INFERTILITY

Definition
Infertility is defined as a failure to conceive within one or more years of regular
unprotected coitus.
Subfertility refers to a state in which a couple has tried unsuccessfully to have a child before a
year or more. The term sub fertile means less fertile than a regular couple.
Primary infertility denotes those patients who have never conceived. Secondary infertility
indicates previous pregnancy but failure to conceive subsequently (either carried the pregnancy
to term or had a miscarriage).
Fecundability is defined as the probability of achieving a pregnancy within one menstrual
cycle. In a healthy young couple it is 20 per cent. Fecundity is the probability of achieving a
livebirth within a single cycle.

Incidence
Eighty per cent of the couples achieve conception if they so desire, within one year of having regular
intercourse with adequate frequency (4-5 times a week). Another 10 per cent will achieve the
objective by the end of second year. As such, 10 per cent remain infertile by the end of second year.

Factors Essential for Conception

 Healthy spermatozoa should be deposited high in the vagina at or near the cervix (male
factor).
 The spermatozoa should undergo changes (capacitation, acrosome reaction) and
acquire motility (cervical factor).
 The motile spermatozoa should ascend through the cervix into the uterine cavity and
the fallopian tubes
 There should be ovulation (ovarian factor).
 The fallopian tubes should be patent and the oocyte should be picked up by the
fimbriated end of the tube (tubal factor).
 The spermatozoa should fertilise the oocyte at the ampulla of the tube.
 The embryo should reach the uterine cavity after 3-4 days of fertilisation.
 The endometrium should be receptive (by oestrogen, progesterone, IGF-1, cytokines,
integrins) for implantation and the corpus luteum should function adequately.
Physiological consideration
Due to anovulation infertility is the rule prior to puberty and after menopause. But it should be
remembered that the girl may be pregnant even before menarche and pregnancy is possible
within few months of menopause. Conception is not possible during pregnancy as the pituitary
gonadal axis is suppressed by hCG and hence no ovulation. During lactation, infertility is said
to be relative. Despite the fact that the patient is amenorrhoeic during lactation, ovulation and
conception can occur. However, in fully lactating women (breast-feeding 5-6 times a day
and spending 60 minutes in 24 hours), pregnancy is unlikely upto 10 weeks postpartum.

CAUSES OF INFERTILITY
Conception depends on the fertility potential of both the male and female partner. The male is
directly responsible in about 30-40 per cent, the female in about 40-55 per cent and both are
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responsible in about 10 per cent cases. The remaining 10 per cent, is unexplained in spite of
thorough investigations with modern technical knowhow. It is also strange that 4 out of 10
patients of unexplained category become pregnant within 3 years without having any specific
treatment.
It is also emphasised that the relative subfertility of one partner may sometimes be
counterbalanced by the high fertility of the other.

Faults in the male

 Defective spermatogenesis
 Obstruction of the efferent duct system.
 Failure to deposit sperm high in the vagina.
 Errors in the seminal fluid.
Defective spermatogenesis
FSH stimulates spermatogenesis from basal cells of the seminiferous tubules. Sertoli cells
envelope the germ cells and support spermatogenesis. Sertoli cell function is controlled by FSH
and testosterone. Scrotal temperature should be 1°-2°F less than the body temperature. LH is
required for the synthesis of testosterone from the Leydig cells. FSH also
stimulates the Sertoli cells to produce androgenbinding proteins (ABP) and inhibin B. ABP
binds to testosterone and dihydrotestosterone to maintain the local high concentration of
androgens. Spermatogenesis and sperm maturation need a high androgenic environment.
Inhibin B inhibits FSH secretion. Spermatogenesis is controlled predominantly by the genes
on Y chromosome. Approximately 74 days are required to complete the process of
spermatogenesis. Additional 12-20 days are needed for spermatozoa to travel the epididymis.

Causes of male infertility

The important causes of male infertility are:
(1) Hypothalamic-pituitary disorders (1-2 %).
(2) Primary gonadal disorders (30-40 %).
(3) Disorders of sperm transport (10-20%) and
(4) Idiopathic (40-50 %).

 Congenital
 Undescended testes- the hormone secretion remains unaffected, but the
spermatogenesis is depressed. Vas deferens is absent (bilateral) in about 1-2 per
cent of infertile males
 Kartagener syndrome (autosomal disease)- there is loss of ciliary function and
sperm motility
 Hypospadias causes failure to deposit sperm high in vagina.
 Thermal factor.
 The scrotal temperature is raised in conditions such as varicocele. Varicocele
probably interferes with the cooling mechanism or increases catecholamine
concentration. However, no definite association between varicoceles and
infertility has been established.

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 Infection-
(a) Mumps orchitis after puberty may permanently damage spermatogenes
(b) The quality of the sperm is adversely affected by chronic systemic illness like
bronchiectasis. Bacterial or viral infection of the seminal vesicle or prostate
depresses the sperm count.
(c) T. mycoplasma or Chlamydia trachomatis infection is also implicated
 General factors
Chronic debilitating diseases, malnutrition or heavy smoking reduce spermatogenesis.
Alcohol inhibits spermatogenesis either by suppressing Leydig cell synthesis of
testosterone or possibly by suppressing gonadotrophin level
 Endocrine
Testicular failure due to gonadotrophin deficiency (Kallmann's syndrome) is rare. FSH
level is raised in idiopathic testicular failure with germ cell hypoplasia (Sertoli-cell-
only-syndrome). Hyperprolactinaemia is associated with impotence.
 Genetic
Common chromosomal abnormality in azoospermic male is Klinefelter's syndrome 47
XXY). Gene deletion have been detected in the long arm of Y chromosome (Yq) for
patients with severe oligospermia and azoospermia.
 Iatrogenic
Radiation, cytotoxic drugs, nitrofurantoin, cimetidine, ß blockers, antihypertensive,
anticonvulsant and antidepressant drugs are likely to hinder spermatogenesis.
 Immunological factor
Antibodies against spermatozoal surface antigens may be the cause of infertility. This
results in clumping of the spermatozoa after ejaculation.
 Obstruction of the efferent ducts
The efferent ducts may be obstructed by infection like tubercular, gonococcal or by
surgical trauma (herniorrhaphy following vasectomy. In Young's syndrome there is
epididymal obstruction and bronchiectasis.
 Failure to deposit sperm high in the vagina (coital problems)
 Erectile dysfunction
 Ejaculatory defect-premature, retrograde or absence of ejaculation
 Hypospadias.
 Sperm abnormality
Loss of sperm motility (asthenozoopermia), abnormal sperm morphology (round
headed sperm, teratozoospermia) are the important factors.
 Errors in seminal fluid
 Unusually high or low volume of ejaculate.
 Low fructose content.
 High prostaglandin content
 Undue viscosity.

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 COMMON CAUSES OF MALE INFERTILITY
Pre-testicular Testicular Post-testicular
Endocrine  Immotile cilia (Kartagener) Obstruction of efferent duct
syndrome
 Gonadotrophin  Congenital
deficiency  Cryptorchidism - Absence of Vas
 Obesity  Infection (mumps orchitis) deferens (Cystic
 Thyroid dysfunction  Toxins: Drugs, Smoking, fibrosis)
Radiation
 Hyperprolactinaemia - Young's syndrome
 Varicocele  Acquired Infection:
Psychosexual  Immunologic Tuberculosis, Gonorrhoea
 Erectile dysfunction  Sertoli-cell-only syndrome  Surgical
 Impotence  Primary testicular failure Herniorrhaphy.
 Oligoasthenoteratozoospermia Vasectomy
Drugs
Others
 Antihypertensives
 antipsychotics  Ejaculatory failure
 Retrograde ejaculation
Genetic
 Hypospadius
 47XXY  Bladder neck surgery
 Y chromosome
deletions
 Single gene
mutations

CAUSES OF FEMALE INFERTILITY

According to FIGO manual (1990) cases are: Tubal and peritoneal factors (25-35%), Ovulatory
factor (30-40%) and Endometriosis (1-10%).
Ovarian factors
The ovulatory dysfunctions (dysovulatory) encompass:
 Anovulation or oligo-ovulation
 Decreased ovarian reserve
 Luteal phase defect (LPD)
 Luteinised unruptured follicle (LUF)

Anovulation or oligo-ovulation
The ovarian activity is totally dependent on the gonadotrophins and the normal secretion of
gonadotrophins depends on the pulsatile release of GnRH from hypothalamus. As such, ovarian
dysfunction is likely to be linked with disturbed hypothalamo-pituitary-ovarian axis either
primary or secondary from thyroid or adrenal dysfunction
Thus, the disturbance may result not only in anovulation but may also produce
oligomenorrhoea or even amenorrhoea. Anovulatory cycles usually represent a lesser degree
of disturbance with these normal pathways than does amenorrhoea.

