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IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)
e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 18, Issue 9 Ser.13 (September. 2019), PP 27-32
www.iosrjournals.org
DOI: 10.9790/0853-1809132732 www.iosrjournals.org 27 | Page
Male and Female Infertility: Causes, And Management
Murtaza Mustafa!, AM,Sharifa2,Janan Hadi3,EM.IIIzam4,,S.Aliya5,
1,3, Faculty of Medicine and Health Sciences, UniversityMalaysia,Sabah,KotaKinabalu,Sabah,Malaysia.
2. Quality Unit Hospital Queen Elizabeth,KotaKinabalu,Sabah,Malaysia
4, Poly Clinic Sihat,Likas,KotaKinabalu,Sabah,Malaysia
5,MedicalCollege,ZiauddinUniversity,Karachi,Pakistan
* Corresponding Author:Murtaza Mustafa
Abstract:Infertility is a common problem worldwide. Childlessness could be male infertility,femaleinfertility or
combined infertility. Infertility has psychological and social impact. Female infertility is due to ovulatory
problem, in male semen quality, and idiopathic cause. Sexually transmitted disease (STD), genetic, diabetes,
pituitary factors, and toxins also play and importantrole.Diagnosisinclude, semenanalysis, for male, female
partner tested for hormonal para meters,e.g.,FSH,TSH, abnormal levels indication of infertility. If the
conservative medical treatment fail, physician my advice the patient to undergo in-vitro fertilization(IVF),and
assisted reproductive technology (ART).IVF has promising results.
Keywords:Infertility,Causes, Psychological and social impact,Treatment.
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Date of Submission: 12-09-2019 Date of Acceptance: 28-09-2019
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I. Introduction
Inhumans, infertility is the inability to become pregnant or carry a pregnancy to full term, There are
many causes of infertility, including some that medical intervention can treat [1].Estimates from 1997 suggest
that worldwide “between three to seven per cent of all (heterosexual) couples have an unresolved problem of
Infertility. Many more couples, however experience involuntary childlessness for at least one year; estimates
range from 12% to 28% [2,],20-30 % of infertility cases are due to male infertility,20-35% are due to female
infertility, and 25-40% are due to combined problems in both parts [3].In 10 – 20 % cases no cause is found
[3].The most common cause of female infertility is ovulatory problems which generally manifest themselves by
sparse or absent menstrual periods [4].Male infertility due to deficiencies in the semen, and semen quality is
used as surrogate measure of male fecundity [5].Young and healthy couples with infertility problem should seek
prompt help from the healthcare providers [6].Treatment depends on the cause of infertility, but may include
counselling, fertility treatments, which include in vitro fertilization [7].
II. Interpretation of infertility
“Demographers tend to interpret (define) infertility as childlessness in a population of women of
reproductive age”, whereas “the epidemiological definition refers to “trying for” or “time to” a pregnancy in a
population of women exposed to a probability of conception [8].A female is most fertile within age 24 and
diminishes after 30,with pregnancy occurring rarely after age 50 [9].The time needed to pass(during which the
couple tries to conceive) for that couple to be diagnosed with Infertility differs between different jurisdictions.
Existing definitions of infertility lack uniformity, rendering comparisons in prevalence between countries or
over time problematic Therefore, data estimating the prevalence of infertility cited by various sources differs
significantly [8].A couple that tries unsuccessfully to have a child after a certain period to time (often short
period, by definition vary) is sometimes said to be subfertile, meaning less fertile than a typical couple. Both
infertility and subfertility are defined as the inability to conceive after a certain period of time (the length of
which vary),so often two terms overlap [8].
World Health Organization (WHO),defines infertility as: Infertility is”a disease of the reproductive
system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular sexual
intercourse(as there is no other reason, such as breastfeeding or postpartum amenorrhea).Primary infertility is
infertility in a couple who have never had a child. Secondary infertility is failure to conceive following a
previous pregnancy. Infertility may be caused by infection in the man or woman, but often there is no obvious
underlying cause.”[10].
