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TC(884).(20).Sexology Case No 37. Infertility / বন্ধ্যাত্ব

Infertility / বন্ধ্যাত্ব

1) Definition / সংজ্ঞা

Infertility হলো male বা female reproductive system-এর disease, যেখানে ১২ মাস বা তার বেশি সময় regular unprotected intercourse করার পরও pregnancy হয় না। Female partner-এর বয়স ≥35 বছর হলে ৬ মাস চেষ্টা করার পর evaluation শুরু করা উচিত। WHO ও NICE infertility-কে disease হিসেবে define করে; NICE NG257 2026-এ health-related fertility problem বলতে ১২ মাস regular unprotected intercourse-এর পর pregnancy না হওয়াকেও অন্তর্ভুক্ত করেছে।

Types:

  • Primary infertility: আগে কখনো pregnancy হয়নি।
  • Secondary infertility: আগে pregnancy হয়েছিল, পরে আর pregnancy হচ্ছে না।
  • Male factor, female factor, combined factor, unexplained infertility.

2) Etiology / Cause + Pathophysiology — Bangla point akare

A. Female causes

  1. Ovulation disorder / ডিম্বস্ফোটন না হওয়া
    • Common cause: PCOS, hypothalamic amenorrhea, obesity, underweight, thyroid disease, hyperprolactinemia।

Mechanism: ovulation না হলে mature ovum বের হয় না, তাই fertilization হয় না। PCOS-related anovulatory infertility-তে 2023 international PCOS guideline অনুযায়ী letrozole first-line pharmacological ovulation induction।

  1. Tubal factor / Fallopian tube blockage
    • Cause: PID, Chlamydia/Gonorrhea infection, TB, previous ectopic pregnancy, pelvic surgery, endometriosis।
    • Mechanism: sperm ও ovum tube-এ meet করতে পারে না; hydrosalpinx থাকলে IVF success-ও কমে যায়। NICE suspected tubal disease-এ HSG/HyCoSy এবং comorbidity থাকলে laparoscopy + dye recommend করে।
  2. Endometriosis
    • Mechanism: pelvic inflammation, adhesion, tubo-ovarian anatomy distortion, reduced oocyte quality।
    • Symptoms: dysmenorrhea, dyspareunia, chronic pelvic pain, infertility। NICE 2026 endometriosis-associated fertility problem-এ expectant management, surgery, IUI/IVF options discuss করতে বলে।
  3. Uterine factor
    • Fibroid, endometrial polyp, intrauterine adhesion/Asherman syndrome, congenital uterine anomaly।
    • Mechanism: implantation failure, miscarriage, abnormal uterine cavity। NICE clinically suspected uterine/endometrial abnormality ছাড়া routine hysteroscopy recommend করে না।
  4. Age-related diminished ovarian reserve
    • Female age বাড়লে oocyte number ও quality কমে যায়; miscarriage ও chromosomal abnormality risk বাড়ে। NICE maternal age-কে spontaneous conception ও IVF outcome-এর initial predictor হিসেবে ব্যবহার করতে বলে।

B. Male causes

  1. Sperm abnormality
    • Oligozoospermia, asthenozoospermia, teratozoospermia, azoospermia।
    • Cause: varicocele, infection, genetic disorder, cryptorchidism, heat exposure, smoking, anabolic steroid/testosterone use, diabetes, hypogonadotropic hypogonadism।
  2. Varicocele
    • Testicular temperature ও oxidative stress বাড়িয়ে sperm count/motility কমাতে পারে। NICE clinically detected varicocele + reduced semen parameters থাকলে radiological/surgical treatment consider করতে বলে।
  3. Hypogonadotropic hypogonadism
    • Low GnRH/LH/FSH → low testosterone ও poor spermatogenesis। NICE male hypogonadotropic hypogonadism-এ gonadotrophin therapy recommend করে।
  4. Obstructive azoospermia
    • Vas deferens blockage, post-vasectomy, congenital bilateral absence of vas deferens, epididymal obstruction।

