There are two types of infertility, primary and secondary. Primary infertility is when couples have never conceived (at least one year having sex). Secondary infertility referred as couples have conceived previously but now not able. Infertility problem is increasing in Pakistan 15 to 20 per cent couples suffer from. The cause of infertility can be in man, woman or both may have problem.

Polycystic Ovarian Syndrome: it is found now much more in women of child bearing age than before. 1 in every 10 woman suffering and situation in Pakistan is even worst. Abnormal function of the hypothalamic-pitutary-ovarian (HPO) axis is found in PCOS.

Thyroid disorder: low thyroxin and high thyroid stimulating hormoes in your Thyroid profile make it difficult to conceive. However it is easy to control and treatable.
Diabetes: high blood sugar also effects fertility, diabetes may associated with abnormal menses such as secondary amenorrhea.

Blocked fallopian tube: As sperm reach to egg (ovum) in fallopian tube, blocked fallopian tube make it difficult to conceive. Tubal blockage may result of previous pelvic inflammatory disease, such as chlamydia infection, also be the result of any inflammatory process within the abdominal/pelvic cavity. It can be partial or complete blockage of the tubes. If both tubes are blocked, women cannot conceive without treatment.
Adhesion: formation of scar tissues in uterus or adhesions may result of previous surgery can make it difficult to get pregnant

Fibroids: fibroids are tumor growth in the uterus cavity. It can be small or large, single or many which may cause heavy bleeding / menorrhagia and abdominal pain. Uterine fibroids prevent the successful implantation of the embryo and make it difficult to conceive or can result in miscarriage (loss of the pregnancy), preterm delivery, abnormal position of the fetus, and the need for cesarean (C-section or surgical) delivery. Fibroids cannot be removed once a woman gets pregnant. Women can get pregnant in the presence of fibroids in uterus.

Polyps: polyps are abnormal growth in the lining of uterus can cause heavy bleeding and infertility.

Endometriosis is a condition when tissues that line the uterus form on other areas of pelvic organ like fallopian tube/ovary. Endometriosis may result in the formation of internal scars, called adhesion, which may result in organs adhering abnormally to each other, in result tubes block partially or completely hence difficulty I getting pregnant. If women conceive with endometriosis there is a higher risk of miscarriage.

Diminished ovarian reserve (DOR): Woman with low egg count or quality loses their reproductive potential can be a reason of infertility. Women have fixed number of eggs in the ovaries which gradually decrease with time. Factors responsible for DOR includes menopause (women usually have DOR), genetic abnormalities, injury and other. FSH test and ultrasound imaging are used to estimate a woman’s ovarian reserve.

Congenital uterine anomalies: abnormalities in Uterus shape present from birth may results in becoming or remaining pregnant.

Cervical Stenosis: narrowing of cervix is not common but potential cause of infertility in women.

Cervical Mucus problem: Mucus present in women’s cervix help to transport sperm to the egg in fallopian tube. If there is no cervical mucus or problem with cervical mucus, it may cause problem in getting pregnant.

Low sperm production, abnormal sperm function, blockage that prevents the delivery of sperm and others are causes of male infertility. Approximately one in 20 men are infertile, approximately 80 percent have suboptimal semen quality, while azoospermia (semen contain no sperm), coital dysfunction and immune factors contribute to the rest.
Whether genetic, physiological, pathological, or mechanical factor that affect the spermatogenesis (peoduction of sperm from primordial germ cell) process from the production to time of ejaculation will influence male fertility.

key points in performing history and examination in patient with infertility

*Length of time spent trying for pregnancy
*Any previous pregnancies
*Coital frequencies
*Menstrual history
*Previous history of pelvic inflammatory disease
*Previous medical and surgical history
*Previous fertility treatment
*Cervical smear history
*General health-screen for history of thyroid disorders

*Pelvic examination- any uterine pathology such as fibroid
*General BP,pulse,hight, and weight

*Length of time spent trying for pregnancy
*Fathered any previous pregnancies
*History of mumps and measles
*History of testicular trauma, surgery to testis occupation
*Medical and surgical history.

*Testicular examination- testicular volume, consistency, masses, absence of vas deferens, varicocele, evidence of surgical scars

Sperm concentration………>20million per ml
Total sperm number………>40million per ejaculation
Motility…………….>50 % grade a and b
Morphology…….>30% normal formsl

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