One definition of infertility that is frequently used in the United States by reproductive endocrinologist,
doctors who specialize in infertility, to consider a couple eligible for treatment is: (a). a woman under 35 has not
conceived after 12 months of contraceptive intercourse. Twelve months is the lower reference limit for Time to
Male and Female Infertility: Causes, And Management
DOI: 10.9790/0853-1809132732 www.iosrjournals.org 28 | Page
Pregnancy (TTP) by the WHO [5].(b).a woman over 35 has not conceived after 6 months of contraceptive-free
sexual intercourse.
In the UK, previous NICE guidelines defined infertility as failure to conceive after regular unprotected
sexual intercourse for 2 years in the absence of known reproductive pathology [11].Updated NICE guidelines do
not include a specific definition, but recommend that “A woman of reproductive age who has not conceived
after one year of unprotected vaginal intercourse ,in the absence of any know cause of infertility, should be
offered further clinical assessment and investigation along with her partner, with earlier referral to a specialist if
the woman is over 36 years of age [12].Researchers commonly base demographic studies on infertility
prevalence on a five year period. Practical measurement problems, however, exist for much definition, because
it is difficult to measure continuous exposure to risk of pregnancy over period of years [13].
Primary infertility is defined as the absence of a live birth for woman who desire a child and have been
in a union for at least 12 months, during which they have not used any contraceptives [14].WHO also adds that „
woman whose pregnancy spontaneously miscarries, or whose pregnancy results in a still born child, without
ever having had a live birth would present with primarily infertility [15].Secondary infertility is defined as the
absence of a live birth for woman who desire a child and have been in a union for at least 12 months since their
last live birth, during which they did not use any contraceptives [15].
III. Psychological and social impact
Mental stress orPsychological effect: The consequences of infertility are manifold and can include social
repercussions and personal suffering. Advances in assisted reproductive technologies, such as IVF,can offer
hope to many couples where treatment is available, although barriers existed in terms of medical coverage and
affordability. The medicalization of infertility has unwittingly led to a disregard for the emotional responses that
couples experience, which include distress, loss of control, stigmatization, and a disruption in the development
of trajectory of adulthood [16].Infertility may have profound-psychological effects. Partners may become more
anxious to conceive, increasing sexual dysfunction [17].Marital discord often develop in infertile couples,
especially when they are under pressure to make medical decisions. Woman trying to conceive often have
clinical depression rates similar to women who have heart disease or cancer [18].Even couples undertaking IVF
face considerable stress [19].The emotional losses created by infertility include the denial of motherhood as a
rite of passage; the loss of one‟s anticipated and imagined life; feeling of loss control over one‟s life; doubting
one‟s womanhood; changed and sometimes loss of friendship; formany, the loss of one‟s religious environment
as a support system[20].Emotional stress and marital difficulties are greater in couples where the infertility lies
with the man [21].
Society and social effect: In many cultures, inability to conceive bears a stigma. In closed social groups, a
degree of rejection (or a sense of being rejected by the couple) many cause considerable anxiety and
disappointment. Some respond by actively avoiding the issue altogether; middle-class men are the most likely to
respond this way [22].In an effort to end the shame and secrecy of infertility. Redbook in October 2011,
launched a video campaign.TheTruthaboutTrying, to start an open conversation about infertility, which strikes
one in eight women in the United States.
In a survey of couples having difficulty conceiving, conducted by the Pharmaceutical company Merk,61 percent
of respondents hid their infertility from family and friends[23].Nearly half didn‟t even tell their mothers. The
message of those speaking out: it‟s not always easy to get pregnant, and there is no shame in that. There are
legal ramifications as well. Infertility has begun to more exposure in legal domain. An estimated 4 million
workers in the U.S.used the Family and Medical Leave Act (FMLA) in 2004 to care for a child, parent or
spouse, or because of their own personal illness. Many treatments for infertility, including diagnostic tests,
surgery and therapy for depression, can qualify one for FMLA leave. It has been suggested that infertility be
classified as a form of disability [24].