NICE obstructive azoospermia-তে surgical correction বা sperm retrieval recommend করে।

Infertility-এর Causes — Bangla te point akare details

Infertility-এর cause সাধারণত ৪ ভাগে দেখা হয়: Female factor, Male factor, Combined factor, Unexplained infertility। WHO অনুযায়ী infertility male, female বা unexplained factor—যেকোনো কারণে হতে পারে।

A) Female factor causes

1) Ovulation disorder / ডিম্বস্ফোটন সমস্যা

এটা female infertility-এর সবচেয়ে common causeগুলোর একটি। Ovulation না হলে ovary থেকে mature egg বের হয় না, তাই sperm fertilize করতে পারে না। CDC PCOS-কে female infertility-এর common cause হিসেবে উল্লেখ করেছে, কারণ PCOS-এ ovulation irregular বা absent হয়।

Common causes:

  • PCOS: irregular period, weight gain, acne, hirsutism, insulin resistance।
  • Hypothyroidism: thyroid hormone কম হলে menstrual cycle ও ovulation disturb হয়।
  • Hyperprolactinemia: prolactin বেশি হলে GnRH কমে যায় → FSH/LH কমে → ovulation বন্ধ হতে পারে।
  • Premature ovarian insufficiency: 40 বছরের আগে ovarian function কমে যাওয়া।
  • Extreme weight: obesity বা underweight—দুটোতেই ovulation problem হতে পারে।
  • Stress/excess exercise: hypothalamic suppression করে ovulation বন্ধ করতে পারে।

Core meaning: egg release না হলে pregnancy হবে না।

2) Tubal factor / Fallopian tube blockage

Fallopian tube হলো জায়গা যেখানে sperm ও ovum normally মিলিত হয়। Tube blocked বা damaged হলে fertilization হয় না অথবা ectopic pregnancy হতে পারে। NICE tubal disease suspicion থাকলে tubal patency test যেমন HSG/HyCoSy বা laparoscopy + dye recommend করে।

Common causes:

  • PID: Chlamydia/Gonorrhea infection-এর পর tube scarred হতে পারে।
  • Genital tuberculosis: South Asian region-এ গুরুত্বপূর্ণ cause।
  • Previous ectopic pregnancy: tube damage করে।
  • Pelvic surgery: appendix surgery, ovarian surgery, tubal surgery-এর পর adhesion হতে পারে।
  • Endometriosis: tube ও ovary-এর around adhesion তৈরি করে।

Core meaning: tube blocked হলে sperm ও egg meet করতে পারে না।

3) Endometriosis

Endometriosis-এ uterus-এর lining-এর মতো tissue uterus-এর বাইরে থাকে। এতে inflammation, pelvic adhesion, ovarian endometrioma, tube-ovary anatomy distortion হয়। ফলে egg release, tube function, fertilization ও implantation সবই affect হতে পারে। NICE endometriosis-associated fertility problem আলাদাভাবে manage করতে বলেছে।

Clinical clue:

  • Severe dysmenorrhea
  • Deep dyspareunia
  • Chronic pelvic pain
  • Infertility
  • Painful bowel movement during period

Core meaning: pelvic inflammation ও adhesion fertility কমায়।

4) Uterine factor / জরায়ুর সমস্যা

Fertilized embryo uterus-এ implant করতে হয়। Uterine cavity abnormal হলে implantation fail হতে পারে বা miscarriage হতে পারে। ASRM female infertility evaluation-এ uterine/tubal/ovulatory assessment গুরুত্বপূর্ণ বলে উল্লেখ করে।

Common causes:

  • Submucosal fibroid: uterine cavity distort করে।
  • Endometrial polyp: implantation disturb করতে পারে।
  • Asherman syndrome: D&C, infection বা surgery-এর পর intrauterine adhesion।
  • Congenital uterine anomaly: septate uterus, bicornuate uterus।
  • Chronic endometritis: chronic inflammation implantation problem করতে পারে।

