1. Infertility Boyarsky C., MD, PhD

2. Infertility Infertility is the inability to conceive after a year of unprotected intercourse.

3. Infertility and Subfertility Infertility – in a case than a pregnancy is impossible (for example, after two salpingoectomies or stable azoospermia) Subfertility – the probability of pregnancy is significantly reduced, but it is possible (endometriosis, PCOS etc.)

4. Infertility Primary infertility – Couples with primary infertility have never been able to conceive secondary infertility is difficulty conceiving after already having conceived

5. Age of women Infertility is impaired in 10-15% of married couples In 20 years only 6% firstly married women can have infertility In 30 years 10-15% firstly married women can have infertility In 40 years up to 50% firstly married women can have infertility

6. Infertility Male causes Female causes

7. Infertility Male infertility Ovulatory dysfunction Tubal disease Endometriosis Immunological infertility Idiopathic infertility

8. Male infertility The main method of male infertility investigation is semen analysis, twice during one month Normal values by WHO

9. Normal values by WHO, 1999 and 2010 19992010 Volume, ml>1,5 Concentration, mln./ml 2015 Motility, A+B 50%40% Morphology14%4%

10. Semen analysis Aspermia - complete lack of semen Azoospermia - absence of sperm cells in semen Oligospermia or ** Oligozoospermia - decreased number of spermatozoa in semen Asthenozoospermia - reduced sperm motility Teratospermia - increase in sperm with abnormal morphology Oligoasthenoteratozoospermia – complex abnormalities

11. Aspermia One of the causes of aspermia is retrograde ejaculation Diabetes mellitus type 1 Multiple sclerosis Spinal cord injury

12. Azoospermia Obstructive Unobstructive

13. Obstructive azoospermia Unborn causes, CTFR mutations, a gene of cystic fibrosis After vasectomy for male contraception purpose After serious inflammatory disease of male ejaculatory tract

14. Unobstructive azoospermia Mutation in long arm of Y-chromosome AZF gene – locus a,b,c Mutation in locus c can be associated with sperms during testicular biopsy Klinefelter's syndrome – 47, XXY Sertoli cell only syndrome

15. Testicular biopsy During biopsy vital sperm can be received

16. Oligoasthenoteratozoospermia – complex abnormalities AIH – artificial insemination by husband sperm IVF-ET – in vitro fertilization and embyo transfer ICSI – intracytoplasmatic sperm injection

17. Ovulation is the process in a female's menstrual cycle by which a mature ovarian follicle ruptures and discharges an ovum an oocyte.

19. An anovulatory cycle is a menstrual cycle during which the ovaries fail to release an oocyte. WHO classification of anovulation. WHO I type – low gonadotrophin level (Kallmann syndrome – hypogonadism + inosmia) WHO II type – normal gonadotrophin level (PCOS) WHO III type – high gonadotrophin level (POF – POI)

20. WHO I type Kallmann syndrome – hypogonadism, anosmia (an inability to perceive odors), low GNRH secretion, Low FSH and LH Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight

21. WHO II type, PCOS (2003 a consensus workshop sponsored by ESHRE/ASRM in Rotterdam) Anovulation (Oligomenorrhea, amenorrhea — irregular, few, or absent menstrual periods). Hyperandrogenism - is a medical condition characterized by excessive production and/or secretion of androgens. Hirsutism — excessive mild symptoms of hyperandrogenism. Biochemical hyperandrogenism – high level of testosterone. Ultrasound signs – multifollicular ovaries (more than 12 follicles by one view)

22. WHO III type – high gonadotrophin level (POF – POI) Age less than 40 years FSH level > 40 IU/L Amenorrhoea more than 6 months

23. Endometriosis is a gynecological medical condition in women in which endometrial-like cells appear and flourish in areas outside the uterine cavity

26. Tubal disease