IV. Contributory factor
There are several contributory factors or causes of infertility that includes:
Sexually transmitted disease (STD): Infections with the following sexually transmitted pathogens have a
negative effect on fertility: Chlamydia trachomatis and Neisseriagonorrhoeae.There is consistent association of
Mycoplasma genitalium infection and female reproductiove tract syndromes.M .genitaliun infection is
associated with increased risk of infertility [25].
Role of genetic: ARobertsonian translocation in either partner may cause recurrent spontaneous abortions or
complete infertility.Mutations to NR5RA1 gene encoding Steroidogenic Factor-1(SF-1) have been found small
subject of men with no-obstructive male factor infertility where the cause unknown. Results of one study
investigating a cohort of 315 men revealed changes within the hinge region of SF-1 and no rare allelic variants
in fertile controlmen.Affectedindividuals displayed more severe forms of infertility such as
Male and Female Infertility: Causes, And Management
DOI: 10.9790/0853-1809132732 www.iosrjournals.org 29 | Page
azoospermia(absence of sperm in the semen) and severe oligozoospermia(below normal spermatozoa in the
semen).[26].
Miscellaneous infertility factor in male and in female:
DNA damage reduces fertility in female ovocytes,as causes by smoking [27].DNA damage reduces fertility
in male sperm, as caused by oxidative DNA damage [28].
Diabetes mellitus, thyroiddisorders, undiagnosed and untreated coeliac disease, and adrenal disease [29-32].
Hypothalmic pituitary factors,hyperprolactinemia,hypopituitarism,and presence of anti-thyroid
antibodies[33].
Toxins such as glues, volatile organic solvent or silicones, chemicaldust, and pesticides [34].
Immune infertility due to the anti-sperm antibodies [35].
German scientists have reported that a virus called Adeno-associated virus might have a role in male
infertility [36].
Female infertility:
For a woman to conceive, certain things to happen:vaginal intercourse must take place around the time
when egg is released from her ovary; the system that produce eggs has to be working at optimum levels and her
hormones must be balanced [37].For women, problems with fertilization arise mainly from either structural
problems in the Fallopian tube or uterus or problem releasing eggs. Infertility may be caused by blockage of the
Fallopian tube due to malformation, infections such as Chlamydia and or scar tissue. Forexample, endometriosis
can cause infertility with the growth of endometrial tissue in the Fallopian tubes and or around the ovaries,
Endometriosis is more common in women in their mid- twenties and older, especially when postponed
childbirth has taken place [38].`
Another major cause of infertility in women may be inability to ovulate. Malformations of the eggs
themselves may complicate conception. For example, polycystic ovarian syndrome in which eggs only partially
developed within ovary and there is excess of male hormones. Some women are infertile because their ovaries
do not mature and release eggs. In this case synthetic FSH injection or Clomid(Clomiphene citrate) via pill can
be given to stimulate follicles to mature in the ovaries. Other factors that can affect a woman‟s chances of
conceiving include being overweight or underweight or her age as female fertility declines after the age of 30
[39,40].
Common contributory factors-causes of infertility of females include:
(a).Ovarian problems(e.g.polycystic ovarian syndrome-PCOS),the leading reason why women present to
fertility clinic due to anovulatory infertility [41].
(b).tubal blockage
(c).pelvic inflammatory disease (PID) caused by infections like tuberculosis
(d).age related factors
(e)..uterine problems
(f).previous tubal ligation
(g). endometriosis
(h).advance maternal age
Male infertility
The main cause of male infertility is low semen quality. In men who have the necessary reproductive
organs to procreate, infertility can be caused by low sperm count due to endocrine problems, drugs, radiation, or
infection. There may be testicular malformation, hormone imbalance, or blockage of man‟s duct system.