Core meaning: embryo বসার জায়গা ঠিক না থাকলে pregnancy establish হয় না।

5) Cervical factor

Cervix-এর mucus sperm transport-এ সাহায্য করে। Cervical mucus hostile হলে বা cervix structurally damaged হলে sperm uterus-এ উঠতে সমস্যা হয়।

Causes:

  • Previous cervical surgery
  • Cervical stenosis
  • Chronic cervicitis
  • Poor cervical mucus
  • Anti-sperm antibody, rare

Core meaning: sperm cervix পার হয়ে uterus/tube-এ পৌঁছাতে পারে না।

6) Age-related ovarian reserve কমে যাওয়া

Female age বাড়ার সাথে egg number ও egg quality কমে যায়। 35 বছরের পর fertility দ্রুত কমতে থাকে; miscarriage ও chromosomal abnormality risk বাড়ে। NICE fertility assessment-এ maternal age-কে important predictor হিসেবে বিবেচনা করে।

Core meaning: বয়স বাড়লে egg কমে ও quality খারাপ হয়।

7) Lifestyle ও systemic disease

কিছু lifestyle ও chronic disease fertility কমাতে পারে।

Important factors:

  • Obesity
  • Underweight
  • Smoking
  • Alcohol
  • Diabetes mellitus
  • Thyroid disease
  • Autoimmune disease
  • Chemotherapy/radiotherapy history
  • Chronic renal/liver disease
  • Certain drugs: chemotherapy, antipsychotics causing hyperprolactinemia, long-term steroids

Core meaning: body-এর hormonal ও metabolic balance নষ্ট হলে ovulation/implantation কমে যায়।

B) Male factor causes

AUA/ASRM guideline অনুযায়ী infertility-এর etiologic causes male ও female—দুই দিক থেকেই হতে পারে; male infertility-তে semen abnormality, varicocele, obstruction, endocrine/genetic causes গুরুত্বপূর্ণ।

1) Sperm production problem

Testis পর্যাপ্ত sperm তৈরি করতে না পারলে infertility হয়।

Types:

  • Oligozoospermia: sperm count কম।
  • Azoospermia: semen-এ sperm নেই।
  • Asthenozoospermia: sperm motility কম।
  • Teratozoospermia: sperm morphology abnormal।

Causes:

  • Varicocele
  • Undescended testis
  • Mumps orchitis
  • Testicular trauma
  • Chemotherapy/radiotherapy
  • Genetic disorder: Klinefelter syndrome, Y-chromosome microdeletion
  • Smoking, alcohol, heat exposure
  • Anabolic steroid/testosterone abuse

Core meaning: sperm quantity বা quality কম হলে fertilization হয় না।

2) Varicocele

Varicocele হলো testicular vein dilatation। এতে testicular temperature বাড়ে, oxidative stress বাড়ে এবং sperm production/motility কমে যেতে পারে। NICE clinically detected varicocele + reduced semen parameters থাকলে treatment consider করতে বলে।

Clinical clue:

  • Scrotal heaviness
  • Left-sided “bag of worms” feeling
  • Low sperm count/motility
  • Testicular size কমে যেতে পারে

Core meaning: testis-এর temperature ও blood flow problem sperm quality নষ্ট করে।

3) Obstructive azoospermia / sperm passage blockage

Testis sperm তৈরি করলেও sperm semen-এ আসতে পারে না।

Causes:

  • Congenital absence of vas deferens
  • Epididymal obstruction
  • Vas deferens blockage
  • Previous vasectomy
  • Infection-related scarring
  • Hernia/scrotal surgery injury

Core meaning: sperm তৈরি হচ্ছে, কিন্তু বের হওয়ার রাস্তা বন্ধ।

4) Hormonal male infertility

Hormone imbalance থাকলে testis sperm তৈরি করতে পারে না।

Causes:

