18, September, 1997, 1st year resident J. S. Lee. M .D.
A. Oocyte depletion B. Spontaneous abortion B. Causes of infertility 1. Male factor
Ⅰ. Introduction
cycle (normal couple : 20 ~ 25%)
Ⅱ. Infertility and age
54% in > 35yrs
.Late 30s - small increase in FSH → correlates with subtle changes in oocyte number
and perhaps oocyte competence → reduced fertility
.As FSH levels rise and a woman approaches menopause, the chances of successful
pregnancy decline further oocyte donation
older women
→ Pregnancy rate - older women (up to50yrs) approximate those of the younger women
⇒ age of the oocyte, rather than the age of endometrium that accounts for the age-related decline in
female fertility
: more than doubles between 20 & 40yrs of age
.↑loss rate with ↓conception rate - significantly reduces the chance of a live birth over 40 yrs.
Ⅲ. The infertile couple
A. Initial visit
. Specifically, information regarding menstrual cyclicity, pelvic pain, obstetrical history
. Risk factor for infertility - PID, IUD use, pelvic surgery, intrauterine exposure to DES, ??
pituitary,
?? adrenal & thyroid function
. Male partner - genital surgery, infection, trauma, history of mumps
. Coital frequency, dyspareunia, sexual dysfunction
galactorrhea & pelvic exam.
ejaculatory duct, bulbourethral gland. & urethra
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Leydig cell - the site of androgen synthesis
→ enter epididymis which they traverse in 12-21 days as they mature & become progressively
more motile
outer surface membrane before fertilization
breakdown of the outer plasma membrane & its fusion with the acrosome membrane
→ sperm's penetration of the egg's zona pellucida
- which prevents penetration by additional sperm
low in cases of retrograde ejaculation
high in long period of abstinence, inflammation of the accessory gland.
absence of fructose or high pH - ejaculatory tract obstruction or seminal vesicle dysfunction
→ distinguished by an immunoperoxidase staining
???????????
> 1 million leukocyte per milliliter → abnormal
for fertilization
oocyte membrane & to undergo nuclear decondensation
→ Zona-free eggs are exposed to sperm
→ presence of one or more swollen sperm heads within the oocyte demonstrate penetration
2. Ovulatory factor
assessment of the infertile couple
hyperandrogenic oligoovulation
(Methods to document ovulation)
→ biphasic patter → indicative of ovulation
document an LH surge
?? →lead to poor secretory endometrial development
?? →could cause a failure of implantation or a very early abortion
women
3. Tubal/Peritoneal factors
infection
4. Cervical factor
- Cause of infertility in no more than 5% of cases
reproductive tract after coitus, interaction between cervical mucus & sperm
&
?????????????
?? ???
motility of sperm per several HPF
hormonal abnormality (oligoovulation)
production of poor guilty cervical mucus
anatomic factor (prior cervical conization or cryotherapy)
infection
medication (clomiphene citrate)
antisperm antibodies
unknown degree of reproducibility
infectious factor
5. Uterine factor
congenital uterine malformation)
6. Immunologic factors
plasma
? sperm agglutination test (Kibrick's or Franklin-Dukes)
? sperm complement-dependent immobilization test (Isojima's)
7. Infection
C. Unexplained infertility
Ⅳ. Treatment options
: occurring in untreated patients or occurring more than 3months after last medical treatment or more
than 12months after adnexal surgery
: impressive rate of 'spontaneous cure' illustrates why it is best to view the treatment of infertility as an attempt to improve fertility efficacy
A. Male factor infertility
1. Medical therapy
2. Surgical therapy
3. Artificial insemination
female reproductive tract : permits sperm-oocyte interaction in the absence of intercourse
polygenic / multifactorial
B. Ovulatory factor
1. Clomiphene citrate
begin on the 5th day after onset of a spontaneous or progesterone induced menses
continued through day 9 of the menstrual cycle
2. Gonadotropins
hypercoagulability , ovarian torsion or rupture, severe electrolyte disturbance, seizure, respiratory compromise, renal failure, even death
3. Pulsatile GnRH therapy
4. Bromocriptine and Dexamethasone supplementation
5. Surgical treatment
6. Luteal phase defect
C. Tubal and peritoneal factor
??? hydrosalpinx >30cm in dia
??? absence of visible fimbriae
??? dense pelvic or adnexal disease
D. Cervical factor infertility
? : anatomic patency, production of adequate amounts of hospitable mucus
? : exposure to DES, prev cone biopsy or cauterization, congenital anomalies, cervicitis, anovulation, use of clomiphene citrate for ovulation induction, antisperm antibodies
E. Uterine factor
?? : conjugated estrogen at dosage of 2.5mg/day for 1-2months
F. Unexplained infertility