Although many these can be treated through surgery or hormonal substitutions, some may be indefinite
[42].Infertility associated with immotile sperm may be caused by primary ciliary dyskinesia. The sperm must
provide the zygote with DNA centrioles, and activation factor for the embryo to develop. A defect in these
sperm structures may result in infertility that will not be detected by semen analysis [43].
Environmental factors like exposure to chemical dust and pesticides have adverse effect of male
fertility [34].Widely used pesticides DDT(1,1,1-trichloro-2,22-bis(p-chlorophenyl)ethane) and industrial
chemical e.g. PCBs(Polychlorinated biphenyls),and environmental pollutants such as dioxin and human
therapeutics such as anti-cancer drugs [44,45].Perry and associates also showed the effects of environmental and
occupational pesticide on human sperm[46}.Hossain, and colleagues in a series of 160 subjects, with 52
(32.5%) exposed, advocate that overall the decline in semen quality may adversely affect the fertility index of
exposed subjects [47].
Male and female infertility: In some cases, both the man and woman may be infertile or sub-fertile, and
couple‟s infertility arises from the combination of these conditions. In other cases, the cause is suspected to be
Male and Female Infertility: Causes, And Management
DOI: 10.9790/0853-1809132732 www.iosrjournals.org 30 | Page
immunological or genetics; it may be that each partner is independently fertile but the couple cannot conceive
together without assistance [43].
Infertility due to unknown cause (idiopathic):In the U.S, up to 20% of infertile couples have unknown
(unexplained) infertility [48].In these cases abnormalities are likely to be present but not detected by current
methods. Possible problems could be that the egg is not released at optimum time for fertilization that it may not
enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur, transport of
zygote may be disturbed, or implantation fails. It increasingly recognized that egg equality is of critical
importance and woman of advanced maternal age have eggs of reduced capacity for normal and successful
fertilization. Also, polymorphisms in foliate pathway genes could be one reason for fertility complications in
some women with unexplained infertility [49,].However, a growing body of evidence suggests that epigenetic
modifications in sperm may partly responsible [50].
V. Diagnosis
If both partners are young and healthy and have been trying to conceive for one year without success, a
visit to a physician or woman health nurse practitioner (WHNP) could help to highlight potential medical
problems earlier than later. The doctor of WHNP may also be able to suggest lifestyle changes to increase the
chances of conceiving [6].Woman over the age of 35 should see their physician or WHNP after six months as
fertility tests can take some time to complete, and age may affect the treatment options that are open in that case.
A doctor or WHNP takes a medical history and gives a physical examination. They can also carry out some
basic tests on both partners to see if there is an identifiable reason for not having achieved a pregnancy. If
necessary, they refer patients to a fertility clinic or local hospital for more specialized tests. The results of these
tests help determine the best fertility treatment [6].
Frequently used diagnostic tests include semen analysis for male partner (volume 2.5 to 10ml,sperm
count over 20 million, motility over 70 % morphology over 60%,low volume, count, and motility-infertility).For
female partner is tested for Follicle stimulating hormone-serum (FSH), and Thyroid stimulating hormone
(TSH),.Any abnormal levels of FSH and TSH – infertility.[5
VI. Treatment
Treatment depends on the cause of infertility, but may include counselling, fertility treatments, which
include in vitro fertilization. According to ESHRE recommendations, couples with an estimated live birth rate of
40% or higher per year are encouraged to continue aiming for a spontaneous pregnancy [7].Treatment methods
for infertility may be grouped as medical or complementary and alternative treatments. Some methods may be
used in concert with other methods. Drugs used for both women and men [52], include clomiphene citrate,
human menopausal gonadotropin(hMG),follicle stimulating hormone (FSH),human chorionic
gonadotropin(hCG),gonadotropin releasing hormone(GnRH) analogues, aromataseinhibitors, and metformin.