  • Hypogonadotropic hypogonadism
  • Pituitary tumor
  • Hyperprolactinemia
  • Thyroid disease
  • Testosterone/anabolic steroid use
  • Obesity-related low testosterone

Core meaning: brain-pituitary-testis axis ঠিক না থাকলে sperm production কমে।

5) Sexual dysfunction

Semen normal হলেও intercourse বা ejaculation ঠিকমতো না হলে pregnancy হয় না।

Causes:

  • Erectile dysfunction
  • Premature ejaculation
  • Retrograde ejaculation
  • Diabetes neuropathy
  • Spinal cord injury
  • Psychological stress
  • Some drugs: SSRI, antihypertensive, antipsychotic

Core meaning: sperm female reproductive tract-এ properly deposit হয় না।

6) Infection/inflammation

Male genital tract infection sperm count, motility ও semen quality খারাপ করতে পারে।

Causes:

  • Epididymitis
  • Orchitis
  • Prostatitis
  • STI: Chlamydia, Gonorrhea
  • Mumps orchitis

Core meaning: infection testis/epididymis damage করে sperm quality কমায়।

C) Combined causes

অনেক couple-এ male ও female দুই দিকেই mild/moderate problem থাকে।

Example:

  • Wife-এর PCOS + husband-এর low motility
  • Wife-এর endometriosis + husband-এর varicocele
  • Wife-এর age >35 + husband-এর borderline sperm count

Core meaning: একদিকে problem mild হলেও দুইজনের factor একসাথে pregnancy chance কমিয়ে দেয়।

D) Unexplained infertility

সব test normal—ovulation normal, tube open, uterus normal, semen normal—তবুও pregnancy না হলে তাকে unexplained infertility বলা হয়। Carson & Kallen review অনুযায়ী common causes হলো ovulatory dysfunction, male factor infertility ও tubal disease; কিছু couple-এ standard evaluation normal থাকলেও infertility থাকে।

Possible hidden mechanisms:

  • Egg quality issue
  • Sperm DNA fragmentation
  • Fertilization defect
  • Subtle endometriosis
  • Tubal pickup defect
  • Implantation defect
  • Immunological or molecular-level problem

Core meaning: basic tests normal, কিন্তু fertilization/implantation-এর microscopic বা functional problem থাকতে পারে।

Clinical shortcut: Cause ধরার সহজ way

FindingProbable cause
Irregular periodPCOS, thyroid, prolactin, ovulation disorder
Severe period pain + dyspareuniaEndometriosis
PID/ectopic/TB historyTubal blockage
Heavy bleedingFibroid, polyp
GalactorrheaHyperprolactinemia
Low sperm count/motilityMale factor, varicocele
No sperm in semenAzoospermia: obstruction or testicular failure
Age >35Low ovarian reserve/egg quality issue
All tests normalUnexplained infertility

Overview / Summary

Infertility-এর main causes হলো female ovulation problem, tubal blockage, endometriosis, uterine cavity problem, age-related ovarian reserve decline, male sperm abnormality, varicocele, obstruction, hormonal disorder, sexual dysfunction, এবং unexplained infertility। Clinical practice-এ cause ধরতে হলে শুধু female নয়, couple-based evaluation করতে হয়।

Actionable Plan / Steps

  1. Female history: period regularity, pain, PID/TB, surgery, age, weight।
  2. Male history: semen issue, varicocele, mumps, surgery, smoking, steroid/testosterone।
  3. First-line tests: semen analysis, ovulation confirmation, TVS, TSH/prolactin if indicated, tubal patency test।

4.Cause-specific management plan করুন: PCOS, tubal disease, endometriosis, uterine lesion, male factor—প্রত্যেকটার treatment আলাদা।