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As there is no ovulation, there is no corpus luteum formation. In the absence of progesterone,
there is no secretory endometrium in the second half of the cycle. The other features of
ovulation are absent.
Luteal phase defect (LPD)
In this condition there is inadequate growth and function of the corpus luteum. There is
inadequate progesterone secretion. The life span of corpus luteum is shortened to less than 10
days. As a result there is inadequate secretory changes in the endometrium which hinder
implantation. LPD is due to defective folliculogenesis which again may be due to varied
reasons. Drug induced ovulation, decreased level of FSH and/or LH, elevated prolactin,
subclinical hypothyroidism, older women pelvic endometriosis, dysfunctional uterine bleeding
are the important causes.
Luteinised unruptured follicular syndrome (trapped ovum)
In this condition, the ovum is trapped inside the follicle which gets luteinised. The cause is
obscure but may be associated with pelvic endometriosis or with hyperprolactinemia.
Tubal and Peritoneal factors
These are responsible for about 30-40% cases of female infertility.
The obstruction of the tubes may be due to
a) Pelvic infections causing:
 Peritubal adhesions
 Endosalpingeal damage
 Previous tubal surgery or sterilization
 Salpingitis isthmica nodosa
 Tubal endometriosisand others.
 Polyps or mucous debris within the tubal lumen, or tubal spasm.
Peritoneal factors
In addition to peritubal adhesions, even minimal endometriosis may produce infertility. Deep
dyspareunia too often troubles the patient.
Uterine factors
The endometrium must be sufficiently receptive enough for effective nidation and growth of
the fertilised ovum. The possible factors that hinder nidation are uterine hypoplasia, inadequate
secretory endometrium, fibroid uterus,endommetritis (tubercular in particular, uterine
synechiae or congenital malformation of uterus.
Cervical factors
Anatomic
Anatomic defects preventing sperm ascent may be due to congenital elongation of the cervix,
second degree uterine prolapse and acute retroverted uterus. These conditions prevent the
external os to bathe in the seminal pool. Pinhole os may at times be implicated, or the cervical
canal may be occluded by a polyp.

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Physiologic
The fault lies in the composition of the cervical mucus, so much that the spermatozoa fail to
penetrate the mucus. The mucus may be scanty following amputation, conisation or deep
cauterisation of the cervix. The abnormal constituents include excessive, viscous or purulent
discharge as in chronic cervicitis. Presence of antisperm or sperm immobilising antibodies may
be implicated as immunological factor of infertility.
Vaginal factors
Atresia of vagina (partial or complete vaginal septum, septate vagina or narrow introitus
causing dyspareunia are included in the congenital group.
Vaginitis and purulent discharge may at times be implicated but pregnancy too often occurs in
presence of vaginitis, specific or nonspecific. However, dyspareunia may be the real problem
in such cases
Combined factors
 These include the presence of factors both in congenital malformation of uterus
the male and female partners causing infertility.
 General factors: Advanced age of the wife beyond 35 years is related but
spermatogenesis continues throughout life although ageing reduces the fertility in male
also.
 Infrequent intercourse, lack of knowledge of coital technique and timing of coitus to
utilise the fertile period are very much common even amongst the literate couples.
 Apareunia and dyspareunia
 Anxiety and apprehension
 Use of lubricants during intercourse may be spermicidal.
 Immunological factors

POSSIBLE MECHANISM OF INFERTILITY IN WOMEN WITH PELVIC

ENDOMETRIOSIS
Ovarian dysfunction Tubal dysfunction Others
- Endocrinopathies  Altered tubal motility  Dyspareunia
 Defective  Pelvic adhesions,  Abnormal peritoneal
folliculogenesis tubal obstruction. fluid
 anovulation  Distortion of normal  Abnormal systemic
 luteal phase defect tube and ovarian immune response
 LUFS relationship.  Increased sperm
 Hyperprolactinemia  Impaired pickup of phagocytosis by
- Oocyte maturation defect oocyte by the fimbria macrophages.
- Luteolysis due to  Fertilization and
increased PGF2alpha implantation failure
 Miscarriage

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INVESTIGATIONS OF INFERTILITY
Objectives of investigation
 To detect the aetiological factor(s).
 To rectify the abnormality in an attempt to improve the fertility.
 To give assurance with explanation to the couple if no abnormalities are detected.
When to investigate?
As per the definition, the infertile couple should be investigated after one year of regular
unprotected intercourse with adequate frequency. The interval is however, shortened to 6
months after the age of 35 years of the woman and 40 years of man.
What to investigate?
The basic investigations to be carried out are:
(1) Semen analysis.
(2) Confirmation of ovulation and
(3) Confirmation of tubal patency.
It is important that both partners should come at the first visit. Detailed general and
reproductive history should be taken in presence of both. Howeverer, the clinical examination
of each partner is carried out separately. No one is to be blamed.
Clinical approach to investigation
 Male
 female

MALE
History
Age, duration of marriage, history of previous marriage and proven fertility if any, are
to be noted.
A general medical history should be taken with special reference to sexually transmitted
diseases, mumps orchitis after puberty, diabetes, recurrent chest infection or bronchiectasis.
Enquiry about relevant surgery such as herniorrhaphy, operation on testes, also about the sexual
history, social habits, particularly heavy smoking and alcohol are of importance and to be made.
Examination
A full physical examination is performed to determine the general state of health. Examination
of the reproductive system includes inspection and palpation of the genitalia. Attention should
be paid to the size and consistency of the testicles. Testicular volume (measured by an
orchidometer) should be at least 20 mL. Presence of varicocele should be elicited in the upright
position.
Investigations
(a) Routine investigations include urine and blood examination including postprandial sugar
(b) Semen analysis

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This should be the first step in investigation because, if some gross abnormalities are detected
(example being absence of sperm), the couple should be counselled for the need of assisted
reproductive technology
Collection
The collection is best done by masturbation failing which by coitus interruptus. The semen is
collected in a clean wide mouthed dry glass jar. The sample so collected should be sent to the
laboratory as early as possible so that the examination can be performed within two hours. The
coitus should be avoided for 2-3 days prior to the test (abstinence).
Semen analysis: normal reference value WHO (2010).
Semen Normal reference value and Lower reference limit
analysis
Volume 2.0 ml or more (1.5 ml)
pH 7.2-7.8
Viscosity <3 (scale 0-4)
Sperm 20 million/ml(15 million /ml)
concentration
Total sperm >40 million/ejaculate (39 million /ejaculate)
count
Motility >50% progressive forward motility (progressive motility = 32%)
Morphology >14% normal form (4%)
viability 75 % or more living (58%)
Leucocytes Less than 1 million per ml
Round cells <5 million/ml
Sperm <10% spermatozoa with adherent particles.
agglutination

In selected cases, biochemical tests of creatine phosphokinase and reactive oxygen species are
done as sperm function tests. Creatinine phosphokinase helps sperm transport while reactive
oxygen species and the peroxides interfere with sperm function.
Normal male fertility requires a count of over 20 million spermatozoa per ml and a progressive
motility of over 32 per cent. Semen values normally vary widely. Two properly performed
semen
analysis at least 4 weeks apart should be done when one report is abnormal.
Nomenclature
 Aspermia: failure of emission of semen(no ejaculate)
 Oligospermia/oligozoospermia:sperm count is less than 20 million per ml
 Polyzoospenmia Count is more than 350 million/mi.
 Azoosmenmis: No spermatozoon in the semen.
 Asthenezeospermia Reduced sperm motility.
 Leacocytospermia Increased white cells in semen.

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  Necrezoospermia Spermatozoa are dead or motionless
 Tentozaosperma. > 70% spermatozoa with abnormal morphology
 Oligoasthenoteratozoospermia: disturbance of all 3 variables.
In depth evaluation
These are needed in cases of - (a) Azoospermia b) Oligospermia () Low volume ejaculate (d)
Problems of sexual potency.
 Serum FSH, LH, testosterone, prolactin, and TSH: testicular dysfunction causes rise
in FSH and LH. Low level of FSH and LH suggest hypogonadisom. Leydig cell
dysfunction causes low testosterone and high LH level. Elevated prolactin due to
pituitary adenoma may cause impotency
 Fructose content in the seminal fluid -Its absence suggests congenital absence of
seminal vesicle or portion of the ductal system or both.
 Testicular biopsy - is done to differentiate primary testicular failure from obstruction as
a cause of azoospermia or severe oligospermia. The biopsy material is to be sent in
Bouin's solution and not in formol saline. Testicular tissues may be cryopreserved for
future use in IVF/ICSI.
 Trans rectal Ultrasound (TRUS)-is done to visualise the seminal vesicles, prostate and
ejaculatory ducts obstruction. Indications of TRUS are:
(i) Azoospermia or severe oligospermia with a normal testicular volume (ii) Abnormal
digital rectal examination. (iii) Ejaculatory duct abnormality (cysts, dilatation or
calcification) (iv) Genital abnormality (hypospadius)
 Vasogram is a radiographic study done to evaluate the ejaculatory duct obstruction. It
is mostly replaced by TRUS
 Karyotype analysis This is to be done in cases with azoospermia or severe oligospermia
and raised FSH. Klinefelter's syndrome (XXY) is the commonest. Micro deletions of
the long arm of Y chromosome can also cause severe seminal abnormalities.
 Immunological tests-Two types of antibodies have been described-sperm agglutinating
and sperm immobilising; the latter is probably related to infertility. The antibodies are
produced following infection (orchitis) trauma or vasectomy. These antibodies can be
detected from the serum by the sperm immobilising test. Presence of sperm antibodies
in the cervical mucus is demonstrated by postcoital test
 Presence of plenty of pus cells requires prostatic massage. The collected fluid is to be
examined by staining and culture to detect the organisms and appropriate antibiotic
sensitivity.
FEMALE
History: Age, duration of marriage, history of previous marriage with proven fertility if any,
are to
noted.
A general medical history should be taken with special reference to tuberculosis, sexually
transmitted diseases, features suggestive of pelvic inflammation or diabetes.
The surgical history should be directed specially history is towards abdominal or pelvic
surgery. This may be may be related to peritubal adhesions.