Medical treatment of infertility generally involves the use of fertility medication, medical device,
surgery, or a combination. If the sperm are of good quality and the mechanics of the woman‟s reproductive
structures are good (patent fallopian tubes, no adhesion or scarring), a course of stimulating medication may be
used. The physician or WHNP may also suggest using a conception cap-cervical cap, which patient uses at
home by placing the sperm inside the cap and putting the conception device on the cervix, or intrauterine
insemination(IUI),in which the doctor or WHNP introduces sperm into uterus during ovulation, via catheter .In
these methods fertilization occurs inside the body[52].If conservative medical treatments fail to achieve full time
pregnancy, the physician or WHNP may suggest the patient undergo in vitro fertilization(IVF).IVF and related
(ICSI,ZIFT,GIFT) are called assisted reproductive technology (ART) techniques. ARTtechniques generally
start with stimulating ovaries to increase eg.production. After stimulation, the physician surgically extracts one
or more eggs from the ovary, and unites them with sperm in a laboratory setting, with the intent of producing
one or more embryos. Fertilization takes place outside the body, and the fertilized egg is reinserted into the
woman‟s reproductive tract, in a procedure called embryo transfer. Other medical techniques are e.g.
turboplasty,assistedhatching, and Preimplantation genetic diagnosis. [52].
IVF is the most commonly used ART. It has been proven useful in overcoming infertility conditions,
such as blocked or damaged tubes, endometriosis, repeated IUI failure, unexplained infertility, poor ovarian
reserve, poor or even nil sperm count. ICSI(Intracytoplasmic sperm injection) technique is used in case of poor
semen quality, low sperm count or failed fertilization attempts during prior IVF cycles. This technique involves
an injection of a single healthy sperm directly injected into mature egg. The fertilized embryo is then transferred
to womb [52].Medical or Fertility tourism is the practice of traveling to another country for fertility treatments.
The main reason for fertility tourism is legal regulation of the sought procedure in the home country or lower
price.In-vitro fertilization and donor insemination are major procedures involved [53].
Male and Female Infertility: Causes, And Management
DOI: 10.9790/0853-1809132732 www.iosrjournals.org 31 | Page
VII. Conclusion
World health Organization (WHO) defines infertility is a “disease” of the reproductive system. It may
be primary or secondary. Ovarian problems (polycystic ovary),tubal blockage, PID,age related factors, and
endometriosis are frequent contributory factors. In-vitrofertilization (IVF) and ART techniques have promising
results.
References
[1]. Makar RS,TothTL.The evaluation of infertility. Am J ClinPathol.2002;117(Suppl):S05-103.
[2]. HimmelW,IttnerE,KochenMM,etal.Voluntary Childlessness and being Childfree.British Journal of General
Practice.1997;47(415):111-5.
[3]. ART fact sheet (https://www..eshre.eu/guidelinee-and legal/art-sheet.aspx)..EuSoc Hum Rep Embryol.2014.Archieved 4 March
2016..
[4]. Causes of infertility (http://www.nhs .uk/Conditions/ infertility Pages/ causes.aspx).National Health Service.
[5]. Cooper TG,NoonanE,vonEckardsteinS,etal.World Health Organization references for human semen characteristics.HumReprod
Update.2010;16(3):231-45.
[6]. Infertility Help:When& where to get help for fertility treatment (http:// www. hfea.gov.uk/en/804.html).
[7]. Failures(with some successes)of assisted reproduction and gamete donation programs Hum Reprod Update.2013;19(4):353-65.
[8]. GurunathS,PandianZ,AndersonRA,etal.Defining infertility-asystematic review of prevalence studies.HumReprod
Update.2011;17(5):575-88.
[9]. TamparolCarol,LewisMarcia.Diseases of Human body.Philadelphia.PA:F.A.Davis Comapany.p.459.ISBN9780803625051.
[10]. WHO.Infertility(http://www.who.int/reproductivehealth/topics/infertility/definitions.en/)Who.int.2013-03-19.Retrieved 2013-06-17.