3) Symptoms / Clinical Features — Bangla point akare

Female symptoms

  • ১২ মাস চেষ্টা করেও pregnancy না হওয়া
  • Irregular period / oligomenorrhea / amenorrhea
  • PCOS features: weight gain, acne, hirsutism, oily skin
  • Galactorrhea, headache, visual problem → hyperprolactinemia/pituitary lesion suspect
  • Dysmenorrhea, deep dyspareunia, chronic pelvic pain → endometriosis
  • Previous PID: lower abdominal pain, vaginal discharge history
  • Recurrent miscarriage
  • অনেক ক্ষেত্রে কোনো symptom থাকে না, শুধু infertility থাকে।

Male symptoms

  • Pregnancy না হওয়া
  • Erectile dysfunction, ejaculatory dysfunction
  • Low libido, fatigue, reduced beard/body hair → hypogonadism
  • Testicular pain/swelling, varicocele
  • Past mumps orchitis, undescended testis, genital surgery history
  • অনেক ক্ষেত্রে symptom নেই; semen analysis ছাড়া ধরা পড়ে না।

Infertility-এর Symptoms / লক্ষণসমূহ — Bangla point akare details

Core meaning: Infertility-এর প্রধান symptom হলো regular unprotected intercourse করার পরও pregnancy না হওয়া। অনেক couple-এর infertility ছাড়া অন্য কোনো clear symptom থাকে না। তবে underlying cause অনুযায়ী female বা male partner-এর কিছু লক্ষণ থাকতে পারে।

A) Common main symptom

1) ১২ মাস চেষ্টা করেও pregnancy না হওয়া

  • বয়স <35 বছর হলে ১২ মাস regular unprotected intercourse-এর পরও pregnancy না হলে infertility evaluation দরকার।
  • বয়স ≥35 বছর হলে ৬ মাস চেষ্টা করেও pregnancy না হলে evaluation শুরু করা উচিত।
  • যদি period irregular, pelvic pain, PID/endometriosis history, male sexual problem বা semen problem থাকে, তাহলে আরও আগে evaluation করা উচিত। NICE fertility assessment-এ irregular/absent periods, significant pelvic pain, endometriosis/PID history ইত্যাদি important clinical clues হিসেবে উল্লেখ করেছে।

B) Female infertility-এর symptoms

1) Irregular period / অনিয়মিত মাসিক

  • Period ২১ দিনের কম বা ৩৫ দিনের বেশি interval-এ হলে ovulation problem suspect করতে হয়।
  • PCOS, thyroid disease, hyperprolactinemia, ovarian reserve কমে যাওয়া—এসবের কারণে হতে পারে।
  • Irregular period মানে অনেক সময় egg নিয়মিত release হচ্ছে না, তাই pregnancy chance কমে যায়।

2) Amenorrhea / মাসিক বন্ধ থাকা

  • ৩ মাস বা তার বেশি সময় period না হলে anovulation, pregnancy, thyroid disorder, hyperprolactinemia, premature ovarian insufficiency, hypothalamic problem চিন্তা করতে হয়।
  • মাসিক না হলে ovulation না হওয়ার possibility বেশি, তাই infertility হতে পারে।

3) Severe dysmenorrhea / অতিরিক্ত মাসিক ব্যথা

  • খুব বেশি period pain, painkiller ছাড়া সহ্য না হওয়া, সময়ের সাথে pain বাড়া—endometriosis-এর clue হতে পারে।
  • Endometriosis pelvic inflammation ও adhesion করে fertility কমাতে পারে। NICE infertility evaluation-এ significant pelvic pain-কে important symptom হিসেবে বিবেচনা করে।

4) Deep dyspareunia / সহবাসের সময় গভীর pelvic pain

  • Deep intercourse pain endometriosis, pelvic adhesion, PID বা ovarian pathology-এর sign হতে পারে।
  • এই pain থাকলে শুধু symptomatic treatment না দিয়ে pelvic evaluation দরকার।

