Natural fertilization & Infertility(male & Female) Dr.Rayan G. Albarakati Assistant prof Majmaah University

Objectives By the end of this lecture the student will be able to: Describe the steps of natural fertilization Define infertility and classify types of infertility. Describe the causes of infertility. Outline the required investigations for infertile couple. Analyze infertility causes and investigations Plan initial management of an infertile couple and the suitable treatment Identify the psychosocial issues associated with infertility.

Fertilization Fertilization, or conception, is the union of male and female pronuclear elements forming the Zygote. Conception normally takes place in the fallopian tube, after which the fertilized ovum continues to the uterus, where implantation occurs and development of the conceptus continues.

Physiology of Conception Conception requires both of the male and female gametes to be placed together at the optimal stage of maturation followed by transportation of the conceptus to the uterine cavity at a time when the endometrium is supportive of its continued development and implantation For these events to occur, the male and female reproductive systems must be both anatomically and physiologically intact coitus must occur with sufficient frequency and at the proper time

Fertility and conception rate over time Considering the vast complexity of the reproductive process, it is remarkable that 80% of couples achieve conception within 1 year. 25% Conceive within the first month 60% within 6 months 75% by 9 months, and 90% by 18 months. * After 18 months the remaining couples have a low monthly conception rate. ** Many may have absolute defects preventing fertility (sterility).

Definition of infertility A couple in the fertility age is considered infertile after unsuccessfully attempting to achieve pregnancy for 1 year. It is estimated that 10% to 15% of couples in the United States are involuntarily infertile.

Types Infertility is termed primary when it occurs without any prior pregnancy and secondary when it follows a previous conception. Another classification is based on who the cause: Male factor Female factor Combined Unexplained

Factors affecting conception Frequency of intercourse Age BMI (obesity and under weight) Irregular cycle Smoking occupation Alcohol Tight underwear's On Male

Chances of conception in relation to intercourse frequency One time per week  17 % Three times per week  50%

AGE Age substantially decreases the rate of conception because of: lower embryo quality reduced ovulation more diseases or decrease in general health condition possibly decreased coital frequency

Menstrual cycle Most women with regular cycles (every 22 to 35 days) are ovulating Recent studies indicate reduced fecundity associated with very irregular cycles.

Infertility Infertility may result from either one major deficiency (e.g., tubal occlusion) or multiple minor deficiencies. 40% of infertile couples has multiple causes. 10% may have combined male and female causes Therefore, in general, a complete infertility evaluation should be performed on each couple.

Causes Of Infertility Female No ovum (ovulation disorders) Pathway problems (uterine and tubal factors) Inability to fertilize and implant (e.g. endometriosis, thin endometrium,hydrosalpinx) Male factors Unexplained Female

General principles in the evaluation of the Infertile Couple History and physical examination for both couples is a must. Evaluation and therapy may be started earlier when obvious defects are identified, or they may be delayed, for instance, when a correctable factor, such as infrequent intercourse, is identified. 40% of infertile couples has multiple causes. In 5% to 10% of couples, have idiopathic infertility

Investigations For The Infertile Couple

In general, the first 6 to 8 months of evaluation involve relatively simple and noninvasive tests the performance of a radiologic evaluation of tubal patency can sometimes have a therapeutic effect. Operative evaluation by laparoscopy is for: 1. couples who have not conceived after 18 to 24 months 2. who have specific abnormalities or indications of a pelvic factor.

Investigation Ovarian reserve HSG Laparoscopy Hysteroscopy Basic Advance Blood tests Urinary LH Ultrasound Endometrial biopsy HVS Pap Smear Spinnbarkeit test Semen Analysis Ovarian reserve HSG Laparoscopy Hysteroscopy Post coital test

Male factors approach

History The history from the male partner should cover any pregnancies previously sired any history of genital tract infections, such as prostatitis or mumps orchitis; surgery or trauma to the male genitalia or inguinal region (e.g., hernia repair). any exposure to lead, cadmium, radiation, or chemotherapeutic agents. Excessive consumption of alcohol or cigarettes or unusual exposure to environmental heat should be elicited. Some medications, such as furantoins and calcium channel blockers, reduce sperm quality or function.

Physical Examination Is done on referral to a urologist when semen analysis is abnormal. The normal location of the urethral meatus should be ensured. Testicular size should be estimated by comparison with a set of standard ovoid's. The presence of a varicocele should be elicited by asking the patient to perform Valsalva’s maneuver in the standing position.

A semen analysis should be performed following a 2-to 4-day period of abstinence. The entire ejaculate should be collected in a clean, nontoxic container and not to be exposed to heat or light An accurate appraisal of abnormal semen requires at least three analyses. Periodic reassessment is necessary.

Endocrine evaluation of the male with subnormal semen quality may uncover a specific cause. Hypothyroidism can cause infertility Low levels of gonadotropins and testosterone may indicate hypothalamic pituitary failure. An elevated prolactin concentration may indicate the presence of a prolactin-producing pituitary tumor. An elevated level of follicle-stimulating hormone (FSH) generally indicates substantial parenchymal damage to the testes, as inhibin, produced by the Sertoli cells of the seminiferous tubules, provides the principal feedback control of FSH secretion.

Female factors investigation Evidence of ovulation: By history of menstrual cycle Serum progesterone level in mid-luteal phase LH surge by urine kit Ultrasound to assess the leading follicle at time of ovulation Ovarian reserve : Total antral follicle count ( by USS) Anti-mullerian hormone level FSH level

Continue Investigations for suspected tubal and uterine causes: Ultrasound HSG Laparoscopy Hysteroscopy

Management Counselling & waiting (correct habits and instructions) Treatment of identifiable cause O.I Artificial insemination(IUI) IVF

Treatment Options

The Psychosocial Issues Associated With Infertility Stress Depression Irritability Violence Divorce Social isolation Lack of confidence Family pressure

The End