Dr. Farhat R Malik Associate Professor Community Health Sciences- PMC INFERTILITY Dr. Farhat R Malik Associate Professor Community Health Sciences- PMC

Session Objectives At the end of this lecture the students will be able to; Know infertility facts with respect to WHO. Enlist global as well as Pakistani burden of infertility. Define and classify infertility. Explain risk factors and causes of infertility. Explain how to investigate a couple suffering from infertility. List down options that can work for an infertile couple

WHO Facts File Infertility and sub-fertility affect a significant proportion of humanity. WHO has calculated that over 10% of women are inflicted – women who have tried unsuccessfully, and have remained in a stable relationship for five years or more. Estimates in women using a two year time frame, result in prevalence values 2.5 times larger. One in every four couples in developing countries had been found to be affected by infertility,

Infertility- Global Burden 72.4 million females live with infertility (2007) 8-10 % of couples do face some infertility related issue during their reproductive life 90-95% of couples can be offered treatment with success rate of 20-80%.

National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys

INFERTILITY BURDEN PAKISTAN About eight per cent population of the country is facing infertility. 90 per cent causes of the diseases are curable. 10 per cent of infertility is unexplainable. 

Definitions Clinical Demographic 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 sub- fertility using a variety of clinical interventions, and also from a laboratory evaluation of semen.” (Semen manual, 5th Edition3) An inability of those of reproductive age (15-49 years) to become or remain pregnant within five years of exposure to pregnancy. (DHS2) 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. (Systematic analysis of health surveys)

Classification 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. Women whose pregnancy spontaneously miscarries, or whose pregnancy results in a still born child, without ever having had a live birth would present with primary infertility.  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. 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 able to carry a pregnancy to a live birth would present with secondarily infertility. 

RISK FACTORS Age Smoking Alcohol Over weight Over exercising STDs Frequency & timing of sexual intercourse Mental stress

Causes of Infertility Ovarian Tubal & peritoneal Uterine Cervical Female Factors Male Factors Ovarian Tubal & peritoneal Uterine Cervical Vaginal Combined Defective Spermatogenesis Obstruction of Efferent Duct Failure to deposit sperm Seminal Fluid Errors

Monitoring infertility prevalence in women NUMERATOR: Number of 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 x100. DENOMINATOR: The number of 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 for a pregnancy for two years or more.

How to investigate the problem History taking General physical examinations Gynecological examinations Semen analysis Cervical mucus study Hormone estimation Endometrial biopsy Sonography Rubin’s test Hystero Salpino Graphy [ HSG]

MANAGEMENT Maintenance of body weight. Regular exercise. Healthy eating Avoid smoking & alcohol. Maintain ideal coital frequency. ( 3-4 times / week in fertile period) Avoid lubricants, spermicidal jellies and creams. Avoid fertility impairing medications. Psychological support.

ASSISTED REPRODUCTIVE TECHINQUES “Assisted reproductive techniques involving direct retrieval of oocyte from ovary , manipualtion of gametes and embroyos outside body for purpose of establishing pregnancy”

TYPES OF ART IUI IVF- ET 3. GIFT ZIFT ICSI IUI [ Intra Uterine Insemination] IVF- ET [ In vitro fertilization & Embryo Transfer] 3.GIFT [ Gamete Intra fallopian Transfer] ZIFT [ Zygote Intra Fallopian Transfer] ICSI [ Intra Cytoplasmic Sperm Injection]

Samples Multiple Choice Question Inability to conceive even after twelve months of living together and without use of any contraceptive method is known as which of the following terms?  Fertility Infertility Sub Fertility Pregnancy Abortion Short Answer Question a) Differentiate between infertility and sub fertility. b) Enlist risk factors related to infertility.