5) Chronic pelvic pain / দীর্ঘদিন তলপেটে ব্যথা

  • Endometriosis, chronic PID, pelvic adhesion, ovarian cyst, fibroid—এসব cause হতে পারে।
  • Chronic pelvic pain + infertility থাকলে tubal factor বা endometriosis বেশি ভাবতে হয়।

6) Abnormal vaginal bleeding / অস্বাভাবিক bleeding

  • Period-এর বাইরে bleeding, heavy bleeding, prolonged bleeding, postcoital bleeding—uterine polyp, fibroid, endometrial pathology, cervical lesion বা hormonal imbalance-এর sign হতে পারে।
  • Uterine cavity abnormal হলে embryo implantation disturb হতে পারে।

7) Hirsutism / মুখে-শরীরে অতিরিক্ত লোম

  • Upper lip, chin, chest, abdomen-এ male-pattern hair growth হলে androgen excess suspect করা হয়।
  • PCOS-এর common sign; PCOS-এ irregular ovulation infertility-এর major cause। CDC PCOS-কে female infertility-এর common cause হিসেবে উল্লেখ করেছে।

8) Acne, oily skin, hair thinning

  • Androgen excess-এর কারণে acne, oily skin, scalp hair thinning হতে পারে।
  • Irregular period-এর সাথে থাকলে PCOS বেশি likely।

9) Galactorrhea / breast থেকে দুধের মতো discharge

  • Pregnancy বা breastfeeding ছাড়া nipple discharge হলে hyperprolactinemia suspect করতে হয়।
  • Prolactin বেশি হলে GnRH suppression হয় → FSH/LH কমে → ovulation বন্ধ বা irregular হতে পারে।

10) Weight gain বা obesity

  • Obesity insulin resistance, PCOS ও anovulation-এর সাথে related।
  • Weight বেশি হলে ovulation induction response কমতে পারে, miscarriage risk বাড়তে পারে।

11) Underweight বা অতিরিক্ত weight loss

  • BMI খুব কম, crash dieting, excessive exercise হলে hypothalamic suppression হয়।
  • এতে period বন্ধ বা irregular হতে পারে, ovulation কমে যায়।

12) Recurrent miscarriage

  • Pregnancy হয় কিন্তু বারবার নষ্ট হয়ে গেলে সেটিও fertility problem-এর অংশ।
  • Cause হতে পারে uterine anomaly, antiphospholipid syndrome, chromosomal problem, thyroid disease, uncontrolled diabetes, progesterone/luteal issue।

C) Male infertility-এর symptoms

1) কোনো symptom না থাকা

  • Male infertility-এর অনেক case-এ বাইরে থেকে কোনো symptom থাকে না।
  • তাই infertility evaluation-এ semen analysis mandatory; শুধু female partner-এর test করলে diagnosis miss হতে পারে। WHO male infertility causes হিসেবে semen ejection problem, absent/low sperm, abnormal morphology/motility উল্লেখ করে।

2) Erectile dysfunction / erection problem

  • Erection maintain না হলে proper intercourse ও semen deposition হয় না।
  • Cause হতে পারে diabetes, vascular disease, psychological stress, medication, low testosterone।

3) Ejaculatory problem

  • Premature ejaculation, delayed ejaculation, anejaculation বা retrograde ejaculation হলে sperm female genital tract-এ properly পৌঁছায় না।
  • Diabetes neuropathy, spinal injury, prostate surgery, কিছু medicine-এর কারণে হতে পারে।

4) Low libido / যৌন ইচ্ছা কমে যাওয়া

  • Low testosterone, hyperprolactinemia, depression, chronic illness বা drug effect-এর কারণে হতে পারে।
  • Low libido + infertility থাকলে hormonal evaluation দরকার।

5) Testicular pain, swelling বা heaviness

  • Varicocele, epididymitis, orchitis, testicular pathology-এর sign হতে পারে।
  • Varicocele থাকলে scrotum-এ heaviness বা “bag of worms” feeling হতে পারে এবং sperm quality কমতে পারে।