Menstrual history should be taken in details. Wide spectrum of abnormalities ranging from

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hypomenorrhoea – oligomenorrhoea to amenorrhoea are associated with disturbed
hypothalamopituitary ovarian axis which may be either primary or secondary to adrenal or
thyroid dysfuction.
Previous obstetric history including number of pregnancies, the interval between them and
pregnancy related complications are to be enquired. In the case of secondary infertility, the
obstetric history is important. The history of puerperal sepsis may be responsible for ascending
infection tubal damage. Uterine synechiae may be due to vigorous curettage.
Contraceptive practice should be elicited. IUCD use may cause PID.
sexual problems such as dyspareunia, and loss of libido are to be enquired. It should be borne
in mind that the female orgasm is not essential for fertility and loss of semen from the vaginal
orifice following coitus is normal.
Examinations
General, systemic and gynaecological examinations are made to detect any abnormality which
may hinder fertility
General examination must be thorough-special emphasis being given to obesity or marked
reduction in weight (BMD. Hirsutism, acne, acanthosis nigricans or underdevelopment of
secondary sex characters are to be noted. Physical features pertaining to endocrinopathies are
carefully evaluated to detect features of PCOS and galactorrhoea.
Systemic examination may accidentally detect such abnormalities like hypertension, organic
heart disease, chronic renal lesion, thyroid dysfunction and other endocrinopathies.
Gynaecological examination includes adequacy of hymenal opening, evidences of vaginal
infections, cervical tear or chronic infection, undue elongation of the cervix, uterine size,
position and mobility, presence of unilateral or bilateral adnexal masses - fixed or mobile with
or without tenderness and presence of nodules in the pouch of Douglas.
Speculum examination may reveal abnormal cervical discharge. The discharge is to be
collected for Gram stain and culture. Cervical smear is taken as a screening procedure as a
routine or in suspected cases.
Special Investigations: Guidelines
 In the presence of major fault in male such as azoospermia due to testicular destruction
or intersex, there is very little scope to proceed for investigation for the female partner.
However, considering the place of Assisted
Reproductive Technology (ART) female investigation may not be withheld.
 Similarly, when a major defect is detected in female such as müllerian agenesis or
intersex, infertility investigations should be suspended However, correctable
abnormality should be rectified first prior to investigation, e g narrow vaginal introitus,
overt hypothyroidism or diabetes mellitus.
 Noninvasive or minimal invasive methods are to be employed prior to major invasive
one. However, it is not uncommon to have pregnancy soon after the first visit
 Detection of abnormality of one factor does not negate investigation for another d
elsewhere. Multiple defects may be present in the same case, e.g. tubal defects may be
associated with anovulation.
 Pregnancy following laparoscopy and dye test or hysterosalpingography is not
uncommon. It is presumed that small flimsy adhesions any mucus plug obstructing the
tubal lumen is removed during such procedures. The cervical spasm may be relieved
during dilatation
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  Genital tuberculosis as a cause of infertility is to be kept in mind specially in the
developing countries. The association is as high as 10-15
per cent in contrast to a low figure of 0.5 per cent in the developed countries
 Ovarian factors : Ovarian dysfunctions (dysovulatory) commonly associated with
infertility are
- Anovulation or oligo-ovulation (infrequent ovulation)
- Luteal phase defect (LPD).
- Luteinised unruptured follicle (LUF).
DIAGNOSIS OF OVULATION
The various methods used in practice to detect ovulation are grouped as follows
 Indirect
 Direct
 Conclusive

DIAGNOSIS OF OVULATION
Indirect
o Menstrual history
o Evaluation of peripheral or endorgan changes
 BBT
 Cervical mucus study
 Vaginal cytology
 Hormione estimation
 Serum progesterone
 Serum LH
 Serum oestradiol
 Urine LH
 Endometrial biopsy
o Sonography (TVS)
Direct
 Laparoscopy
Conclusive
 Pregnancy
INDIRECT
The indirect or presumptive evidences of ovulation are commonly used in clinical practice.
These are inferred from

Menstrual history

Evaluation of peripheral or endorgan changes due to oestrogen and progesterone

Direct assays of gonadotrophins or steroid hormones preceeding, coinciding or
succeeding the ovulatory process
1. Menstrual history

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The following features in relation to menstruation are strong evidences of ovulation.
 Regular normal menstrual loss between the age of 20-35.
 Midmenstrual bleeding (spotting) or pain or excessive mucoid vaginal discharge
(Mittels-chmerz syndrome)
 Features suggestive of premenstrual syndrome or primary dysmenorrhoea.

2. Evaluation of peripheral or endorgan changes

 Basal body temperature (BBT)
Observation-- There is "biphasic pattern" of temperature variation in ovulatory cycle.
If pregnancy occurs, the rise of temperature sustains along with absence of the period.
In anovulatory cycle there is no rise of temperature throughout the cycle.

Principle-- The rise of temperature is secondary rise in progesterone output following

ovulation. Progesterone is thermogenic. The primary reason for the rise is the increase
in the production and secretion of norepinephrine which is also thermogenic.

Procedures--The patient is instructed to take her oral temperature daily on waking in

the morning before rising out of the bed. The temperature is recorded on a special chart.
Days when intercourse takes place should also be noted on the chart for better
evaluation of coital frequency.

Interpretation--The body temperature maintaining throughout the first half of the cycle
is raised to 0.5 to1 F (0.2-0.5 C) following ovulation. The rise sustains throughout the
second half of the cycle and falls about 2 days prior to the next period -
called “biphasic pattern". There may be a drop in the temperature to about 0.5°F before
the rise and almost coincides with either LH surge or ovulation. The demonstrable rise
actually occurs about 2 days after the LH peak and with a peripheral level of
progesterone greater than 5 ng/ml

Clinical importance-- Maintenance of BBT chart during investigation is of help in

determining ovulation and timing of post-coital test, endometrial biopsy, cervical
mucus or vaginal cytology study for ovulation. It also helps the couple to determine the
most fertile period, if the cycle is irregular.
- Limitations of BBT
 BBT indicates ovulation retrospectively
 It cannot predict ovulation precisely with time
 Rarely ovulation has been observed though
BBT is monophasic
- How long to keep the record?
It should not be continued for more than 3-4 months for investigation
purpose. However, it has to be maintained for longer periods during
management of ovulation induction
- Cervical mucus study

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 Alteration of the physicochemical properties of the cervical mucus
occurs due to the effect of oestrogen and progesterone.

Disappearance of fern pattern beyond 22nd day of the cycle which was present
in the midcycle is suggestive of ovulation. Persistence of fern pattern even
beyond 22nd day suggests anovulation Progesterone causes dissolution of the
sodium chloride crystals. Following ovulation, there is loss of stretchability
(spinbarkeit) which was present in the midcycle
- Vaginal cytology
Maturation index shifts to the left from the midcycle to the mid second
half of cycle due to the effect of progesterone. However, a single smear on day
25 or 26 of the cycle reveals features of progesterone effect, if ovulation occurs.
- Hormone estimation
 Serum progesterone --Estimation of serum progesterone is done on day
8 and 21 of a cycle (28 days). An increase in value from less than 1
ng/ml to greater than 6 ng/ml suggests ovulation.
 Serum LH-- Daily estimation of serum LH at mid cycle can detect the
LH surge. Ovulation occurs about 34-36 hours after beginning of the LH
surge. It coincides about 10-12 hours after the LH peak.
 Serum oestradiol-- attains the peak rise approximately 24 hours prior to
LH surge and about 24-36 hours prior to ovulation.
Serum LH-- and oestradiol estimation is used for in vitro fertilisation.
- Urinary LH
LH kits are available to detect midcycle LH surge Ovulation usually occurs
within 14-26 hours of detection of urine LH surge and almost always within 48
hours. (The test should be done on a daily basis. It is started 2 to 3 days before
the expected surge depending upon the cycle length).
- Endometrial biopsy
Endometrial tissues to detect ovulation (endometrial sampling) can easily be
obtained as an outpatient procedure using instruments such as Sharman curette
or Pipelle endometrial sampler. Dilatation and curettage is however reserved in
cases where bulk endometrial study is required as in endometrial tuberculosis.

