Peritoneal factor infertility:
Causes: the most important are endometriosis & chronic salpingitis.
Mechanism: (both affect the mechanism of ovum pick up by the tube) via:
1) Mechanical interference: adhesions.
2) Chemical interference: e.g. interleukin 1 & 6, tumour necrosis factor alpha & PGs.
Investigations: laparoscopy is the best.
Uterine factor infertility:
Causes:
1) Congenital: aplasia or severe hypoplasia.
2) Traumatic: Asherman syndrome.
3) Inflammatory: TB endometritis.
4) Neoplastic: submucous fibroid & bilateral cornual fibroid.
Diagnosis:
A. Symptoms:
1) Primary amenorrhea: aplasia.
2) Hypomenorrhea or recurrent abortion: hypoplasia.
3) History of curettage followed by amenorrhea: Asherman syndrome.
4) Menorrhagia: submucous fibroid.
B. Signs:
1) Absent or small uterus: aplasia or hypoplasia.
2) Failure to pass sound: Asherman syndrome.
3) Symmetrical enlargement: submucous fibroid.
Investigations:
1. U/S: detects congenital & neoplastic causes.
2. HSG: detects intrauterine adhesions, and space occupying mass.
3. Hysteroscopy: detects SMF & Asherman syndrome.
4. Endometrial biopsy: detects TB especially in basal layer.
Treatment:
treatment of the cause e.g. myomectomy for fibroid
Cervical factor infertility:
Causes :
A. Organic causes:
1. Congenital: *stenosis i.e. pin point os. *Elongation.
2. Traumatic: *Stenosis: due to excessive cauterization.
*Cervical incompetence: due to conization.
3. Inflammatory: chronic cervicitis ( hostile cervical mucus).
4. Miscellaneous:
*RVF uterus: external os of cervix a way from seminal pole.
*Virginal prolapse.
5. Neoplastic: cervical fibroid & cervical polyp.
B. Functional causes:
1. Poor quality of cervical mucus, or may contain anti- sperm antibodies.
Diagnosis:
A. History:
1) History of cervical operation e.g. cauterization or conization.
2) Vaginal discharge, backache & congestive symptoms: cervicitis.
3) Dyspareunia & urinary manifestations: cervical polyp.
B. Examination: Detect organic causes e.g. cervicitis, cervical polyp & stenosis.
C. Investigations:
1) Investigations for organic causes: e.g. culture & sensitivity of discharge
2) Investigations for functional causes:
i. Quality of cervical mucous:
• Normally: at mid cycle, cervical mucous under estrogen effect (thin, clear, profuse, acellular, +ve fern test & +ve thread test).
• Abnormally: quality changes: thick mucopurulent & cellular.
ii. Postcoital test (Sims-Huhner test)(in vivo test):
• Precautions:
a) Before coitus:
*semen analysis should be normal.
*No intercourse & no v. douches for 2 days.
b) During the coitus:
*should be at the time of ovulation.
*No use of lubricant during intercourse.
c) After the coitus:
* Sample should be examined within 6 hours postcoital.
* 2 Samples from posterior fornix & cervical mucous then microscopically observe number of motile sperms •
Idea: study of viability of sperms in vaginal fluid & cervical mucus.
• Results:
• N.B. : the test is considered normal with presence of ≥ 5 progressively motile sperms /HPF.
iii. Sperm mucus penetration test:
• Synonyms: Miller-Kurzrok test, in vitro test.
• Idea: study of sperm penetration through cervical mucus in vitro.
• Timing: day of ovulation.
• Technique: a cervical mucus drop is put with a drop of seminal fluid on a slide observing interaction.
• Results:
Normally: sperms penetrate mucus in a spearhead manner.
Abnormally: Dead sperms at the contact of cervical mucus.
iv. Anti-sperm antibodies:
• Types: * Ig A is present in cervical mucus.
* Ig E is present in wife serum.
• Procedure: * The husband sperms mixed with wife cervical mucus.
* The sample is incubated & examined for:
Sperm agglutinating Ab: agglutination of sperms.
Sperm immobilizing Ab: immobilization of sperms.
Sperm cytotoxic Ab: destruction of sperms.
Treatment:
A. Treatment of organic causes: e.g. cautery & proper antibiotics for cervicitis.
B. Treatment of functional causes:
1. Treatment of poor quality of the cervical mucus: e.g. due to clomid:
small dose of estrogen is added from 10th day to 15th day of the cycle.
2. Treatment of anti-sperm antibodies:
• Males: use condom for 6months.
• Females: receive prednisolone 5 mg tds for one week/month.
C. Assisted reproductive techniques
• AIH & GIFT if failed IVF is done.
Vaginal factor infertility:
1. Congenital: e.g. aplasia or transverse vaginal septum interfere with coitus.
2. Traumatic: e.g. vaginal operations causing dyspareunia due to tender scar & narrowing of the vagina.
3. Inflammatory: vaginitis.
4. Neoplastic: tumours interfere with coitus.
5. Miscancelleous: a) Vaginismus. b) High vaginal acidity: treated by precoital alkaline vaginal douches (NaHCO3 1%).