6) Small testis / testicular atrophy

  • Testicular size ছোট হলে primary testicular failure, Klinefelter syndrome, past mumps orchitis, undescended testis history suspect করা হয়।
  • এতে sperm production কমে যেতে পারে।

7) কম beard/body hair, muscle কম, fatigue

  • Hypogonadism বা low testosterone-এর sign হতে পারে।
  • Low testosterone sperm production ও sexual function দুইটাই affect করতে পারে।

8) Past history clue

  • Childhood undescended testis
  • Mumps orchitis
  • Testicular trauma
  • Hernia/scrotal surgery
  • Chemotherapy/radiotherapy
  • Anabolic steroid/testosterone use
    এসব history থাকলে semen abnormality বা azoospermia হতে পারে।

D) Cause অনুযায়ী symptom shortcut

SymptomPossible cause
Irregular periodPCOS, thyroid disease, hyperprolactinemia, anovulation
No periodPregnancy, hypothalamic amenorrhea, POI, prolactin, thyroid
Severe period painEndometriosis, adenomyosis
Deep pain during sexEndometriosis, pelvic adhesion, PID
Chronic pelvic painEndometriosis, chronic PID, ovarian pathology
Heavy menstrual bleedingFibroid, polyp, adenomyosis
Hirsutism + acnePCOS / androgen excess
GalactorrheaHyperprolactinemia
Pregnancy হয় কিন্তু বারবার নষ্টRecurrent pregnancy loss causes
ED/ejaculation problemMale sexual dysfunction
Testicular swelling/heavinessVaricocele, infection
No symptom but no pregnancyMale factor, tubal factor, unexplained infertility

Red flag symptoms — দ্রুত specialist referral দরকার

  • Female age ≥35 with ৬ মাস infertility
  • Amenorrhea বা very irregular period
  • Severe pelvic pain / suspected endometriosis
  • Previous ectopic pregnancy, PID, genital TB history
  • Recurrent miscarriage
  • Male partner-এর azoospermia/severe low sperm count
  • Testicular swelling/pain or very small testes
  • Galactorrhea + headache/visual problem
  • Postcoital bleeding বা abnormal cervical finding

Overview / Summary

Infertility-এর সবচেয়ে গুরুত্বপূর্ণ symptom হলো pregnancy না হওয়া। Female side-এ common clues: irregular/no period, severe period pain, dyspareunia, pelvic pain, abnormal bleeding, hirsutism, acne, galactorrhea। Male side-এ clues: ED, ejaculatory problem, low libido, testicular swelling/pain, small testis, কিন্তু অনেক male infertility case asymptomatic থাকে।

Actionable Plan / Steps

  1. Symptoms থাকুক বা না থাকুক—couple দুজনকে evaluate করুন।
  2. Female: menstrual pattern, pelvic pain, PCOS sign, galactorrhea, previous PID/TB/surgery history নিন।
  3. Male: semen analysis, sexual function, testicular exam, steroid/testosterone use history নিন।
  4. Red flag থাকলে early gynecologist/fertility specialist/urologist referral দিন।

4) Clinical diagnosis & specific investigations

Step 1: Couple-based evaluation

Infertility evaluation সবসময় husband-wife দুজনের একসাথে করা উচিত। ASRM female fertility evaluation systematic, cost-effective ও least invasive approach দিয়ে শুরু করতে বলে।