When to do? Biopsy is to be done on 21st-23rd day of the cycle. Barrier

contraceptive should be prescribed during the cycle to prevent accidental
conception. However, if the cycle is irregular, it done within 24 hours of the
period.
Findings- Evidences of secretory activity of the endometrial glands in the
second half of the cycle give not only the diagnosis of ovulation but can predict
the functional integrity of the corpus luteum.

Subnuclear vacuolation is the earliest evidence appearing 36-48 hours

following ovulation.

Cause- The secretory changes are due to the action of progesterone on the
oestrogen primed endometrium.

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 2. Sonography Serial sonography (TS midcydle can precisely measure the Graafian
follicle just prior to ovulation (18-20 mm). It is particularly helpful for confirmation of
ovulation following ovulation induction, artihiial insemination and vitro fertilisation.
The features of recent ovulation are collapsed follicle and fluid in the pouch of Douglas
DIRECT
Laparoscopy: Laparoscopic visualisation of recent corpus luteum or detection of the ovum
from the aspirated peritoneal fluid from the pouch of Douglas is the only direct evidence of
ovulation.
Conclusive: Pregnancy is the surest evidence of ovulation.

LUTEAL PHASE DEFECT (LPD)

Diagnosis of LPD is difficult. However, it is based on the following:
 BBT chart- (a) Slow rise of temperature taking 4-5 days following the fall in the
midcycle (b) Rise of temperature sustains less than 10 days
 Endometrial biopsy- Biopsy done on day of the period reveals the endometrium at least
3 days out of phase (Example : If the biopsy is done on 25th day of cycle, the
endometrial change observed correspond to the day 22). This lag phase endometrium
must be proved in more cycle. However, it is not conclusive
 Serum progesterone estimated on 8th day following ovulation is less than 10 ng/ml.

LUTEINISED UNRUPTURED FOLLICLE (LUF)

Luteinised unruptured follicle (LUF) syndrome refers to an infertile woman with regular
menses and presumptive evidences of ovulation without release of the ovum from the follicle
(trapped ovum). The features of ovulation formation of corpus luteum
and its stigma are absent. It is often associated with
endometriosis.
Diagnosis- In the presence of biologic effects of progesterone in the early luteal phase
 Sonography Persistence of echo-free dominant follicle beyond 36 hours after LH peak
 Laparoscopy Failure to observe a stigma of ovulation.
 Ovarian biopsy-Conclusive proof is deter- mination of ovum amidst the structure of
corpus luteum.
TUBAL FACTORS
The anatomical patency and functional integrity of the tubes are assessed by the following tests:
 Dilatation and insufflation test (DI )
 Hysterosalpingography (HSG)
 Laparoscopy and chromopertubation
 Sonohysterosalpingography
 Falloposcopy
 Salpingoscopy
Insufflation test (Rubin's test)

14
Principle -The underlying principle lies with the fact that the cervical canal is in continuity with
the peritoneal cavity through the tubes. As such, entry of air or CO, into the peritoneal cavity
when pushed transcervically under pressure, gives evidence of tubal patency
when to be done? It should be done in the post menstrual phase at least 2 days after stoppage
of menstrual bleeding.
Limitation- it should not be done in the presence of pelvic infection
observations The patency of the tube is confirmed by (1) fall in the pressure when raised beyond
120 mm Hg, (2) hissing sound heard on auscultation on either iliac fossa and (3) shoulder pain
experienced by the patient (irritation of the diaphragm by the air)
Drawbacks -In about one-third of cases, it gives a false-negative findings due to cornual spasm.
It also cannot identify the side and site of the block in the tube. As such, it is inferior to other
methods of tubal study. This test is not commonly done these days

Hysterosalpingography (HSG)
Principle--The principle is the same like that of insufflation test. Instead of air or CO, dye is
instilled transcervically.
When to be done? As in D+I
Limitation- As in D+I
Advantages-- It has got distinct advantages over insufflation test. It can precisely detect the
side and site of block in the tube. It can reveal any abnormality in the uterus (congenital or
acquired like synechiae, fibroid). As such insufflation of the tubes has largely been replaced by
HSG
Disadvantages: It involves radiation risk

LAPAROSCOPY AND CHROMOPERTUBATION

Laparoscopy is the gold standard (definitive method) for evaluation of tubal factors of
infertility. It is done after male factor and ovulatory functions have been found normal or
corrected.

INDICATIONS OF LAPAROSCOPY
Diagnostic  Age > 35 years
 Abnormal HSG
 Failure to conceive after
reasonable period (6 months)
with normal HSG
 Women with comorbid pelvic
pathology (PID, endometriosis)
 Unexplained infertility

15
 Operative  Ovarian drilling
 Reconstructive tubal surgery
 Adhesiolysis
 Fulguration of endometriotic
implants
 GIFT and ZIFT procedures

Sonohysterosalpingography
This test involves a slow injection of physiological saline into the uterine cavity using a
pediatric Foley's catheter. The catheter balloon is inflated at the level of the cervix to prevent
fluid leak. Ultrasonography of the uterus and fallopian tubes is then done. Ultrasound can
follow the fluid through the tube up to the peritoneal cavity and in the pouch of Douglas.

MANAGEMENT OF INFERTILITY
Management of infertility or subfertility would depend upon the cause identified, duration and
age of the couple especially the female.
General Instructions
When minor defects are detected in both the husband and wife, each of which alone could not
cause infertility, but in combination they decrease the fertility potential the faults
should be treated simultaneously:
1. Body weight: Overweight or underweight ofany partner should be adequately dealt with
to obtain an optimal body weight
2. Smoking and alcohol: Excess smoking or alcohol consumption to be avoided.
3. Ideal coital frequency: Intercourse on multiple days during the fertile window period,
which includes the five preceding and the day of anticipated ovulation should be
reviewed with the couple.
4. Use of at home ‘fertility monitor’ and checking of vaginal mucus discharge to
determine the optimal timing of intercourse may be most helpful
5. Use of LH surge kit: Use of the kit can detect LH surge in urine by getting a deep blue
color of dipstick. The test performed between 12th and 16th day of regular cycle and
timed intercourse over 24-36 hours after the color change reasonably succeeds to
conception
6. Avoidance of lubricants and douches to be stressed.
7. The use of fertility impairing medications should be avoided by both partners if
possible, e.g. hormones
8. Psychological support should be offered as the couple may face significant stress and
sadness as the investigations and consultations progress

Management of Male Infertility

The treatment of male partner is indicated in extreme oligospermia, azoospermia, low-volume
ejaculate and impotency. Measures to improve spermatogenesis are advised:
1. General care:
a. Improvement of general health

16
  Reduction of weight in obese
 Avoidance of alcohol and heavy smoking
 Avoidance of tight and warm undergarments
 Avoidance of occupation that may elevate
testicular temperature.
b. Avoiding medications that interfere with spermatogenesis such as
 Cytotoxic drugs, nitrofurantoin, cimetidine, anticonvulsants, antidepressants
and beta blockers.
2. Medications to treat specific causes:
a. Human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG) for
hypogonadism.
b. Dopamine agonist (cabergoline) for hyperprolactinemia and altered testosterone level
and to improve libido, potency and fertility
c. The GnRH therapy for hypogonadism
d. Clomiphene citrate to increase serum levels of FSH, LH and testosterone
e. Antibiotics for genital tract infections
3. special treatments for causes identified such as:
a. Intrauterine insemination (IUI).
b. In vitro fertilization (IVF)
c. Intracytoplasmic sperm injection (ICSI)
d. Artificial insemination with donor (AID) sperm.
4. Surgical treatment:
a. In men, whose testicular biopsy shows normal spermatogenesis and obstruction is
suspected, vasoepididymostomy or vasovasostomy may help
b. Correction of hydrocele

MANAGEMENT OF FEMALE INFERTILITY

Treatment for females is also according to the disorders identified:
I. For ovulatory dysfunction:
a. Induction of ovulation using drugs such as clomiphene citrate, letrozole, FSH, hCG and
GnRH
b. Correction of biochemical abnormality: Metformin for hyperinsulinemia,
dexamethasone for androgen excess, bromocriptine for prolactin excess
c. Substitution therapy: Thyroxin for hypothyroidism, antidiabetic drugs for diabetes
mellitus.
II. Surgery
a. Laparoscopic ovarian drilling (LOD) or laser vaporization for polycystic
ovarian syndrome (PCOS)
b. Surgical removal of virilizingor functioning ovarian, or adrenal tumor.
c. Tubotubal anastomosis for adhesion in tube.
d. Cannulation and balloon tuboplasty for block in
tube
e. Fimbrioplasty for fimbrial adhesion.
f. Adhesiolysis for separation or division of adhesion.
g. Salpingostomy to create an opening in tube in a
completely occluded tube.

17
MANAGEMENT OF UNEXPLAINED INFERTILITY
Unexplained or persistent infertility refers to those couples who have undergone complete basic
infertility workup and in whom no abnormality has been detected and still remains infertile.
The reported evidence is about 10-20%. About 60-80% of those couples become pregnant
within 3 years without any treatment.
The recommended treatment for unexplained infertility is induction of ovulation, IUI
and super ovulation combine with IUI.