[11]. Fertility:assessment and treatment for people with fertility
problems,(https://www.webcitation.org/5rhjtxNOs?url=http:www.nice.org.uk/nicemedia/pdf/CGO11publicinfoenglish.pdf).London.
RCOG Press.2004.ISBN 1-900364-97-2.
[12]. Fertility:assessment and treatment for people with fertility problems.section:defininginfertility.NICE Clinical
Guidelines,CG156.February 2013.
[13]. http://www.who.int/reproductivehealth/topics/infertility/DHS-CR9.pdf.
[14]. [1](http://www.who.int/reproductivehealth/topics/infertility/definitions/en).
[15]. http://www.who.imt/reproductivehealth/tioics/infertility/definition/en).
[16]. CousineauTM,DomarAD.Psychological impact of infertility. BestPract Res ClinGynaecol.2007;21(2):293-308.
[17]. Donor insemination Edited by C.L.R.Barratt and I.D.CookeCambridge(England).Cambridge University Press.1993.231 pages.page
13,,citing Berger(1980).
[18]. DomarAD,ZuttermeisterPC,FriedmanR.The psychological impact of infertility: a comparison with patients with other medical
conditions‟ PsychosomObst Gynaecol.1993;14(Suppl):45-52.
[19]. BeutelM,KupferJ,KirchmeyerP,etal.Treatment- related stresses and depression in couples undergoing assisted reproductive
treatment by IVF or ICSI. Andrologia. 1999;31(1):27-35.
[20]. Recovery From Traumatic Loss:A Study of Women Living without Children After
Infertility.(http://repository.upenn.edu/edissertation_sp2/20/20).Doctratein SocialWork (DSW) Dissertation.Paper20.2012.
[21]. Donor Insemination Edited by C.L.R.BarrattandI.D.Cooke.Cambridge (England):CambridgeUniversioty Press.1993.231
pages.,page 13,in turn citing Connolly, Edelmann& Cooke1987.
[22]. Schmidt L,ChristensenU,HolsteinBE.The Social epidemiology of coping with infertility.Hum Reprod.2005;20(4):1044-52.
[23]. The invisible pain of Infertility.Redbook.October 2011.
[24]. KhetarpalA,SinghS.Infertility:Why can‟t we classify the inability as disability. The Austraalasian medical Journal.2012;5(6):334-9.
[25]. Lis R,RowhaniRathbarA,ManhartLE.Mycoplasmagenitallium Infection and Female Reproductive Tract Disease:A Meta-
Analaysia.Clinical Infectious Disease. 2015; 61:418-26.
[26]. Ferraz-de-Souza,Bruno,Lin Lin AchermannJC.Steroidogenic factor-1(SDF-1,NR5A1) and human disease.Molecullar and
CellularEndicrinology.2011;336(1-2):198-205.
[27]. ZenzesMT.Smoking and reproduction:gene damage in human gametes and embryos.Hum Reprod.Update.2000;6(2):122-31.
[28]. CharagozlooP,AitkenRJ.The role of semen oxidative stress in male infertility and the significant antioxidant
therapy.HumReprod.2011;26(7):1628-40.
[29]. JangirRN,JainGC.Diabetes mellitus induced impairment of male reproductive functions:areview.Curr DiabetesRev.2014;10(3):147-
57.
[30]. AndreevaP.Thyroid gland and fertility.[Article in Bulgarian].AkushGinkol(Sofia).2014;53(7):18-23.
[31]. TersiginiC,CastellaniR,deWaureC,etal.Celiac disease and reproductive disorders:meta-analysis of epidemiology association and
potential pathogenic mechanisms.HumReprod Update.2014;20(4):582-93.
[32]. ReichmanDE,WhitePC.NewMI,etal.Fertility in patients with congenital adrenal hyperplasia.Fertil Steril.2014;101(2):301-9.
