedure that
cuts and seals the ends of the tubes.

In males, age is known to reduce the quality of sperm, which affects the sperm's
ability to reach or fertilize an egg. Men also produce fewer sperm as they age.
Other age-related causes of reduced fertility in males include:
Genetic abnormalities of the sperm; which can reduce the chances of their
partner becoming pregnant or increase the likelihood of miscarriage or of an
infant having a condition such as Down syndrome
Erectile dysfunction; which can be affected by decreasing testosterone levels as
a man ages or by medications for age-related conditions such as hypertension
Changes to the reproductive tissues or organs; For example, testicle volume
decreases with age. Also, men may have an enlarged prostate, which can cause
problems with ejaculations.
Lifestyle and Environmental Factors In Males

Major lifestyle factors that are associated with male infertility are
• Smoking
• Cigarettes,
• Alcohol intake,
• Use of illicit drugs,
• Obesity,
• Psychological stress
• Advanced paternal age
• Dietary practices, and coffee consumption.
• Other factors such as testicular heat stress, intense cycling training, lack of sleep and
exposure to electromagnetic radiation from mobile phone use are briefly discussed.

When health care providers cannot find a specific or even likely
cause for infertility in males, they will diagnose the infertility as
"idiopathic" or unexplained.
This diagnosis applies to about 50% of male infertility cases.
In some cases, however, knowing the exact cause may not be
necessary. The health care provider may begin treatment to
improve the chances of conception, including fertility
treatments, even if no cause can be identified.
Idiopathic or Unexplained Infertility Males

PART 03
INFERTILITY IN FEMALES

Getting pregnant and carrying a pregnancy to term are actually very
complicated processes.
Many things can go wrong during these processes to lead to infertility.
For this reason, the following list includes only some of the common
causes of infertility in females; it is not meant to be all-inclusive.
A woman who is having difficulty getting pregnant or carrying a
pregnancy to term should talk with her health care provider about
possible treatments.
INFERTILITY IN FEMALES

The most common overall cause of female infertility is the failure to ovulate,
which occurs in 40% of women with infertility issues.
Not ovulating can result from several causes, such as:
Ovarian or gynecological conditions; such as primary ovarian insufficiency
(POI) or polycystic ovary syndrome (PCOS)
Aging; including "diminished ovarian reserve," which refers to a low number of
eggs in a woman's ovaries due to normal aging
Endocrine disorders; such as thyroid disease or problems with the
hypothalamus, which affect the hormones produced by the body so that there
might be too much or too little of a hormone or group of hormones
Lifestyle and environmental factors
1) FAILURE TO OVULATE

Problems with the menstrual cycle, the process that prepares the female body for
pregnancy, can lead to infertility.
The menstrual cycle includes several phases, and problems at any one of the
stages can lead to difficulty getting pregnant or to infertility.
For most women, a normal menstrual cycle ranges from 21 to 35 days. However,
14% to 25% of women have irregular menstrual cycles, meaning the cycles are
shorter or longer than normal; are heavier or lighter than normal; or are
experienced with other problems, like abdominal cramps.
Irregular cycles can be ovulatory, meaning that ovulation occurs, or anovulatory,
meaning ovulation does not occur.
2) PROBLEMS WITH MENSTRUAL CYCLE

The most common menstrual irregularities include:
Amenorrhea (pronounced ey-men-uh-REE-uh) or absent menstrual periods:
When a woman does not get her period by age 16, or when she stops getting her
period for at least 3 months and is not pregnant.
Oligomenorrhea (pronounced ol-i-goh-men-uh-REE-uh) or infrequent
menstrual periods:
Periods that occur more than 35 days apart.
Menorrhagia (pronounced men-uh-REY-jee-uh) or heavy menstrual periods:
Also called excessive bleeding. Although anovulatory bleeding and menorrhagia
are sometimes grouped together, they do not have the same cause and require
different diagnostic testing.
PROBLEMS WITH MENSTRUAL CYCLE cont. 1