ASSISTED REPRODUCTIVE TECHNOLOGY

Assisted reproductive technology encompasses all means. It involves manipulation of gametes
and to partially artificial of used to achieve pregnancy by artificial or partally artificial means.it
involves manipulation of gametes and embryos outside the body for the treatment of infertility.
In ARD process of intercourse is bypassed either by IUI or fertilization of the oocytes in the
laboratory environment as in IVF
Different Techniques of ART
 Intrauterine insemination
 In vitro fertilization and embryo transfer (NF-ET)
 Gamete intrafallopian transfer (GIFT)
 Zygote intrafallopian transfer (ZIFT)
 Intracytoplasmic sperm injection.

Inrauetne insemination
Iurauterine insemination involves placing increased concentration of motile sperms close to the
fallopian tubes bypassing the endocervical canal which is abnormal. IUI may be artificial
Insemination husband (AIH), AID or insemination with donor eggs.
Indications
 Hostile cervical mucus
 Cervical stenosis
 Oligospermia or athenospermia
 Immune factor (male or female)
 male factor impotency or anatomical defect, but normal
ejaculate can be obtained, e.g, hypospadias (AIH)
 Unexplained infertility
Technique
About 3 mL of washed and concentrated sperms are injected through a flexible polyethylene
catheter within the uterine cavity around the time of ovulation. The processed
sperms for insemination should at least be 1 million fertilizing capacity of spermatozoa is 24-
48 hours. The procedure may be repeated two to three times over a period of 2-3 days.
Generally, four to six cycles of insemination with or without superovulation are advised
When large volumes of washed and processed sperms are placed within the uterine cavity
around the time of ovulation, it causes perfusion of the fallopian tubes with spermatozoa Hence,
this method is known as fallopian tube sperm perfusion.

18
In conjunction with ovulation induction, pregnancy rate is 25-30% per cycle.

Artificial insemination donor

When the semen of a donor is used for insemination, it is called artificial insemination donor.
Indications
 Untreatable azoospermia or athenospermla of husband
 Genetic disease affecting spermatogenesis in husband
 Rh-sensitization of the woman
Technique.
The donor should be healthy and serologically and bacteriologically free from venereal disease,
human Immunodeficlency virus (HIV) and hepatitis. The recipient änd donor must be matched
for blood group and Rh typing either fresh or frozen semen is used.
About three to six cycles may be used for success. Insemination when combined with
superovulation enhances success rate. Two inseminations 18-42 hours after hcG administration
(for ovulation) give higher result when compared to single insemination alter 36 hours.

Arlificial Insemination husband

An AIH is done for four cycles, The results are better, if combined with ovulation induction
for multiple ovulations.
Indications
 Impotency
 Oligospermia.
 Hypospadias
 Antisperm antibodies in cervical mucus
 Unexplained infertility
 Premature ejaculation or retrograde ejaculation
 X-Y fractionation of sperms for sex selection in genetic and chromosomal
abnormalities.
Technique
Semen collection, washing, centrifugation and swim-up methods are done. Washed and
concentrated sperm is then placed in uterine cavity as in AID technique.

In Vitro Fertilization and Embryo Transfer

Fertilization of an ovum outside the body is a technique used when a woman has blocked
fallopian tubes or some other impediment to the union of sperm and ovum in the reproductive
tract. The woman is given hormone therapy causing a number of ova to mature at the same
time (superovulation). Several of them are then removed from the ovary through a laparoscope
The ova are mixed with spermatozoa from her spouse and incubated in a culture medium until
a blastocyst is formed. The blastocyst is then implanted in the mother's uterus and the
pregnancy allowed to continue normally.

19
Indications
1. Tubal disease or block
2. Endometriosis.
3. Cervical hostility
4. Unexplained infertility
5. Ovarian failure (donor oocyte IVF) Donor oocyte IVF is done for women with no eggs
due to surgery, chemotherapy, genetic causes or poor egg quality.
Patient selection
1. Age of women (egg donor) less than 35 years.
2. Presence of at least one functioning ovary
3. Normal seminogram for husband
4. Couple negative for HIV and hepatitis.

Technique/Procedure steps
1. Induction of superovulation using drugs clomiphene
drugs citrate and GnRH.
2. Monitoring of follicular growth: This is done by cervical mucus study, sonographic
measurement of the follicle and serum estriol estimation.
3. Ovum retrienal: This is done either laparoscopically or vaginally. If vaginal route is
used, a small needle is inserted through the back of the vagina and guided via ultrasound
into the ovarian follicle to collect the fluid that contains the ova about 36 hours after
hCG
administration, but before ovulation occurs.
4. Fertilization (in vitro): The sperm for insemination in vitro is prepared by the wash and
swim technique. Approximately 50,000-100,000 sperms are placed into the culture
media containing the oocyte within 4-6 hours of retrieval. The semen is collected just
prior to o0vum retrieval. Sperm density and motility are most important criteria for
successful IVF
5. Embryo transfer: The fertilized ova at the four to eight cell stages are placed into the
uterine cavity close to the fundus about 48-72 hours later though a fine flexible tube
transcervically. Not more thar three embryos are transferred per cycle to minimize
multiple pregnancies

Gamete Intrafallopian Transfer

In this procedure, both the sperm and the unfertilized oocyte are transferred into the fallopian
tubes using laparoscopy following transvaginal ovum retrieval. Fertilization is then achieved
in vivo.
The prerequisite for GIFT procedure is to have normal fallopian tubes. The result is poor in
male factor abnormality. Superovulation is done as in IVF. About 2 hours prior to ovum
retrieval, semen specimen is obtained. The semen is washed by'swim-up' technique and the
most fertile fraction of the sperm is obtained and used for transfer

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Zygote Intrafallopian Transfer
In ZIFT, egg cells are removed from the woman's ovaries and fertilized in the laboratory. The
resulting zygote is then placed in the fallopian tube following vitro fertilization through
laparoscope or through uterine opening under ultrasonic guidance
The technique is a suitable alternative of GIFT. GIFT procedures are avoided when tubal
factors of infertility are present.

Intracytoplasmic Sperm Injection

Intracytoplasmic sperm injection method is beneficial in the case of male factor infertility
where the sperm counts are very low or failed fertilization with previous IVF attempts. The
ICSI procedure involves a single sperm carefully injected in to the centre of an egg using a
micro needle. Sperm is retrived from the ejaculate or by testicular sperm estraction CTESE) or
by microsurgical epididymal sperm aspiration (MESA). Indications are azoospermia, severe
oligospermia, sperm antibodies and obstruction of afferent duct system and failure of IVF
Prognosis of artificial reproductive methods
The pregnancy rate within 2 years after the start of investigations ranges from 30%% to 4'%.
The rate is higher, If AID cases are included. However, if pregnancy occurs, there is two-fold
increased chance of abortion, five times ectopic pregnancy and the perinatal mortality doubles.

Role of nurses in management of infertility

Nurses meet couples seeking help for treatment of infertility in special centers or clinics, where
such service are available. Those working in infertility centers usually are the first contact
persons who coordinate various activities for the couple's treatment. Their role with such
couples includes assessing, educating and counseling in addition to therapeutic assistance as
they undergo tests and procedures.
When a couple presents with concerns about infertility, it is important for the nursé to
understand that men and women very concerned and possibly emotionally fragile. Entering a
medical facility for evaluation is in itself for some an admission of failure.
Before or even beginning, the medical aspects of care is important to understand and assist the
couple to understand their motivation for pregnancy and to offer support. The couple should
understand and accept that the evaluation and treatment for infertility will be stressful and will
involve both partners throughout the process. It is important to meet the couple together.
An important step in evaluation for infertility is taking a detailed medical and family history
from each partner Treatment may be individualized for each partner Nursing interventions
include assisting in reducing stress in the relationship, encouraging cooperation, protecting
privacy and fostering understanding. Because infertility evaluations and treatments are
expensive, time consuming, invasive, stressful and not always successful, couples need great
support in working together to deal with the process. During the period of therapy, couple need
to avoid smoking, continue good diet, exercise maintain health and take folic acid supplements,
if prescribed.

INFERTILITY COUNSELING
• Infertility counseling deals with the psycho- social impact of infertility in terms of :

21
– Intervention,
– Treatment, and
– After-effects of both successful and unsuccessful treatments.
• It also involves therapeutic work to help patient cope with the consequences of infertility &
treatment.
Objectives & need of infertility counseling:
–Informed consent.
–To offer coping strategies to couples.
–To facilitate decision making.
–To offer preparation for procedures.
–To help client in achieving a better quality of life.
–To provide genetic counseling.
:
–IVF- group discussion by staff.
–Third party reproduction for both donors & recipients.
–Therapeutic counseling.
–Crisis counseling.
–Assessment & Follow-up.
Advantages of infertility counseling:
–Helps to deal with the emotional stress.
–Provide extra support.
–Allow the client in exploring all possible options for family.
–Help the couples in overcoming the dilemmas & deciding the right fertility treatment.
–Explains about the infertility management & specific treatment.
ling:
–Receiving the patient & family, and make them accessible & comfortable for counseling.
–Fertility nurse specialists provide care for the individuals and couples before, during, and
after fertility treatment.
–Nurse need to obtain history as prenatal, family and other relevant history.
–Nurse has to perform primary physical examination and collect other relevant information
regarding patient of reports.

