PRIMARY SUBFERTILITY SHORT KEY

CAUSES:
FEMALE FACTORS:
Ovulatory dysfunction cyclic irreg ( HMB, Anovulation)
Tubal factor  endometriosis , PID , fibroid blocking tubes, STD (multiple
Partners, unprotected coitus, perineal lesions)
Non-STD ( prev c.sec, D& C IUCD Purperial pyrexia –)
Pelvic TB.
Uterine Uterine fibroids/ endometrial polyp/ IUCD / asherman’s synd/
Endometritis/ anatomical defects
Ovarian PCOs / chemo / radio / hormones
Endocrine abnThyroid dysfunction  hyper/ hypo
Hypothalamic dysfunction  hypothalamic hypogonadism( kallman’s),
POF
Pituitary disease  Hyper prolactinemia prolactinomas/ drugs ( antipsychotic /
anti depressants)
Congenital defects turner / MRKH , AIS
MALE FACTORS:
Age/ profession ( hot environment)/ chemical industry (lead, paints, pesticides)/
radiation/ surgery/trauma/ch.uncorected inguinal hernia/ Prostate surgery
retrograde ejaculation
Primary testicular failurech disorders, maldecendant, microdeletion of genes at
y chromosomes Abn semen analysis  oligo/Azoospermia/ Aspermia/
uncorrected maldecendant testes torsion
Drugs alcohol, smoking, anabolic steroids, anti hypertensive, sedatives,
antipsychotic, antidepressants
Endocrinologicalhypogonadotrophic hypogonadism , hyperprolactinemia
Testicular failure, genital infections (polygamy), diabetes.
Obstructive causescongenital/ inflammatory/ iatrogenic/ cystic fibrosis
Other Infections epididymo-orchitis
Autoimmune antisperm antibodies
PhysiologicalErectile/ ejaculatory dysfunction
Congenital abn Klinifelters synd , sweyer syndrome
MANAGEMENT:
FEMALE FACTOR TREATMENT:
Conditions Treatment
Unexplained infertility Re-assure
1st line cc
2nd line aromataze inhibitors(
letrozole)
3rd line IUI/ IVF
4th (donor/ surrogacy/ not in
PK)Adoption

PID: a.Tubes patent:

treat PID
ovulation induction
IUI
IVF
adoption

b: tubes not patent:

IVF
Adoption
Stage I and II  ov induction
Endometriosis: Better result with ablation/ excision
 Stage II & IV surgery for symptomatic
Rx
IVF

TB: Treat TB / IVF/ adoption

PCOS: Weight reduction

Ov induction
By cc/ letrozole/ GnRh
/IUI/IVF/Adoption

Hyperprolactinemia: Dopamine agonists  bromocriptine/

cabargoline

Fibroid: Symptomatic:
a. <3cm fl up/medical Rx
b. >3cm ---< 5cm sub/m 
hysteroscopic resection
c. > 5cm sub/m , intra/m
myomectomy
/dye test
Asymptomatic:
a. <3 yrs infertility with patent
tubes fl up / reassurance
b. >3 yrs infertility with patent tubes/
and b/l blocked tubes
myomectomy , dye test

Polyp: small vaginal avulsion/ thick pedicle

hysteroscopic resection

MALE FACTOR Rx:

Improve Nutrition
Ensure Cf 2—3 / week
Life style/ job /duty adjustment to less hazard environment
Correct deformity
Diabetes control
Quit smoking
If Congenital absence of Vas def/ cystic fibrosis / obstructive causes  surgical
sperm retrieval f/b IVF & ICSI
Hyperprolactinemia impotence  erectile dysfunction phosphodiestrase
type 5 inhibitors / intracavernosal inj of alprostadil
Klinifelters/ sweyer syndrome donor sperms

Dr. Shamim