Prolonged menstrual bleeding: Bleeding that exceeds 8 days in duration on a
regular basis.
Dysmenorrhea (pronounced dis-men-uh-REE-uh): Painful periods that may
include severe menstrual cramps.
Additional menstrual irregularities include:
Polymenorrhea (pronounced pol-ee-men-uh-REE-uh): Frequent menstrual
periods occurring less than 21 days apart
• Irregular menstrual periods with a cycle-to-cycle variation of more than 20
days
• Shortened menstrual bleeding of less than 2 days in duration.
Intermenstrual bleeding: Episodes of bleeding that occur between periods, also
known as spotting
PROBLEMS WITH MENSTRUAL CYCLE cont. 2

Structural problems usually involve the presence of abnormal tissue in the fallopian tubes or
uterus.
If the fallopian tubes are blocked, eggs are not able to move from the ovaries to the uterus
and sperm is not able to reach the egg for fertilization.
3) STRUCTURAL PROBLEMS WITH REPRODUCTIVE SYSTEM.
Structural problems with the uterus, such as
those that may interfere with implantation, can
also cause infertility.
Some specific structural problems that can
cause infertility include:
Endometriosis; when tissue that normally
lines the inside of the uterus is found in other
places, such as blocking the fallopian tubes

Uterine fibroids;
growths that appear within and around the wall of the
uterus, although most women with fibroids do not
have problems with fertility and can get pregnant.
However, some women with fibroids may not be able
to get pregnant naturally or may have multiple
miscarriages or preterm labor.
Polyps, which are noncancerous growths on the
inside surface of the uterus. Polyps can interfere with
the function of the uterus and make it difficult for a
woman to remain pregnant after conception. Surgical
removal of the polyps can increase the chances for a
woman to get pregnant.
STRUCTURAL PROBLEMS WITH REPRODUCTIVE SYSTEM cont. 1

Scarring in the uterus from previous injuries,
infections, or surgery. Scarring may increase the risk
of miscarriage and may interfere with implantation,
thus leading to infertility.
An unusually shaped uterus, which can affect
implantation and the ability to carry a pregnancy to
term
STRUCTURAL PROBLEMS WITH REPRODUCTIVE SYSTEM cont. 2

Infections can also cause infertility in men and women.
Untreated gonorrhea and chlamydia in women can lead to pelvic inflammatory
disease, which might cause scarring that blocks the fallopian tubes.
Untreated syphilis increases the risk for a pregnant woman to have a stillbirth.
Chronic infections in the cervix and surgical treatment of cervical lesions
associated with human papillomavirus (HPV) infection can also reduce the
amount or quality of cervical mucus.
Problems with this sticky or slippery substance that collects on the cervix and in
the vagina can make it difficult for women to get pregnant.
4) INFECTIONS

Eggs may not mature properly for a variety of reasons, ranging from conditions
such as PCOS, to obesity, to a lack of specific proteins needed for the egg to
mature.
An immature egg may not be released at the correct time, may not make it down
the fallopian tubes, or may not be able to be fertilized.
5) FAILUTRE OF AN EGG TO MATURE
6) IMPLANTATION FAILURE
Refers to the failure of a fertilized egg to implant in the uterine wall to begin
pregnancy. While the specific cause of implantation failure are often unknown,
possibilities include:
• Genetic defects in the embryo
• Thin endometrium (pronounced en-doh-MEE-tree-uhm)
• Embryonic defects
• Endometriosis
• Progesterone resistance
• Scar tissue in the endometrial cavity

7) POLYCYSTIC OVARIAN SYNDROME
PCOS is one of the most common causes of female
infertility.
It is a condition in which a woman's ovaries and, in
some cases, adrenal glands produce more androgens
(a type of hormone) than normal.
High levels of these hormones interfere with the
development of ovarian follicles and release of eggs
during ovulation. As a result, fluid-filled sacs, or
cysts, can develop within the ovaries.
Researchers estimate that 5% to 10% of women in
the United States have PCOS. The exact cause of
PCOS is unknown, but current research suggests
that a combination of genetic and environmental
factors leads to the disease.