22
–Give psychological support throughout the counseling.
–Collect other information about tests, reports & documents.
–Establish plan of care with family and co- ordinate care with other health care professionals.
–Maintain privacy and confidentiality of all cases.
–Performing inseminations.
–Performing embryo transfers.
–Ensure follow-up & supportive services to individual and family during counseling.

ETHICAL & LEGAL ASPECT OF ASSISTED

REPRODUCTION TECNOLOGY (ART)
• The aim of ART (fertility treatment) is to promote the chances of fertilization and subsequent
pregnancy by bringing the sperm and egg close to each other.
• Different types are:
-uterine Insemination (IUI):- • It is indicated as a first-line management where there are
problems such as:
–Hostile cervical mucus,
–Anti-sperm or male fertility problem (low sperm count or premature ejaculation),
–Although tubal patency of female partner must be assured.
• It is also useful for cases of unexplained infertility.
• In order to increase the chances of success:
– Ovulation is monitored,
– Ovulation is induced oftenly,
– Sperms are prepared to maximize their fertility before insertion into uterus.
- vitro fertilization (IVF)/ Embryo transfer:-
• Describes lab techniques where the fertilization occurs outside the body and is one of the
main types of ART.
• IVF is indicated in cases where the female partner has:
– Uterine tube occlusion ,
– Endometriosis or cervical mucus problems,
– Or where male factors are main problem.
• Stimulation of the ovaries to produce more than one egg is required and treatment starts with
pituitary desensitization (done by Gonadotrophin injection).

23
• Developed in 1992.
• It is a highly specialized variant of IVF treatment that involves the injection of a single sperm
into the cytoplasm of an egg with a fine glass needle.
• It is useful technique when sperm quality is poor.
• In azoospermic man sperm can be obtained surgically from the epididymis or by extraction
from testis itself.
-fallopian transfer (GIFT) & Zygote intra-fallopian transfer (ZIFT) :-
–Both GIFT & ZIFT are laparoscopic technique that offer little clinical advantage over in- vitro
fertilization (IVF) and are no longer recommended.
- When couples do not achieve pregnancy from the infertility
treatments or traditional ART, they may choose to use a third party assisted ART method to
have a child.

• Couples can be donated sperm when a man does not produce sperm or produces very low no.
of sperm and if he has a genetic disease.
• Donated sperm can be used with intra-uterine insemination or with IVF.

• This can be used when a women does not produce healthy egg that can be fertilized .
• An egg donor undergoes ovary stimulation and egg retrieval steps of IVF.
• Donated egg can then be fertilized by sperm from the women‘s partner, and resulting embryo
is placed into women’s uterus.
rrogacy:-
• Legal arrangements for surrogacy require the commencing (beginning) couple to both be over
the age of 18, married to each other and the child genetically related to at least one of them .
• Surrogate mother acts as a host as the embryo is placed in her uterus
ETHICAL AND LEGAL ASPECTS OF ASSISTED REPRODUCTIVE
TECHNOLOGY IN INDIA
Present Indian scenario
The Indian scenario in this field is quite bleak. Delhi artificial insemination (Human) Act 1995
is the only statutory act prevailing in India . There is no internal regulatory body like VLA in
U.K, moreover Indian Infertility specialist have rather opposed the steps towards regulation of
practice in this field.
1. Litigation against doctors – doctors can face few litigations like-
a. Not taking proper informed consent: After duly counseling the couple and / or oocytes /
semen donor and informed and written consent should be taken from both the spouses as well

24
as donor. They should be explained various risk factors including risks involve in ovarian hyper
stimulation, anaesthetic procedures, invasive procedures like laparoscopy, aspiration of ovum
etc. in simple language using the words that they can understand well. They should be
explained the possibility of multiple pregnancies, ectopic gestation, increased rate of
spontaneous abortion, premature birth, higher perinatal and infant mortality as well as growth
related problems.
b. Following the birth of a defective child: To avoid this, the donor's chromosomes must be
thoroughly screened for possible genetic defect, and should also inform all the likely
possibilities at the time of taking informed consent.
2. Legitimacy - The child born by ART is considered legitimate with all the rights of parentage,
support and inheritance, provided he is born during lawful wedlock and with consent of both
the spouses. Sperm or oocyte donors shall have no parental rights or duties in relation to the
child. A child can be given status of legitimacy also by adoption.
In a case, on the wife's petition for divorce and custody of the child, a question was raised
before the court: whether the child, who is born to her consequent to AID, consented to by
husband, is legitimate and belongs to mother only? Court held that a child so conceived was
not a child born in wedlock and therefore illegitimate. As such it was the child of mother alone
and the husband had no rights or interest in the child, not even that of visitation. The husband
is not the actual father of the child and, therefore the child is illegitimate.
3. Inheritance of property – Since the child is illegitimate if born out of AID, it cannot inherit
the property of his father. Any attempt to conceal this fact by registering the husband, as the
father amounts to perjury.
4. Consummation of marriage – Conception of the wife by AI (AIH or AID) does not amount
to consummation of marriage, if there is no successful sexual act due to the impotency of
husband. The decree of nullity may still be granted in favor of the wife on the ground of
impotency of the husband or his willful refusal to consummate the marriage. However, such a
decree could be excluded on the grounds of approbation. However in this situation the child
will be illegitimate.
5. Rights of an unmarried woman to AID : There is no legal bar on an unmarried woman going
for AID. A child born to a single woman through AID would be deemed to be legitimate.
However, AID should normally be performed only on a married woman and that too, with the
written consent of her husband, as a two-parent family would be always better for the child
than a single parent one, and the child's interests must outweigh all other interests.
6. Ground for divorce and judicial separation – Mere AI is not a ground for nullity of marriage
and divorce since sterility is not a ground, however if AI is due to impotence of husband, it
becomes the ground. AID without husbands consent can be a ground for divorce and judicial
separation.
7. Maintenance and custody of child – Under Hindu Adoption and Maintenance Act 1956 the
maintenance of the dependents is the responsibility of the parents, whether legitimate or
illegitimate, till the son remains minor and daughter is unmarried.
8. Insemination after the death of the husband – This is seen when semen of the husband is
cryo-preserved by various methods and the women is inseminated after death of the husband.

25
Such Posthumous child is said to be legitimate because the semen is of husband, although the
complexity arises since conception is not during the continuance of marriage.
9. Relation between AIH / AID child with subsequent Natural / Adopted child of same family
- If the child is born of natural course some times after the birth of the child through AI, the
status will remain same for AI child but the natural child born will remain legitimate.
10. Charge of Adultery - AID does not amount to adultery, even if it was done without the
consent of husband. For adultery to be committed both parties should be physically present and
engage in sexual act and sexual union involving some degree of penetration of the female organ
by the male organ should take place. AI is not equivalent to sexual intercourse.
Under section 497 of IPC 1860 , sexual intercourse with a person who is or whom he knows or
has reason to believe to be wife of another person without the consent or connivance of that
man. For the charge of adultery two things must be proved, sexual intercourse took place with
another person's wife and no consent or connivance from another man was granted.
11. Incestous relationship – There is high risk of such relationship between naturally born child
and child born out of AID of the same parent
Challenging Ethical Issues
A. Individual moral constraints on trying for reproduction “at any cost”? 16 , 17 , 18 , 19 , 20 ,
21
The concerns like Sex selection; Genetic screening for so-called “defects”; Selective abortion
with multiple fetuses; Pregnancies and older women; Surrogate motherhood; Cloning etc are
rampant and carrying the headlines these days.
B. Baby factory sells newborns like in Warsaw , Poland of Rs 11,000. It is home to 37 young
surrogate mothers. They say, they are offering services since 1.5 million couple in Poland are
being childless and they need more peoples.
With infertility on the rise, thank to erratic life style and late marriages and late baby plans,
more and more couples an opting for ART or adopted babies. The safe success rate of ART is
40%. ART today is a 30 billion industry in India with more than 300 clinics all over the country.
According to Anirudha Malpani “Infertility is the commonest Medical problem in 30-40 yr age
group of couples in India ”.
C. Posthumous Artificial insemination due to availability of semen banking, giving rise to
problems in connection with the inheritance rights of such a child, born after the death of
genetic father.
D. Dehumanizing aspects of procedures - Moral status of the Left-over Embryos, Egg, Sperm,
and the Fertilized Egg stored for a married woman who subsequently died.
E . In Japanese surrogate baby Manjhi case , a bench said that in commercial surrogacy, a
gestational carrier was paid to carry the child to maturity in her womb and was usually resorted
to by couples to complete their dream of being parents. “This medical procedure is legal in
several countries, including India ” said SC. Similarly a German couple is striving hard for the
citizenship of their twin surrogate baby, born in India , since German law does not recognize

