TREATMENT OF

INFERTILITY

DR RK ROY
DEPT OF PHARMACOLOGY
 Introduction
• REQUIREMENTS FOR FERTILITY :

• The properties of the fecund male include:

• 1) Normal spermatogenesis and ductal system
(normal count, motility, and biologic
structure/function of sperm)
• 2) Ability to transmit the spermatozoa to the female
vagina, through :
• -Adequate sexual drive
• -Ability to maintain an erection
• -Ability to achieve a normal ejaculation
• -Placement of ejaculate in the vaginal vault
 Contd…
The properties of the fecund female include:
 Adequate sexual drive and sexual
function to permit coitus
 Functioning reproductive anatomy and physiology
which includes:
• -A vagina capable of receiving spermatozoa
• -Normal cervical mucus to allow passage of
spermatozoa to the upper genital tract
• Ovulatory cycles
• Fallopian tubes which will function to permit the
sperm and ovum to meet and allow migration of the
fertilized ovum to the uterus
• A uterus capable of developing and sustaining the
conceptus to maturity
• Adequate hormonal status to maintain pregnancy
 Adequate nutritional, chemical, and health status to
maintain nutrition and oxygenation of placenta and
fetus
 Contd…
So:
• Male must produce and mature satisfactory numbers
of normal motile spermatozoa
• He must have patent ducts and enough potency to
ejaculate spermatozoa from urethra into the vagina
• Spermatozoa must reach the cervix, pass through
the cervical mucus and ascend through uterus and
oviduct at an appropriate time to meet the ovum
• Spermatozoa must be capable of penetrating and
fertilising the ovum
• The female must ovulate an ovum which has access
to a patent oviduct
• The fertilised ovum must enter into the uterus, find
well prepared endometrium for implantation
 Infertility
• Failure to conceive within 1 or more years of
unprotected coitus
• What causes it?
• 80 -90% of normal couples will conceive
within 1 year
• 10% - 15% of all couples are infertile
• Both male and female must be investigated
• 35% of infertility is due to male factors
• Up to 10% of cases have no known cause
• >50% of cases involve multiple factors
 Contd…
 Etiology :can involve one/both partners
 Causes of male infertility-
 Defective spermatogenesis – Vericocele,
Cryptorchidism, Orchitis, Genetic 47XXY,
Toxin, Drugs ,Radiation, Primary & secondary
testicular failure
 Obst. of efferent duct –Congenital (absence of
Vas & Young syndrome); Acquired (Infection,
Surgical trauma)
 Failure to deposit sperm high in vagina –
Impotence, Ejaculatory failure, Retrograde
ejaculation, Hypospedius, Bladder neck
surgery, Psychosexual, Drugs
 Defect in sperm & seminal fluid – Immotile
sperm, Terratozoospermia, ↓fructose content,
Sperm antibody
•
Causes of female infertility
 Ovarian factors : Anovulation or oligo-ovulation ,Luteal phase
defect (LPD), Luteinised unruptured follicle (LUF)
 Tubal factors: Defective ovum pick up ,Impaired tubal
motility ,Loss of cilia, Partial to complete obstruction of tubal
lumen
 Peritoneal factors: Peritoneal adhesions, Endometriosis
 Uterine factors :Uterine hypoplasia, Inadequate secretory
endometrium, Fibroid uterus ,Endometritis (tubercular in
particular), Uterine synechiae ,Congenital malformation of
uterus
 Cervical factors: Congenital elongation of cervix ,Uterine
prolapse ,Acute retroverted uterus ,Fault in the cervical mucus
 Vaginal factors: Atresia vagina (partial or complete),
Transverse vaginal septum, Septate vagina, Narrow introitus
causing dyspareunia (pain)
 Others
Combined factors – factors both in male and female
partners causing infertility:
General factors – advanced age of wife beyond 35 yrs,
ageing reduces the fertility of male but
spermatogenesis continues through out life
Infrequent intercourse, lack of knowledge of coital
technique and timing of coitus to utilize the fertile
period (are very much common even amongst
literate couples)
• Dyspareunia
• Anxiety and apprehension
• Use of lubricants during intercourse – may be
spermicidal
• Immunological factors
 Treatment
Two types :
Surgical
Non-surgical –
Restoring fertility
ART
Restoration of fertility :
General measure
Specific measure
 Specific measures