8) PRIMARY OVARIAN INSUFFICIENCY
POI is a condition in which a woman's ovaries stop producing hormones and eggs
at a young age.
Women with POI ovulate irregularly, if at all, and may have abnormal levels of
ovarian and pituitary hormones due to problems with their ovaries.
Women with POI often have trouble getting pregnant. However, pregnancy is still
possible, though rare. About 5% to 10% of women with POI get pregnant without
medical treatment

Uterine fibroids are noncancerous growths that form inside the uterus. Uterine fibroids can
cause symptoms in some cases, depending on their size and location. Scientists do not know
what causes fibroids to form, but it is believed that there may be a genetic basis.
Fibroids can contribute to infertility and are found in 5% to 10% of infertile women. Fibroids
located in the uterine cavity (as opposed to those that grow within the uterine wall) or those that
are larger than 6 centimeters in diameter are more likely to have a negative effect on fertility.
9) UTERINE FIBROID

Fibroids are more likely to affect a woman's fertility if they:
• Change the position of the cervix, which can reduce the number of sperm that enter the
uterus.
• Change the shape of the uterus, which can interfere with the movement of sperm or
implantation.
• Block the fallopian tubes, which prevents sperm from reaching the egg and keeps a fertilized
egg from moving to the uterus.
• Interfere with blood flow to the uterus, which can prevent the embryo from implanting
UTERINE FIBROID cont.

Autoimmune disorders cause the body's
immune system to attack normal body tissues it
would normally ignore.
Autoimmune disorders, such as
• lupus
• Hashimoto's and other types of thyroiditis,
or rheumatoid arthritis, may affect fertility.
The reasons for this are not fully understood
and differ between diseases, but they are
thought to involve inflammation in the uterus
and placenta or medications used to treat the
diseases. Both men and women can make
antibodies that attack sperm or the
reproductive organs
10) Autoimmune Disorders

Treatments for infertility can range from medications to
embryo implantation through assisted reproductive
technology (ART).
There are treatments that are specifically for men or for women
and some that involve both partners.
In 85% to 90% of cases, infertility is treated with
conventional medical therapies, such as medication or
surgery.
If fertility treatments are unsuccessful, it is possible to use eggs
or sperm donated by a third party or to have another woman
carry a fetus. Select a category of treatment to learn more.
INFERTILITY TREATMENT

Treatment with Medication
Medication can treat some issues that affect male fertility, including hormone imbalances and
erectile dysfunction.
• Clomiphene or Clomid
• Anastrazole or arimidex
• hCG (human chorionic gonadotropin) or hMG (human menopausal gonadotropin)
Most of these fertility drugs are taken by mouth except hCG and hMG, which are injections. As
with any medication, these drugs do have side effects
Treatment with Surgery
Surgery can be effective for repairing blockages in the tubes that transport sperm from the
testicles to the penis. Surgery also can be used for repair of varicocele, or varicose veins, in the
testicles. Current research suggests that surgical repair of varicocele can improve health of
sperm, but it has not affected the chances for conception.1
If surgery does not restore fertility, ART can be effective.
Fertility Treatments for Males

Once a woman is diagnosed with infertility, the overall likelihood for successful
treatment is 50%.
Whether a treatment is successful depends on:
• The underlying cause of the problem
• The woman's age
• Her history of previous pregnancies
• How long she has had infertility issues
• The presence or absence of male factor infertility
Fertility treatments are most likely to benefit women whose infertility is due to
problems with ovulation.
Treatment with medications is least likely to benefit infertility caused by damage
to the fallopian tubes or severe endometriosis, although in vitro fertilization can
help women with these conditions to conceive.
FERTILITY TREATMENTS FOR FEMALES