26
surrogate childrens and Indian law is in very infantile stage to decide such issues, hence SC is
in dilemma.
F . An Israeli gay couple categorical has dislike for Section 377 of the Indian law that makes
homosexuality a criminal offence, but they like the `desi' regulation that allowed them to hire
a surrogate mother to deliver their child here. " Israel doesn't allow same-sex couples to adopt
or have a surrogate mother.
Recent advances
A. Several infertility clinics have, announced a low cost technique for test tube baby by certain
replacements, like – The egg & sperm are kept in a plastic vial costing Rs 2 instead of using
expensive carbon dioxide incubators (costing 7 lakhs). They are using a local hot block costing
Rs 15000 to maintain the mixture's temperature at 30 0 C. Alternatively it can be stored in
mother-to-be's vagina for two days using female condom to keep it in place. 22 , 23 , 24 , 25 ,
26 , 27
B. Test Tube babies offer hope to HIV–discordant couples , especially when carried through
ICSI (Intra cytoplasmic Sperm infection). Two Medical Journals, Lancet and New England
Journal of Medicine carried exhaustive studies highlighting for over 5 years back, establishing
a treatment protocol for HIV–discordant couple. HIV affected man's sperms are put through a
“wash” for IVF treatment. The density gradient sperm wash, which is conducted in a centrifuge
machine, continues for almost 60 min and separate the sperms from the other cells and waste
in the semen. The live sperms are again tested for HIV, before being transferred to woman in
a procedure called Intra–uterine transfer. However to be extra cautious we use a technique
called ICSI. In fact, a peer reviewed medical journals, AIDS 2007, recently advocated a wider
use of IVF technique for HIV discordant couple.
C . The world first birth through oocyte freezing and thawing was pioneered by Prof.
Christopher Chen in Australia , 1986. Recently the first pregnancy and birth in India after the
transfer of embryo generated from frozen-thawed oocytes (Cook oocyte freezing media)
accomplished by Dr Priya selvaraj and her team. Birth of a male was accomplished for the first
time in India by newer technique of frozen egg (freezing by vitrification) in Ahemdabad by Dr.
Himanshu and Falguni Bhavishish recently.
D. A gene was found (SMAD-3) by a team from Virginia Commonwealth University whose
absence caused infertility

ADOPTION
Introduction
Adoption is a process whereby a person assumes parenting of another, usually a child from that
person's legal or biological parent or parents, and in so doing, permanently transfers all rights
and responsibilities from the biological parent or parents. Adoption is intended to effect a
permanent change in status and as such requires societal recognition and legal sanction.
Historically some societies have enacted specific laws governing adoption whereas others have
endeavored to achieve adoption through less formal means such as contracts that specified
inheritance rights and parental responsibilities. Modern systems of adoption are governed by
comprehensive status and legal regulations.
Reasons for Adoption

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Adoption can occur either between related family members, or unrelated individuals.
Historically, most adoptions occurred within a family. The most recent data from the US,
indicates about half of adoptions are currently between related individuals such as step-parent
adoption, where the new partner of a parent may legally adopt a child from the parent's previous
relationship. Interfamily adoption may also occur through surrender, as a result of parental
death, or when the child cannot otherwise be cared for and a family member agrees to take
over.
 Infertility is the main reason parents seek to adopt children they are not related to
 Divorce or death of one parent: compassion motivated by religious or philosophical
conviction, to avoid contributing to perceived overpopulation, out of the belief that it is
more responsible to care for otherwise parent-less children than to reproduce
 To ensure inheritable diseases (e.g. Tay-sachs disease) are not passed, and health
concerns relating to pregnancy and childbirth.

Causes of Adoption
 Genuine love for the child
 Couple with two or more children of same sex
 Inheritable disease for the parent
 To control population
 Person having carrier status for certain diseases
 Single parent who wants to experience parenthood
 Infertility.
TYPES OF ADOPTION
Open Adoption
This type of adoption occurs when the birth parents and prospective adoptive families are
allowed to interact with one another. In this type of adoption, the identities of all parties are
shared. The interaction may differ from one family to another. It may involve letters, e-mails,
telephone calls or visits. Open adoption offers several advantages for birth parents, adoptive
parents, and adopted children.
Advantages of Open Adoption for Birth Parents
Some of the possible advantages of open adoption include:
 Sense of control: Having the ability to review, interview and select parents for their
child can provide birth parents a sense of security, power and empowerment
 Reduced uncertainty: Most birth parents feel reassured, and comforted from knowing
about the child's well-being through regular interactions with the adoptive family
 Increased ability to deal with the grief associated with the sense of loss as they can
communicate with the adoptive family.
 Reduced fear-as there is regular communication with the adoptive family both prior to
the birth and following adoption
 Relationship with the child: There is an opportunity develop a positive relationship with
the adoptive family to the level of an extended family.

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  Reduced guilt: With an on-going relationship and opportunity for regular
communication, birth parents often have less of a struggle to deal with guilt of their
decision to put their child up for adoption
For the adoptive family
Possible advantages for adoptive families are:
 Reduced fear: When there is on-going communication with the birth mother or birth
families, there tends to be less concern about the birthmother's intentions
 Medically informed: The need to provide a medical history is a normal requirement in
the adoption process. This offers additional opportunity to obtain new medical
information over time
 Relationship with the birth families: There is an opportunity to develop an on-going
relationship with the birth mother or birth families. Both families often be- come like
part of their extended families.
For the adopted child
 Identity and self-confidence provides greater opportunity for the children to learn about
their family
 Protection against a sense of abandonment: Having the opportunity to communicate
with his or her birth family about the reasons for adoption can help limit or reduce the
child's sense of abandonment
 Availability of medical history: This offers additional opportunity to obtain updated
medical information if new medical symptoms appear in adulthood.
 Relationship with both families: The opportunity to develop a relationship with
birthmother or birth family offers more confidence about self-identity
 Support network: The continued concern of birth mothers and families can contribute
to help them to function effectively as advocates and additional support for the child.
Disadvantages of Open Adoption
For birth patents
 Potential for abuse of trust placed in the adoptive fami-lies by manipulating certain
situations
 Potential for disappointment: This situation occurs if the adoptive family does not meet
expectations
 Feelings of obligation: A birth mother may feel unduly obligated about placing her
child for adoption because of financial commitment or emotional investment
 Potential for change of mind: The adoptive family may choose to halt or terminate the
adoption process at any time resulting in the child being placed in foster home until
other arrangements can be made.
For the adoptive family
 Potenial for increased pressure to accept the demands of birth family for fear of not
getting the child
 Unstable relationship Fear of keeping a relationship with an unhealthy or emotionally
disturbed birth family member

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  Additional support The adoptive family may feel pressured to provide emotional
support for the birth family
For the adopted child
 Reduced ability to assimilate into family interaction with birth family may make it
harder for the child to assimilate into the adoptive family
 Sense of rejection: For some reason, if the contacts between the two families cease, the
child can feel rejected
 Peer communication: The need to give explanation to peers about the relationships with
two families may be a cause for struggle for the child
 Power struggles: The child may manipulate both families by playing one against the
other
 Identity confusion: As the child matures, he/she may have greater struggle to make
sense of the family history and genecology information involving more than one
family.
Semi-open Adoption
A semi-open adoption occurs when the birth mothers or
birth families experience non-identifying interaction with adoptive families. In most cases
interaction is facilitated by a third party, usually an adoption agency or adoption attorney. In
this type of adoption, the identity of all parties is kept confidential. In some cases, there might
be non-identifying e-mails or visits hosted by the adoption professional
Advantages of Semi-open Adoption
For birth parents
 Sense of control Having the ability to review, interview
and select the adoptive parents for their child provide a sense of control
 Privacy Interaction between birth parents and adoptive parents that are facilitated by
adoption agency personnel provides a sense of privacy
 Reduced uncertainties The interactions and updates provided through adoption agency,
or attorney provide reassurance of the child well-being
 Improved mourning Regular updates on the child's well-being can improve the ability
of some birth parents to deal with their sense of grief and loss
 Reduced fear When the adoption professional facilitates on going communication
between both sets of the birth parents have fewer concerns about
of their child
 Reduced guilt Updates and letters from the adoptive
through the adoption agency can lessen a feelings of guilt associated with the decision
they made to place the child for adoption.
For the adoptive family
 Reduced fear When the adoption professional facilitates on going communication
between the biological and adoptive families, concerns regarding the birth mother's
intentions are reduced