For male type infertility :

Treatment indicated in –
Extreme oligozoospermia
Azoospermia
Low vol. ejaculate
Impotency
Retrograde ejaculation
 Contd…
 To improve spermatogenesis:
 In hypogonadotrophic hypogonadism –
Tab. Clomiphen cytrate 25-50mg x 25 days →
rest for 5 days → continue 3cycle
Inj. hCG 5000IU im OD/BD wkly
Inj. hMG & hCG – In Gn def. & failed
Clomiphene
Testosterone – 100-160mg oral/d x 4mts
GnRH therapy
 In presence of antisperm antibody –
Dexamethasone – 0.5mg/d
Currently - IUI
 Contd…
In genital tract inf. – Antibiotic
In retrograde ejaculation – Phenylephrine
low sperm count or when the sperm
carries mutant genetic factors -ARTIFICIAL
INSEMINATION
 In terato/astheno-spermia – Donor
insemination
In genetic abnormality – IUI with donor’s
sperm
 Contd…
 In Impotency :
 Psychological treatment
 Hyperprolactinemia – Further inv. & treatment
 Drugs –Sildenafil & alprostadil
Sildenafil :
 Selective phosphodiesterase- 5 inhibitor→ ↑cGMP
→ relaxation of non vascular sm ms → erection
 Should not be taken˃1/d
 Contraindicated in heart disease/kidney &
impaired liver disease & pt. on nitrate therapy
 Treatment of female
infertility
 Ovarian failure :
 Clomiphen citrate – 50mg/d from 2 to 6th→ up to
100mg/d
 FSH with clomiphen citrate & hMG
 hMG – In pituitary failure
 GnRH analogue- In irregular ovulation/ premature
ovulation with hMG
 Letrozol- Anovulatory not responding to other
 Dexamethasone in ↑androgen
 Bromocryptine in ↑ prolactin
 Substitution therapy
 Contd…
 In Endometriosis :
 Medical –
 Combined OCP
 Progesterone
 Danazole
 GnRH
 Surgery or both
 In Tubal block & Uterine malformation :
Surgery
 ↓of ↑level of-
 Androgen- Dexamethasone
 Prolactin-Bromocryptine
 Insulin- Metformin
 Assisted reproduction technology:
 IVF/GIFT
 Assisted reproductive
techniques
• According to this definition, ART includes all
fertility treatments in which both eggs and sperm
are handled. In general, ART procedures involve
surgically removing eggs from a woman’s
ovaries, combining them with sperm in the
laboratory, and returning them to the woman’s
body or donating them to another woman. They
do NOT include treatments in which only sperm
are handled (i.e., intrauterine—or artificial—
insemination) or procedures in which a woman
takes medicine only to stimulate egg production
without the intention of having eggs retrieved
 Contd…
• IN VITRO FERTILIZATION
(IVF)
(In Vitro means ‘in glass’; test tube baby terminology)  
Once fertilization occurs (in the lab), the tiny embryo
produced is transferred (at the four to eight cell stage)
into the woman’s uterus and is expected to develop
through a normal pregnancy

• Gamete intrafallopian transfer

(GIFT) was developed in 1984 for women with
unexplained infertility. During this procedure, the patient
undergoes a controlled ovarian hyperstimulation. The
oocytes are retrieved transvaginally under
ultrasonographic guidance, and 3-4 oocytes are placed
via laparoscopy into one of the fallopian tubes along with
sperm.
 Contd…
• Zygote intrafallopian transfer
(ZIFT) is used for couples with a significant male
factor. The oocytes are retrieved similar to GIFT, but
they are allowed to fertilize in vitro in the laboratory. At
the 2-pronuclear stage (usually 24 h later), 3-4 embryos
are transferred via laparoscopy into one of the fallopian
tubes. If the embryos are allowed to develop to greater
than a 2-cell stage, the procedure is termed tubal
embryo transfer (TET). The only benefit to a ZIFT or TET
versus the more traditional IVF is for women who are
thought to have compromised embryo quality due to
embryo in vitro culture. Placing these zygotes or
embryos back into their own natural incubators is
thought to enhance subsequent development, with
improved pregnancy rates.
• With the development of enhanced culture media, the
success rates for IVF are now comparable, if not better,
to those of GIFT and ZIFT.
THANK YOU