Infertility

Infertility:  diminution or absence of ability to produce offspring.

Female infertility:  Studies shows approximately 10% to 15% of all couples in the United States cannot conceive after regular intercourse for at least 1 year without contraception.  About 40$ to 50% of all infertility is attributed to the female.  After extensive investigation and treatment, approximately 50% of infertile couples achieve pregnancy.  Of the 50% who don't, about 10% have no pathologic basis for infertility; the prognosis for this group becomes extremely poor if pregnancy is not achieved after 3 years.

Cause:  Infertility may be caused by any defect or malfunction of the hypothalamic pituitary ovarian axis, such as certain neurologic diseases.  Other causes include:

Ovarian factors related to anovulation or oligo ovulation

Uterine abnormalities, which may include congenitally absent, bicornuate, or double uterus; leiomyomas; or Asherman's syndrome, in which the anterior and posterior uterine walls adhere because of scar tissue formation.

Tubal and peritoneal factors, such as tubal loss or impairment secondary to ectopic pregnancy, or tubal occlusion due to salpingitis or peritubla adhesions

Cervical factors, such as infection and possibly cervical antibodies that immobilize sperm

Psychological problems.

Findings:
Diagnosis requires a complete physical examination and health history, including questions about the patient's reproductive and sexual function, past diseases, mental state, previous surgery, types of contraception used in the past, and family history.

Diagnostic tests:

The doctor may order tests to assess ovulation and the structural integrity of the fallopian tubes, the ovaries, and the uterus as well as male-female interaction studies.

Assessing ovulation:  Basal body temperature graph shows a sustained elevation in body temperature after ovulation until just before the onset of menses, indicating the approximate time of ovulation.
Endometrial biopsy done on or about day 5 after the basal body temperature rises, provides histologic evidence that ovulation has occurred.
Progesterone blood levels, measured when they should be highest, can show a luteal phase deficiency.

Assessing structural integrity of female reproductive organs: Hysterosalpingography provides radiologic evidence of tubal obstruction and abnormalities of the uterine cavity after injection of a radiopaque contrast medium through the cervix. 
Endoscopy confirms the results of hysterosalpingography and visualizes the endometrial cavity by hysteroscopy or explores the posterior surface of the uterus, fallopian tubes, and ovaries by culdoscopy. Laparoscopy allows visualization of the abdominal and pelvic areas.

Male-female interaction studies:  The postoital test also known as Sims test examines the cervical mucus for motile sperm cells after intercourse that takes place at midcycle (as close to ovulation as possible).
Immunologic or antibody testing detects spermicidal antibodies in the sera of the female.

Treatment:

Intervention aims to correct the underlying abnormality or dysfunction with in the hypothalamic-pituitary-ovarian complex.  In cases of hyperactivity or hypoactivity of the adrenal or thyroid gland, hormone therapy is necessary.  Progesterone deficiency requires progesterone replacement.

Anovulation requires treatment with clomiphene citrate, human menopausal gonadotropins, or HCG.  Ovulation usually occurs several days after such administration.

Surgical restoration may correct certain anatomic causes of infertility, such as fallopian tube obstruction.
Surgery may be required to remove tumors located within or near the hypothalamus or pituitary gland.

Endometriosis requires drug therapy and or the combination of surgical removal of areas of endometriosis.

* Artificial insemination has proven to be an effective alternative strategy for dealing with infertility problems.

* In vitro (test tube) fertilization has also been successful.


Male infertility:  Studies show approximately 40% to 50% of infertility problems in the US are totally or partially attributed to the male.

Assessment findings:  Clinical features of male infertility include atrophied testes; empty scrotum; scrotal edema; varicocele or anteversion of the epididymis; inflamed seminal vesicles; beading or abnormal nodes on the spermatic cord and vas; penile nodes, warts, plaques, or hypospadias; and prostatic enlargement, nodules, swelling, or tenderness.

Diagnostic test:  Patient history and physical examination.

Most conclusive test for male infertility is semen analysis.

Lab. test such as:  gonadotropin assay to determine the integrity of the pituitary gonadal axis, serum testosterone levels to determine end organ response to LH, urine 17-ketosteroid levels to measure testicular function, and testicular biopsy to help clarify unexplained oligospermia or azoospermia.

Vasography and seminal vesiculography may be necessary.

Cause:  Some of the factors that cause male infertility include:

- Varicocele, a mass of dilated and tortuous varicose veins in the spermatic cord
-Semen disorders, such as volume of motility disturbances or inadequate sperm density
-Proliferation of abnormal or immature sperm, with variations in the size and shape of the head
-Systemic diseases, such as diabetes mellitus, neoplasms, and mumps orchitis
-Genital infection, such as gonorrhea, tuberculosis, and herpes
-Genetic defects
-Disorders of the testes
-Immunologic disorders
-Endocrine imbalance
-Chemicals and drugs that inhibit gonadotropins or interfere with spermatogenesis, such as arsenic, methotrexate, some antihypertensives
-Sexual problems, such as errectile dysfunction, low libido
-Other factors: age, occupation, and trauma to the testes.

Treatment:

Aims to correct the underlying problem

Counseling or therapy (on sexual techniques, coital frequency, and reproductive physiology)

Proper nutrition with vitamin supplements.

Decrease FSH levels may respond to vitamin B therapy

Decreased LH levels, to HCG therapy.

Elevated LH levels require low dosages of testosterone.  Decreased testosterone levels, decreased semen motility, and volume disturbances may respond to HCG.

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