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

2. 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.

3. 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.

5. 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

7. 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).

8. 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.

9. 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

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

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

12. 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

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

14. 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.

15. 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

18. 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

19. Investigations For The Infertile Couple

20. 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.

21. 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

23. Male factors approach

24. 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.

25. 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.

26. 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.

28. 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.

29. 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

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

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

33. Treatment Options

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

35. The End