Female Factor Subfertility

In the female, any factor that prevents the sperm from reaching the egg (ovum) in the fallopian tube will result in subfertility (refer to Figure 5.3).

Anovulation (failure of the ovaries to produce an egg) — This commonly results from stress, excessive weight loss or exercise, poor nutrition, chronic medical conditions, inherent ovarian problems such as polycystic ovarian syndrome or previous ovarian surgeries. They usually manifest as an absence, delay or irregularity in the menses.

Fallopian tube disease

Ovulation disorder

Fallopian tube disease

Ovulation disorder

Womb disease Cervical disease

Figure 5.3 Female factors in subfertility.

Womb disease Cervical disease

Figure 5.3 Female factors in subfertility.

Figure 5.4 Fibroids.

Fallopian tube blockage — Even if an egg is released, blocked fallopian tubes can still prevent fertilization from happening. These may result from previous genital infections, tubal surgeries, endometriosis or pelvic adhesions.

Womb or cervical mucus defects or abnormalities — These can prevent fertilization or implantation, resulting in subfertility. Large fibroids, especially those disrupting the womb cavity, have been known to be associated with an inability to conceive. Womb adhesions (Asherman syndrome) resulting from previous surgeries or instrumentations will result in the obliteration of the entire cavity and prevent subsequent conception. Congenital defects such as septum or abnormal womb structure can contribute to this problem as well.

Endometriosis — This is a very common gynecological condition amongst women in the reproductive age group. It is characterized by the implantation of the womb lining tissue in the abdomen or the pelvic cavity. Menstrual pain and subfertility are the most common symptoms that can affect these women. In severe cases, it can disrupt the fallopian tubes and cause tubal blockage. However, even mild cases have been known to be associated with subfertility and the surgical removal of these deposits can result in an improvement of the fertility.

Male Factor Subfertility

Abnormal sperm parameters can include a low sperm count (oligospermia), lack of sperm (azoospermia), abnormal sperm shape (teratozospermia) or a lack of sperm motility (asthenospermia). There are many underlying factors that may contribute to the above. Prolonged heat exposure may reduce sperm potency, hence explaining the rationale of avoiding tight under-garments. Various other possible underlying causes of poor sperm quality or low counts include

Chapter 5 I Can't Get Tregnantl Is There Anything Wrong?

alcoholism, recreational drug abuse, environmental toxins and long-term usage of certain medications. More commonly, problems may exist in the testicles or testicular ducts, and these affect sperm production. The testicular problems include varicocele (engorged blood vessels surrounding the testes), undescended testes (even if successfully treated in infancy), previous testicular infections (such as mumps), previous testicular or hernia operations. Testicle duct blockage affects sperm delivery and this can be due to testicle duct scarring (from previous sexually transmitted infections) or an inherent genital tract abnormality.

Table 5.1 Analysis of sperm.

Windsock Deformity

Table 5.1 Analysis of sperm.

Human Sperm Analysis

Sperm Parameters

Normal Range (WHO criteria, 1992)

Volume

> 2.0 mL

pH

7.2-8.0

Concentration

> 20 x 106 spermatozoa/mL

Motility

> 50% forward progression

Morphology

> 15% normal forms (Kruger strict criteria)

White blood cells

< 1 x 106 /mL

Testicle duct abnormalities

Penile abnormalities

Testicular abnormalities

Figure 5.6 Male problems in subfertility.

Testicle duct abnormalities

Penile abnormalities

Testicular abnormalities

Figure 5.7 Sperm abnormalities.

Figure 5.6 Male problems in subfertility.

Figure 5.7 Sperm abnormalities.

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