Figure 32.2 Diagnostic and treatment algorithm: anovulation. FSH, follicle-stimulating hormone; LH, luteinizing hormone; E2, estradiol; TSH, thyroid-stimulating hormone; T4, thyroxine; GH, growth hormone; ACTH, adrenocorticotropic hormone; BMI, body mass index; MRI, magnetic resonance imaging; GnRH, gonadotropin-releasing hormone. (From Yao M. Clinical management of infertility. Washington, DC: The Advisory Board: 2000, with permission.)  Associated with increased age, decreased egg quality  Predicts decreased chance of successful treatment  Associated with increased risk of aneupliody and miscarriage Ovarian disorders  Infrequent menses hot flashes  Signs of decreased estrogenization  High FSH, LH (postmenopausal range)  High day 3 FSH  Abnormal CCCT  Advanced age Premature ovarian failure Decreased ovarian reserve Assess for and treat secondary or associated medical problems Premature ovarian failure is usually irreversible, but spontaneous sporadic ovulation and pregnancy have been reported  ART  Donor egg in vitro fertilization embryo transfer  Discuss adoption  May have brief trials of superovulation-intrauterine insemination or in vitro fertilization Figure 32.3 Diagnostic and treatment algorithm: ovarian disorders. FSH, follicle-stimulating hormone; LH, luteinizing hor-mone; CCCT, clomiphene citrate challenge test ART, assisted reproductive technology. (From Yao M. Clinical management of infertility. Washington, DC: The Advisory Board: 2000, with permission.) in the next section. Women who smoke need twice the number of IVF cycles to conceive as nonsmokers, but the effect of alcohol on fertility is less clear (18).
Table 32.1 Causes of Infertility
Relative prevalence of the etiologies of infertility (%)
Spermatogenesis The male reproductive tract consists of the testis, epididymis, vas deferens, prostate, seminal vesicles, ejaculatory duct, bulbourethral glands, and urethra. Gonadotropinresponsive cells in the testes include Leydig cells (the site of androgen synthesis) and Sertoli cells, which line the seminiferous tubules (the site of spermatogenesis). The pituitary gland secretes luteinizing hormone (LH), which stimulates the synthesis and secretion of testosterone by the Leydig cells, and follicle-stimulating hormone (FSH), which acts with testosterone on the Sertoli cells to stimulate spermatogenesis (26). In humans, a new cohort of spermatogonia enter the maturation process every 16 days, and the development from spermatogonia stem cells to the mature sperm cells takes about 75 days (27). Spermatogonia undergo mitotic division to give rise to spermatocytes. These diploid spermatocytes subsequently undergo meiosis to produce haploid spermatids, which contain 23 (rather than 46) chromosomes (26). Maturation of spermatids is called spermiogenesis and involves condensation of the nucleus, formation of the ﬂagellum, and the formation of the acrosome (a structure derived from the Golgi complex covering the tip or head of the sperm nucleus) (28). The resultant spermatozoa are released into the seminiferous tubule lumen and then enter the epididymis, where they continue to mature and become progressively more motile during the 2 to 6 days that are required to traverse this tortuous structure and reach the vas deferens (29).