The most common medications used to treat infertility help
stimulate ovulation. Examples of these types of medications
include:
• Clomiphene or Clomiphene Citrate
• Letrozole
• Gonadotropins or Human Chorionic Gonadotropin (hCG)
• Bromocriptine or Cabergoline
MEDICATION TRTEATMENT FOR FEMALE INFERTILITY

• Clomiphene or Clomiphene Citrate
Clomiphene is a medication patients take by mouth (orally).
It causes the body to make more of the hormones that cause the
eggs to mature in the ovaries.
If a woman does not become pregnant after taking clomiphene
for six menstrual cycles, a health care provider may prescribe
other fertility treatments.
Patients take clomiphene in the beginning of the menstrual cycle.
Clomiphene causes ovulation to occur in 80% of women treated.
About half of those who ovulate are able to achieve a pregnancy
or live birth.
• Use of clomiphene increases the risk of having a multiple
pregnancy.
• There is a 10% chance of twins, but having triplets or more is
rare—less than 1% of cases.

• Letrozole
Letrozole is an oral pill that decreases the amount of estrogen a woman makes, stimulating
her ovaries to release eggs.
Patients take letrozole toward the end of their menstrual cycle for around 5 days.
A 2015 study by researchers in the NICHD Reproductive Medicine Network found that
about 19% of couples with unexplained infertility went on to have a live birth after using
letrozole for 4 months. This rate was slightly lower than the live birth rate for couples
using clomiphene (23%).
Other studies have found that letrozole may work better than clomiphene in women with
polycystic ovary syndrome.

Gonadotropins and Human Chorionic Gonadotropin (hCG)
Gonadotropins such as follicle-stimulating hormone (FSH) are hormones that are injected in a
woman to directly stimulate eggs to grow in the ovaries, leading to ovulation.
Health care providers normally prescribe gonadotropins when a woman does not respond to
clomiphene or to stimulate follicle growth for assisted reproductive technology (ART).
Gonadotropins are injected in the early part of the menstrual cycle for 7 to 12 days.
While a woman is treated with gonadotropins, a health care provider uses transvaginal
ultrasound to monitor the size of the developing eggs, which grow inside tiny sacs called
follicles. The health care providers also draw blood frequently to check the ovarian production
of estrogen.
The chance of a multiple birth is higher with gonadotropins than with clomiphene, and 30% of
women who conceive a pregnancy with this medication have multiple births.
About two-thirds of multiple births are twins. Triplets or larger multiple births account for the
remaining third.
hCG is a hormone similar to luteinizing hormone that can be used to trigger release of the
egg after the follicles have developed.

Bromocriptine or Cabergoline
Bromocriptine and cabergoline are pills taken orally to treat abnormally high levels of the
hormone prolactin, which can interfere with ovulation.
Pituitary growths; certain medications, including antidepressants; kidney disease; and thyroid
disease can cause high levels of prolactin.
Bromocriptine or cabergoline allow 90% of women to have normal prolactin levels.
Once prolactin levels become normal, 85% of women using bromocriptine or cabergoline
ovulate.

If disease of the fallopian tubes is the cause of infertility, surgery can be used to repair the
tubes or remove blockages in the tubes. Success rates of these types of surgery, however, are
low (approximately 20%, depending on the skill of the surgeon).
These surgeries involving the fallopian tubes also increase the risk of ectopic (pronounced
ek-TAH-pik) pregnancy, which is a pregnancy that occurs outside of the uterus.
Ectopic pregnancies are also called "tubal pregnancies," because they most often occur in a
fallopian tube”.
Surgery to remove patches of endometriosis has been found to double the chances for
pregnancy. Surgery can also be used to remove uterine fibroids, polyps, or scarring, which
can affect fertility.
SURGICAL TREATMENT FOR FEMALE INFERTILITY

Infertility

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