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  Medically informed A medical history is normal part of the adoption process, and there
is the opportunity through the adoption agency or attorney to request for based upon
changing
 Roles clearly defined: A semi-open adoption makes it easier to manage the roles of each
party involved rather than an open adoption
 Understanding and confidence. The opportunity to ask questions about the child's
medical history through the adoption agency offers more confidence.
For the adopted child
The semi-open adoption experience can vary with each child
 Identity and self-confidence. The access to birth families through the adoption
personnel enables them to acquire more information about who they are and where did
they come from.
 Protection against a sense of abandonment Having the opportunity receive
communication can help prevent the child from experiencing a sense of abandonment
 Absence of need to search The yearning of a child to
 Medically informed: There is provision to obtain additional medical information that
might become necessary with the onset of medical symptoms in adulthood, or when
planning family life.
Disadvantages of Semi-open Adoption
To birth parents
The parental disadvantages include
 Loss of relationship: There is the potential loss of direct relationship with the adopted
child as the communication occurs through adoption professional.
 Increased grief: In the initial years following placement of the child, there is greater
risk of heightened grief from the liability to observe how the child is doing with the
adoptive family
 Feeling of obligation: The financial and emotional investment on the part of the
adoptive family can make the birth mother feel pressured and obligated to place the
child for adoption.
For the adoptive family
The potential disadvantages of semi-open adoption include
 Limited relationship as the communication is through the adoption professional.
 limited information regarding medical history, family genealogy etc., as
communication is through adoption professional.
 Delyed responses to questions as questions are processed through adoption agency or
attorney
For the adopted child
 Negative perceptions as the birth family is kept away from the adoptive family and the
adopted child may develop misinterpretation that it is wrong to interact with the birth
family

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  Postponed or avoided reunions with the birth family .
 Identity confusion: There is chance for an older child to struggle with his/her identity
because of the limited communication with the birth family
 .Pre-occupation with adoption issues
Closed Adoption
Closed adoption refers to an adoption process where there is no interaction of any kind between
birth mothers and prospective adoptive families. This means that there is no identifying
information provided either to the birth families or adoptive families. However, non-identifying
information such as physical characteristics and medical history may be made available.
Advantages of Closed Adoption
For the birth parents
 Sense of closure: For some birth mothers this provides a sense of closure enabling them
to move on with their lives.
 Privacy: For people who feel threatened and vulnerable about their decision to place
the child for adoption this type of adoption can offer greater privacy
 Reduced fear: For those who have concerns about explaining their decision to others,
closed adoption can offer a way to avoid confrontation.
For adoptive family
 Family freedom: When birth families are not involved, adoptive families are free to
enjoy their family time
 Absence of fuzzy boundaries: Eliminates the risk of complications that can arise from
birthparents interference or co -parenting concerns
For the adopted child
 Absence of fuzzy boundaries: Eliminates the risk of complications that can arise from
birthparents interference or co-parenting concerns
 Protection from unstable or emotionally disturbed birthparents or birth family
members
Disadvantages of Closed Adoption
For birthparents
 Dealing with grief Some birth parents experience grief because of lack of information
about the child Chapter0: Infertility and Adoption
 Dealing with the feeling of guilt due to lack of opportunity to explain to the child the
reasons or her for adoption
 dealing with the the feeling of abandonment because of the inability to communicate
with the chi
 Dealing with lack of information: feelings of guilt can make some individuals
susceptible to depression.
For the adoptive family

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  Increased sense of denial about "fertility status
 Increased fear that the birth mother will change her mind and ask for the return of the
child
 Limited medical history: Concern about obtaining additional information if the child
develops new medical problems as the child grows older
 Less personal control because of the need to rely on an agency to act as a middle person
to get information about the child.
For the adopted child
Potential disadvantages for the child include:
 Identity confusion: As the child grows older, he/she can experience struggles with
personal identity because of the absence of contact with the birth families.
 Preoccupation with adoption issues: Children in closed adoption might feel this more
than those with other types of abortion.
 Limited information: Adopted children may have several unanswered questions about
their medical and general histories.

ADOPTION IN INDIA
Adoption in India was regulated by Governmental Acts from early time. These were (1) The
Guardian and Wards Act of 1890 (GWA), (2) Hindu Adoption and Maintenance Act of 1956
(HAMA) and (3) the Juvenile lustice Act of 2000, amended in 2006 (JA).
1. The Guardian and Wards Act of 1890 (GWA)
This was the first secular law that allowed for a child to be adopted in India. The salient features
of this Act were:

 The parent adopting is a guardian' and the child adoptee is 'a ward, meaning the same
rights of a biological child aren't inherent
 Anyone under the age of 18 years can be a ward
 The guardianship can be revoked by courts or by guardian
 A will is required for any property/goods to be be be queathed to the child
 This will can be legally contested by 'blood' relatives
 Both spouses can legally be guardians where the man adopts with the consent of his
wife
 Single persons can adopt without any age difference restrictions.
2. Hindu Adoption and maintenance act,1956 (HAMA). The act covers Hindus,
Buddhists, Jains and Sikhs
Some relevant parts of the Act are:
 Married couples or single adults can adopt;
 Legally man adopts with the consent of his wife
 A single child already exists in the family. A child of opposite sex has to be adopted
 Children adopted under this Act get the same legal as a biological child might

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  Children under the age of 15 years can be adopted:
 A single man adopting a girl should be at least 21 older than child:
 Adoption under this Act is irrevocable.

3. The Juvenile Justice (Care and Protection) Act of 2000 amended in 2006 (IT Act)
The JJ Act is meant mainly for the care and rehabilitation of children in conflict with the law.
There was the need for a law that would allow children the same rights, whether they were
biological or adopted. There was also the need for a law that delinked adoption from the
religion of the adoptive parent s). The JJ Act filled this space and a tiny section was added on
for adoption. The Amendment Act of 2006 has since expanded the provisions. The main
strengths of this Act are
- Any Indian citizen can adopt a child who is legally free for adoption;
- The adoptee gets the same rights that a biological child might
- The religion of the adoptive parent's) is not relevant
- Single persons can adopt
- The adoption is irrevocable
- Some time limits have been set to ensure that children are considered legally
free for adoption earlier
- The trust is on the best interest of the child
Section 3(a. a) of the Act defines adoption as the process through which the adopted child is
permanently separated from his biological parents and becomes the legitimate child of adoptive
parents with all rights, privileges and responsibilities that are attached to the relationship While
the Act covers all of India, it is only possible to adopt under this Act in areas where JJ Boards
(provided under the Act) have been constituted. This is an ongoing process with majority of
states issuing notifications constituting these boards. Indian Citizens, non-resident Indians and
non-Indians residing outside India can adopt a child from India. While these adoptions are also
legalized under the Acts mentioned above, the rules related to these adoptions can be different.
These are dependent on the regulations of the countries in which the adoptive families reside
and the relevant immigration laws.
Adoption means a legal process that allows someone to become the parent of a child, even
though the parent and child are not related by blood. But in every other way adoptive parents
are the child's parents.
In India the Central Adoption Resource Authority (CARA) is a statutory body of the
Ministry for Women and Child Development, Government of India. It functions as the nodal
body for adoption of Indian Children and is mandated to monitor and regulate in-country and
intercountry adoptions. CARA is designated as the Central Authority to deal with intercountry
adoptions in accordance with the provisions of the Hague Convention on intercountry Adoption
1993, ratified by Government of India in 2003. CARA primarily deals with adoption of
orphans, abandoned and surrendered children through its associated/recognized adoption
agencies.
Eligibility Criteria for Prospective Adoptive Parents

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 1. The prospective adoptive parents shall be physically mentally and emotionally stable,
financially capable and shall not have any life-threatening medícal condition.
2. Any prospective adoptive parent, irrespective of his/ her marital status and whether or
not he has biological son or daughter, can adopt a child subject to following condítions:
a. The consent of both the spouses for the adoption shall be required in case of married
couple
b. A single female can adopt a child of any gender
c. A single male shall not be eligible to adopt a girl child.
3. No child shall be given in adoption to a couple unless they have at least two years of
stable marital relationship
4. The age of prospective adoptive parents, as on the date of registration shall be counted
for deciding the eligibility, and the eligibility of prospective adoptive parents to apply
for children of different age groups shall be as under:
Maximum composite age of Maximum age of single
Age of child prospective adoptive parents prospective adoptive parent
(couple)
Up to 4 years 90 years 45 years

Above 4 and 100 years 50 years

up to 8 years

Above 8 and 110 years 55 years

up to 18 years

5. In case of couple, the composite age of prospective adoptive parents shall be counted.
6. The minimum age difference between the child and either of the prospective adoptive
parent shall not be less than 25 years.
CONCLUSION
Infertility is defined as a failure to conceive within one or more years of regular
unprotected coitus.
Subfertility refers to a state in which a couple has tried unsuccessfully to have a child before a
year or more. The term sub fertile means less fertile than a regular couple.
Primary infertility denotes those patients who have never conceived. Secondary infertility
indicates previous pregnancy but failure to conceive subsequently (either carried the pregnancy
to term or had a miscarriage).
Fecundability is defined as the probability of achieving a pregnancy within one menstrual
cycle. In a healthy young couple it is 20 per cent. Fecundity is the probability of achieving a
livebirth within a single cycle.

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BIBLIOGRAPHY
 Harilal konar. DC Dutta’s textbook of obstertrics , Jaypee publications , 9th
edition 2018 , page no.- 85-95, 102-107
 L. king,C.Brucker .Varney’s midwifery, fifth edition LLC an ascend learning
company, PAGE NO -652,657,139-144
 Kamini rao,Text book of midwifery and obstetrics . jaypee publicatons

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