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Infertility

Pr Fomulu
J.N.

Objectives
At the end of this lecture, M2
students should be able to:
Define, classify and identify the
aetiologies of infertility.
Evaluate the infertile couple
Establish an aetiology-based
management

Plan

Introduction - Definition
Classification of infertility
Review of hypothalamic-pituitary axis
Incidence of infertility in Cameroon and the
world
Aetiologies of male and female infertility
Couple evaluation of infertility
Management of infertility with emphasis on
prevention and treatment of causes of
infertility
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Introduction
Definition: inability of a couple to
achieve pregnancy despite
cohabitation and adequate exposure
to pregnancy for a period of one year
in the absence of contraception.
Incidence: 10-15 of couples and up to
30% in some sub-saharian countries
(Cameroon, Gabon, Congo, RCA,
Sudan, RDC, Burkina-Faso).
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Introduction
Factors affecting incidence:
Socio-cultural;
STI;
Regional/ geographic/ethnic variation.

Classification
Primary infertility: 40%
Secondary infertility: 60%
Unproven infertility.

Review of the hypothalamicpituitary-ovarian axis


Hypothalamus

Pituitary

(Thyroid, Liver, Pancreas


Adrenals)

Ovaries
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Female causes
Ovulatory dysfunction: disturbance in HPO
axis.
Tubal disorders: PID, pelvic endometriosis,
tubal spasm, congenital tubal abnormalities
(tubal aplasia, diverticulae);
Uterine and cervical factors: myoma, polyps,
Ashermans syndrome, developmental
uterine abnormalities (uterine agenesis,
transverse vaginal membrane);
Tuberculosis endometritis;
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Female causes
Cervical hostility: stenosis, dysmenorrhoea,
immunological, cervicitis, cervical
polyps/fibroids;
Vaginal causes: vaginitis, vaginal transverse
septum, congenital absence;
Nutritional/metabolic factors: hyper/
hypothyroidism, diabetes, anaemia, anorexia
nervosa, Cushings and Addisons disease,
adreno-genital syndrome, liver cirrhosis.
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Male causes
Endocrinological factors: hyperprolactinaemia,
Cushings syndrome, diabetes, Parkinsons
disease, hypogonadotrophic hypogonadism
(Klinefelters syndrome 47 XXY, etc.)
Poor semen:
Varicocele, nylon pants;
Hydrocele,
Testicular failure: Klinefelters syndrome, testicular
immune diseases, testicular radiation, mumps
orchitis, cryptorchidism;
Physical/chemical agents: stress, heavy smoking,
alcoolism, drugs;
Immunological disorders.
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Male causes
Ductal obstruction:
Congenital (mucoviscidose, ductal
aplasia);
STI;
Inadvertent herniorrhaphy;
Retrograde ejaculation;

Coital problems:
Low frequency, impotence, hypospadias,
penile phymosis, faulty coital technics.
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Evaluation of the infertile


couple
Clinical history:
menarche, menstrual cycle,
dysmenorrhoea, per vaginal discharge,
contraception, previous pregnancy
outcome, STI, coital frequency;
Medical diseases: goitre, diabetes,
oeritonitis, cirrhosis;
Previous surgery: appendicectomy,
hysterectomy, tubal ligation, herniorrhaphy,
myomectomy, orchidectomy, vasectomy.
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Evaluation of the infertile


couple
Physical exam:
Secondary sex characteristics;
Gynaecological exam.

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Evaluation of the infertile


couple
Female:
Tubal patency tests: Rubens test, HSG,
laparoscopy, hydrotubation;
Ovulation tests: BBT, cervical mucus,
vaginal cytology, EB, laparoscopy,
ultrasonography.
Sperm/mucus interaction test: PCT
Hormonal assays.

Male: SA, vasography, hormone assay.


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Treatment
Prevention:
STI control,
Education against taboos,
Correction of nutritional deficiencies,
X-ray protection,
Trauma: surgical advertency,
Cotton pants,
Avoid hot baths.
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Treatment
Curative treatment:
Surgical: hydrocelectomy, varicocele
surgery, cryptorchidism correction,
tuboplasty, wedge resection, ovarian
tumors, Ashermans syndrome, uterine
malformation, etc.
Medical: induction of ovulation,
treatment of metabolic disorders,
assisted reproduction (AIH, AID,
surrogacy, IVF/ET.
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References
1. Integrated Obstetrics and Gynaecology
for postgraduates by C.J. Dewhurst, 2 nd
edition by Blackwell Scientific
Publications.
2. Obstetrics and Gynaecology (Scientific
Foundations of) by Elliot E Philipp,
Josephine Barns and Michael Newton
International Edition (3rd edition)
3. Principles of Gynaecology, by Sir Norman
Jeffwate, Butterworths, 4th edition.
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