Reproductive problems Infertility is defined by the failure

Reproductive problems

Infertility is defined by the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse (American Society for Reproductive Medicine [ASRM], 2008 b). Sterility is a term applied when there is an absolute factor preventing reproduction. Subfertility is used to describe a couple having difficulty conceiving because both partners have reduced fertility. The term secondary infertility is applied to couples who have been unable to conceive after one or more successful pregnancies. The medical causes are similar to those of infertility in general.

Factors affect male & female fertility Cigarette smoking in females can delay time to conception and increase the risk for spontaneous abortion, preterm labor, and low birth weight. The quantity and quality of male sperm is also affected by cigarette smoking (ASRM, 2008 k). Women weighing 120% or 95% of their predicted ideal body weight can alter the production and storage of sex steroid hormones, which in turn affect a woman’s reproductive cycle. It is estimated that 12% or more of infertile couples have an abnormal body weight as the cause of their infertility and 70% of women will conceive spontaneously if their weight disorder is corrected

Male obesity is associated with increased incidence of low sperm concentration and poor sperm motility (ASRM, 2008 e). Sexually transmitted infections, such as Chlamydia trachomatis, can cause salpingitis and subsequent tubal obstruction, leading to infertility or ectopic pregnancy Environmental pollutants and exposures to chemicals Heavy metals, such as lead, bisphenol A (BPA), phthalates, and certain pesticides can affect fertility and the ability to reproduce.

Initial Investigation: Physical and Psychosocial Issues The easiest and least intrusive infertility testing approach is used first. Extensive testing is avoided until data confirm that the timing of intercourse and the length of coital exposure have been adequate. Preconception counseling, prenatal vitamins are often one of the earliest recommendations for women planning to conceive (400 micrograms/day) taken 1 to 3 months preconceptually and continued through the first trimester. Comprehensive history & laboratory evaluation for both partners At least 20% of infertility is due to a male factor, a semen analysis should be one of the first diagnostic tests performed before moving on to the more invasive diagnostic procedures involving the woman.

Assessment of the Woman’s Fertility A thorough evaluation of the woman’s fertility includes assessment of the hypothalamic-pituitary axis in terms of ovulatory function as well as structure and function of the cervix, uterus, fallopian tubes, and ovaries. Evaluation of Ovulatory Factors Ovulation problems account for approximately 25% of couples’ infertility. One basic test of ovulatory function is the basal body temperature (BBT) recording, which aids in identifying follicular and luteal phase abnormalities

Hormonal assessments of ovulatory function § Gonadotropin levels (FSH, LH) § Progesterone § Prolactin § Thyroid-stimulating hormone § Androgen levels (testosterone, DHEAS, androstenedione) Endometrial biopsy (EMB) provides information about the effects of progesterone produced by the corpus luteum after ovulation and endometrial receptivity.

Transvaginal ultrasound is the method of choice for follicular monitoring of women undergoing ovulation induction cycles, for timing ovulation for insemination and intercourse, for retrieving oocytes for in vitro fertilization (IVF). Evaluation of Cervical Factors To be receptive to sperm, cervical mucus must be thin, clear, watery, profuse, alkaline, and acellular. At ovulation, mucus elasticity (spinnbarkheit) increases to at least 5 cm in length and the viscosity decreases.

The mazelike microscopic mucoid strands align in a parallel manner to allow for easy sperm passage. The mucus is termed inhospitable if these changes do not occur. The postcoital test (PCT), evaluates the cervical mucus, the number of active sperm in the cervical mucus, and the length of sperm survival (in hours) after intercourse

Evaluation of Uterine Structures and Tubal Patency Tubal patency and uterine assessment are usually evaluated by hysterosalpingography or laparoscopy. These tests are usually done after BBT evaluation, semen analysis, and the other less invasive tests. Hysterosalpingography (HSG), or hysterogram, involves an instillation of a radiopaque substance into the uterine cavity. The HSG should be performed in the follicular phase of the cycle to avoid interrupting an early pregnancy.

Hysteroscopy is the definitive method for both diagnosis and treatment of intrauterine patholog Laparoscopy enables direct visualization of the pelvic organs; it is not routinely advised after a normal HSG unless symptoms suggest the need for earlier evaluation

Assessment of the Man’s Fertility Male infertility can be caused by numerous factors, some of which can be identified and are reversible, such as ductal obstruction and varicocele Other identifiable conditions are not reversible, such as bilateral testicular atrophy secondary to viral orchitis and congenital bilateral absence of the vas deferens Oligospermia (semen with a low concentration of sperm) and non-obstructive a zoospermia (impaired or nonexistent sperm production) have an increased risk for chromosome abnormalities and Y chromosome deletions.

Male infertility factor is usually defined by the findings of an abnormal semen analysis. (table. p. 256) Although it is known that low numbers and motility may indicate compromised fertility, other parameters such as morphology, volume, motion patterns, viscosity, p. H, and progression are important prognostic indicators.

Methods of Managing Infertility 1. Pharmacologic Agents CLOMIPHENE CITRATE (Clomid, Serophene) This medication induces ovulation in 70% of women by action at both the hypothalamic and ovarian levels by stimulating the hypothalamus to secrete more gonadotropin-releasing hormone (Gn. RH), which increases the secretion of FSH and LH. 30% to 40% of these women will become pregnant. Approximately 10% of women develop multiple gestation pregnancies. The woman is informed that if ovulation occurs, it is expected to occur 5 to 9 days after the last dose Upon a negative pregnancy test, another trial of clomiphene can be initiated pelvic ultrasound should be done to rule out ovarian enlargement, ovarian cysts, or hyperstimulation

INSULIN SENSITIZING AGENTS Insulin resistance recognized as a common feature of polycystic ovary syndrome (PCOS) and a contributing cause of chronic anovulation GONADOTROPINS & GONADOTROPIN-RELEASING HORMONE (GNRH) BROMOCRIPTINE acts directly on the prolactin-secreting cells in the anterior pituitary. It inhibits secretion of prolactin—thus preventing suppression of the pulsatile secretion of FSH and LH. PROGESTERONE as treatment of luteal phase defects

2. Therapeutic insemination has replaced the previously used term artificial insemination and involves depositing sperm at the cervical os or in the uterus by mechanical means. Therapeutic donor insemination (TDI) is the current term for use of donor semen, and therapeutic husband insemination (THI) is the current term for use of the husband’s semen.

Therapeutic insemination indicated for seminal deficiencies as oligospermia (low sperm count), asthenospermia (decreased motility), and teratospermia (low percentage, abnormal morphology); anatomic defects that are accompanied by inadequate deposition of sperm, such as hypospadias (a congenital abnormal male urethral opening on the underside of the penis); ejaculatory dysfunction, such as retrograde ejaculation

In vitro fertilization (IVF) is selectively used in cases in which infertility has resulted from tubal factors, mucus abnormalities, male infertility, unexplained infertility, male and female immunologic infertility, and cervical factors

Other assisted reproductive techniques include procedures for transferring gametes, zygotes, or embryos; cryopreservation of embryos; IVF using donor oocytes; micromanipulation techniques; and use of a gestational carrier