Causes of infertility in male : 

1.Abnormal spermatogenesis :

• Chromosomal abnormalities
• Mumps orchitis.
• Cryptorchidism
• Varicocele.

2. Abnormal motility : 

• Absent cilia (Kartagener’s syndrome).
• Varicocele.
• Antibody formation.

3. Anatomic disorders : 

• Congenital absence of vas deferens.
• Obstruction of vas deferens..
• Congenital abnormalities of ejaculatory system.

4. Endocrine disorders : 

• Hypothalamic dysfunction.
• Pituitary failure.
• Hyper – prolactinemia
• Exogenous endrogens.

5. Sexual dysfunction : 

• Retrograde ejaculation
• Impotence
• Decreased libido.

Causes of Infertility in female 

1. Ovulatory factor : 

   a) Central defects : 

• Chronic hyper – adrogenemic anovulation.
• Hypothalmic insufficiency.
• Pituitary insufficiency.

   b) Peripheral defects : 

• Gonadal dysgenesis
• Premature ovarian failure
• Ovarian tumor
• Ovarian resistance.

   C. Metabolic disease : 

• Thyroid disease.
• Liver disease
• Renal disease
• Obesity

2. Pelvic factore : 

• Appendicitis
• Pelvic inflammatory disease
• STD
  
• Tuberculosis
• Salpingitis.
• Uterine adhesion
• Myoma

3. Cervical factor : 

• DES exposure.
• Mullerian duct abnormality.
• Infection – cervicitis.

4. Vaginal factors : 

• Vaginal atresia.
• Transverse vaginal septum
• Septate vagina
• Narrow introitus causing dyspareunia.

5. Combined factors : 

1. These include the presence of factors both in the male and female partners causing infertility.
2. General factors : Advanced age of the wife beyond 35 years.
3. Infrequent intercourse.
4. Lack of knowledge of coital technique.
5. Timing of coitus to utilize the fertile period.
6. Apareunia and dyspareunia.
7. Anxiety and apprehension.
8. Use of lubricants during intercourse – which may be spermicidal.
9. Immunological factors.

Diagnosis of male infertility : 

HIstory : 

1. Age of the patient.
2. HIstory of previous marriage & proven fertility.
3. Sexual history should include frequency of coitus, impotence, full penetration, orgasm at right time etc.
4. History of mumps orchitis, TB, gonorrhoea etc.
5. History of diabetes, hypo or hyperthyroidism, recurrent chest infection or bronchiectasis.
6. History of genital trauma or surgery at genital organs or herniorrhaphy.
7. Occupational environment such as hot humid atmosphere as high temperature may impair spermatogenesis.
8. History of chemotherapy or radiation, antihypertensives, sedatives etc.
9. Social habits, particularly heavy smoking or alcoholism.

Examination : 

1. This should cover all systems with particular attention to the reproductive system.
2. In regard to reproductive system look especially for abnormalities of the penis, cryptorchidism : the size & consistency of the testes and epididymis : the presence of vasa : a varicocele  & any prostatic abnormality.

Diagnosis of female infertility : 

HIstory : 

1. Age of the patient 
2. Duration of infertility  (more the duration of infertility, less favorable is the prognosis).
3. Infertility is being primary or secondary.
4. The surgical history should be directed specially towards abdominal or pelvic surgery.
5. Menstrual history : 

• Cycles regular or irregular (regular cycles are usually associated with regular ovulation).
• Premenstrual molimina (breast tenderness, spasmodic dysmenorrhoea, fluid retention, mood change are suggestive of ovulation.
• Mid – cycle pain or bleeding (it indicates ovulation).

 6. Coital frequency (coitus 3-4 times a week associated with good fertility. With more or less frequency fertility declines).

7. Use of lubricants (these may act as spermicidal agent or may prevent sperm motility).

8. History of hirsutism, acne, obesity (these may be related to PCO, androgen producing tumor etc).

9. History of PID, TB, pelvic, surgery, puerperal sepsis (these may be responsible for infertility by affecting the tubes or ovaries by distorting their anatomy.

10. Suggestive history of endometriosis, fibroid (these may be responsible for infertility).

11. History of diabetes (uncontrolled diabetes gives rise to infertility).

12. Galactorrhoea (high prolactin level is associated with anovulation due to low gonadotropin).

Examination : 

1. General examination : obesity, weight loss, acne, hirsutism and goitre should be noted.
2. Systemic examination : Hypertension, organic heart disease, chronic renal failure, endocrinopathies & alike.
3. Gynecological examination : Adequacy of hymenal opening, evidences of vaginal infections, cervical tear or chronic infection, undune elongation of the cervix, uterine size, position & mobility, presence of unilateral or bilateral adnexal masses – fixed or mobile with or without tenderness & presence of nodules in the pouch of Douglas.
4. Speculum examination : may reval abnormal cervical discharg, The discharge is to be collected for Gram stain & culture.

Investigation of infertility : 

Routine investigation : 

1. TC, DC, ESR, Hb%, X- ray chest, mantoux test to exclude tuberculosis.
2. Blood sugar estimation to exclude diabetes.
3. Urine analysis

Special investigation : 

For male : 

1. Semen analysis
2. Prostatic smear & culture to exclude gonorrhoea.
3. Hormone analysis : Estimation of FSH, LH, testosterone, TSH, T3, T4, and prolactin.
4. Karyotype will exclude klinefelter’s syndrome (47XXY).
5. Testicular biopsy will exclude spermatogenic arrest from testicular atrophy.
6. Immunological test : Sperm agglutinating & sperm immobilizing antibodies.

For female : 

1) To see evidence of ovulation : 

• Basal body temperature
• Cervical mucus test
• Estimation of serum progesterone
• Serial estimation of LH level.
• Endometrial biopsy
• Sonographic evidence of enlargement of the follicles and its rupture can be seen by serial study. Mature follicle is 18-24 mm in diameter.
• Laparoscopic visualization of corpus luteum.

2) To see the tubal pathology : 

• Hysterosalpingography.
• Laparoscopic dye test.
• Tubal insufflation test.

3) To see the uterine pathology : 

• Hysterosalpingography.
• Hysteroscopy.

4) To see the cervical pathology :

• Post – coital test.
• Sperm cervical mucus contact test  (Huner’s test)

5) Immunological test : Antibody against sprm can be detected in the female serum by immunological test.

6) Hormone assay : Estimation of FSH, LH, prolactin, oestrogen, progesterone and testosterone can be done depending upon history and examination.