[33]. Van den BoogaardE.VissenbergR,LandJA,etal.Significance of (sub) clinical thyroid dysfunction and thyroid autoimmunity before
conception and in early pregnancy:A systematic review.HumReprod Update.2011;17(5):605-19.
[34]. MendiolaJ,Torres-CanteroAM,Moreno-GaruJM,etal.Exposure to environmental toxins in males seeking infertility treatment:a case
controlled study.Reprod BiomedOnline.2008;16(6):842-50.
[35]. RestrepoB,Maya W Cardona.Anticuerposantiesspermatozoides y suasociacion con la
fertility.ActasUrologicasEspholas.2012;37(9):571-578.
[36]. Common virus linked to male infertility-.New Scientist.2001-10-26.Retrieved 2013-06-17.
[37]. About infertility & infertility problems(http://www.hfea.gov.uk/en/802.html).from Human Fertilisation and Embryology Authority,
[38]. Lessy BA (2000).Medical management of endometriosis and infertility;1089-95.
[39]. Are You at Your Optimal Weight.Chelsea Fertility NYC.RetrievedChelseaFertilityNYC.Retrieved 6 March 2015.
[40]. Shoukd I Freez my Eggs.(Https://www.pacificfertilitycentre/fertility-preser
vation/myegg#assessment).Information on Egg Freezing.Retrieved March 2015.
[41]. BalenAH,DresnerM,ScottEM,etal.Should obese women with polycystic ovary syndrome receive treatment for
infertility.BMJ.2006;332(7539):434-5.
[42]. Mishail A.et al.Impact of a second semen analysis on a treatment decision making in tne infertile man with varcocele:1809-1811.
[43]. Avidor-Reiss T,KhireA.,FishmanEL.Atypical centrioles during sexual reproduction.Front Cell Dev Biol.2015;3:21.
Male and Female Infertility: Causes, And Management
DOI: 10.9790/0853-1809132732 www.iosrjournals.org 32 | Page
[44]. D‟Souza UJ.Tamoxifen induced multinucleated cells (symplasts) and distortion of seminiferous tubules in rat.Asian Journal
ofAndrology.2003;5:217-20.
[45]. D’Souza UJ. Effect of Tamoxifen on spermatozoa and tubular morphology in rats.Asian Journal od Andrology.2004;6:223-6.
[46]. Perry M J.Effects of environmental and pesticide exposure om human sperm: A systematic review.Human
ReproductionUpdate.2008;14(3):233-42.
[47]. FerozHossain,etal.Effects of pesticide use on Semen Quality among Farmers in Rural Areas of
Sabah,Malaysia.J0ccupHealth.2010;52:353-360.
[48]. Unexplained Infertility Background Tests and Treatment Options (http://www.advancedfertility.com/unexplai.htm).Advanced
Fertility Center of Chicago.
[49]. AltmaeS,Stavreus-Evers A,RuizJR,LaanpereM,etal.Variation in folate pathway genes are associated with unexplained female
infertility. Fertility andSterlity.2010;94(1):130-7.
[50]. Kenneth I,Aston Philip J,Uren Timothy G,etal.Aberrant sperm DNA methylation DNA predicts male fertility status and embryo
quality..Fertility and Sterlity.2015;104(6):1388-97
[51]. Pathaid.The Interpretation of Common Pathology Tests andthe Pathological Diagnosis of Disease. An IMS Publication,
Malaysia.1988.
[52]. EdmudS,SabaneghJr,.MaleInfertility:Problems and Solutions.
(http://books.google.com/books?id+YthJp5cfTMC&pg=PA82).Springer Science & Business Media.pp.82-83.ISBN978-1-60761-
193-6.
[53]. Paul McFedries.Fertilitytourism.Word Spy)http:// www.wordspy. com/words/ fertilitytourism.asp).wordsspy.com.
Murtaza Mustafa. “Male and Female Infertility: Causes, And Management.” IOSR Journal of
Dental and Medical Sciences (IOSR-JDMS), vol. 18, no. 9, 2019, pp 27-32.
