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Tubal Factors



(Tubal blocks due to TB/Chlamydia/gonococci/adhesions)


Tests for tubal patency:

  1. Hysterosalpingography (HSG): cavity of the uterus and fallopian tube patency can be checked:
    • Done on 8th day of cycle.
    • As it does not require anesthesia, it is the first-line investigation for checking tubal patency.
    • Disadvantage: While pushing the dye, there can be cornual spasm and the fallopian tubes appears to be blocked even if the tubes are healthy. So HSG cannot differentiate between cornual blocks (pathological) and cornual spasm.
  2. Sonosalpingography / saline USG:
    • Normal saline is introduced into the uterine cavity, and fallopian tube patency can be checked by seeing free fluid in POD.
    • It is also very useful to evaluate endometrial polyps.
  3. Laparoscopy with chromopertubation with methylene blue dye:
    • Best investigation, as tubal patency can be confirmed under vision and, besides, any pathology can simultaneously be corrected with operative laparoscopy.
    • As it requires anesthesia and admission, it is never the first-line investigation for tubal patency.

Tubal Blocks/Adhesions (refer to PID, genital tuberculosis)

Management of tubal factors:

  1. Cornual block: cornual catheterization (operative hysteroscopy) to remove the blocks
  2. Tubal blocks: tuboplasty
  3. Inoperable cases/severely damaged tubes: IVF or adoption

Uterine Factors


Septate uterus is the MC Mullerian anomaly.


Uterine factors, such as submucous leiomyomas, intrauterine synechiae (Asherman's syndrome), and uterine deformities or septa, cause approximately 2% of infertility. The mainstay of treatment for these conditions is surgical correction, frequently via a hysteroscopic approach.


Luteal Phase Defect


During normal luteal phase when there is adequate progesterone secretion by the corpus luteum, adequate development of secretory endometrium occurs for blastocyst implantation. Luteal phase defect refers to a condition when production of progesterone is suboptimal by corpus luteum. It is an inevitable phenomenon in all ART cycles. LPD may cause implantation failure and is thought to account for 4 % of infertility. Diagnosis of LPD is not based on uniform criteria:

  • Low levels of midluteal serum progesterone «10 ng/mL)
  • Endometrial histology done on 25th -27 th day of cycle shows endometrium >2 day out of phase
  • A shortened luteal phase <14 days, are considered for the diagnosis.

Management - Micronized Progesterone


WHO classification of Mullerian anomalies:


Class I = Mullerian agenesis (RMKH)


Class II = Unicornuate uterus


Class III = Didelphys uterus (complete duplication: two uteri, two cervices, and longitudinal vaginal septum)


Class IV = Bicornuate uterus


Class V = Septate uterus


Class VI = Arcuate uterus


Class VII = DES-related abnormalities/T-shaped uterus


Corrective surgeries:


Class III, IV Straussman operation (unification operation) Class V (septate uterus):

  1. Hysteroscopic septal resection (most commonly done)
  2. Jones operation
  3. Tomkins operation

Male Infertility

New Semen Analysis Criteria as per 'WHO Manual for Semen Analysis, 5th Ed, 2010'

  • Semen volume: 1.5 mL or more
  • pH: 7.2 or more
  • Count: 15 million/mL or more
  • Motility (within 1 hour of collection)
    - Total motility (progressive + non progressive): 40 % or more
    - Progressive motility: 32 % or more
  • Vitality (live spermatozoa): 58 % or more
  • Sperm morphology (normal forms): 4 % or more


  • Aspermia: absence of semen
  • Azoospermia: zero sperm count
  • Asthenospermia: less than 40% motile spermatozoa
  • Oligozoospermia: count less than 15 million/mL
  • Teratospermia: less than 4% normal forms

Male infertility: Pretesticular, Posttesticular, Testicular

Causes of male infertility:





 Hypogonadotropic hypogonadism

 Varicocele, orchitis, trauma, torsion

 Obstruction (infection)


 Heat/ irradiation/ chemotherapy

 Kartagener syndrome/Young syndrome

 Kallmann syndrome (deficient GnRH

 Bilateral cryptorchidism

 POST vasectomy

 secretion associated with anosmia)



Erectile dysfunction/ ejaculatory failure

Klinefelter syndrome, Yq 11 microdeletion


Congenital bilateral absent vas deferens (associated with cystic fibrosis) Inguinal hernia repair (accidental damage to vas deferens)

variety is considered to be the MC cause of male infertility.


Varicocele is the MC surgically correctable cause of male infertility.

  • Sr. FSH level estimation helps determine the site of pathology:
    A very high FSH would indicate a testicular cause.
    A very low FSH would indicate pretesticular (hypothalamic /pituitary) cause.
    A normal FSH would indicate a posttesticular cause.
  • Dilated palpable head of epididymis due to block in vas deferens (posttesticular pathology) is called Bayle's sign.


  • Antioxidants, multivitamin, Coenzyme Q, and levocarnitine are thought to improve sperm count/motility.
  • Clomiphene citrate/ gonadotropins can be used in pretesticular pathology to increase the counts.

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