Female investigations

  1. Pregnancy test: delayed period থাকলে আগে urine/serum β-hCG।
  2. Ovulation confirmation:
    • Mid-luteal serum progesterone: 28-day cycle হলে day 21; long cycle হলে period-এর ৭ দিন আগে। NICE mid-luteal progesterone recommend করে।
  3. Hormonal tests:
    • TSH: thyroid symptom থাকলে
    • Prolactin: ovulatory disorder, galactorrhea বা pituitary tumor suspicion থাকলে
    • FSH/LH ± estradiol: irregular cycle/amenorrhea
    • AMH/AFC: ovarian response prediction, especially ART planning; NICE spontaneous conception predict করতে AMH ব্যবহার না করতে বলে, তবে assisted conception counselling-এ AMH/AFC ব্যবহার করা যায়।
  4. PCOS workup: total/free testosterone or FAI, DHEAS if needed, pelvic US/AMH adults only, glucose/lipid profile।
  5. Tubal patency:
    • HSG বা HyCoSy
    • PID/endometriosis/ectopic history থাকলে laparoscopy + dye।
  6. Uterine cavity: TVS, saline infusion sonography, hysteroscopy if suspected polyp/fibroid/adhesion।
  7. Infection screening: Chlamydia before uterine instrumentation; positive হলে partner management সহ treatment। NICE Chlamydia screening before uterine instrumentation recommend করে।

Male investigations

  1. Semen analysis — WHO reference values
    • Volume ≥1.4 ml
    • pH ≥7.2
    • Sperm concentration ≥16 million/ml
    • Total sperm number ≥39 million/ejaculate
    • Total motility ≥42%
    • Progressive motility ≥30%
    • Vitality ≥54%
    • Normal morphology ≥4%
      NICE NG257       এগুলো WHO reference value হিসেবে ব্যবহার করতে বলে; first report abnormal হলে repeat confirmatory test, ideally 3 months পরে।
  2. Physical exam: testes size, varicocele, vas deferens, secondary sexual characters।
  3. Hormone: FSH, LH, total testosterone ± prolactin/TSH।
  4. Genetic testing:
    • Azoospermia বা sperm concentration <1 million/ml হলে Y-chromosome microdeletion।
    • Idiopathic azoospermia হলে karyotype।
    • Suspected obstructive azoospermia/vasal abnormality হলে CFTR testing। NICE এই indications দিয়েছে।

5) Differential diagnosis

  • Pregnancy already achieved but early loss / biochemical pregnancy
  • Sexual dysfunction: infrequent intercourse, ED, vaginismus, premature ejaculation
  • PCOS
  • Hypothyroidism / hyperthyroidism
  • Hyperprolactinemia / pituitary adenoma
  • Premature ovarian insufficiency
  • Endometriosis
  • Tubal blockage / genital TB / PID
  • Uterine fibroid, polyp, Asherman syndrome
  • Male varicocele, azoospermia, hypogonadism
  • Unexplained infertility

6) Complications of infertility — Bangla explanation

  • Psychological stress: depression, anxiety, marital stress, sexual dissatisfaction।
  • Social stigma: পরিবার ও সমাজের pressure, especially female partner blamed হয়।
  • Financial burden: repeated tests, ovulation induction, IUI/IVF cost।
  • Disease-related complications: untreated PID → chronic pelvic pain, ectopic pregnancy; untreated endometriosis → pain/adhesion; untreated hyperprolactinemia → amenorrhea, bone loss।
  • Treatment-related complications: multiple pregnancy, OHSS, ectopic pregnancy, miscarriage, injection complications। Gonadotrophin therapy-তে multiple pregnancy ও OHSS risk সম্পর্কে counselling ও ultrasound monitoring NICE recommend করে।

7) Treatment / Management — Guideline-based

General non-pharmacological management

  • Regular intercourse: fertile window-এ every 1–2 days।
  • BMI optimize: BMI 18.5–24.9 target; obesity ও underweight দুটোই ovulation ও pregnancy outcome খারাপ করে।
  • Stop smoking, alcohol, recreational drug, anabolic steroid/testosterone।
  • Diabetes, thyroid disease, prolactin disorder, STI treat।
  • Folic acid 400 mcg/day preconception; diabetes/antiepileptic/high-risk হলে higher dose specialist advice।
  • Male: heat exposure কমানো, tight underwear/sauna/laptop heat avoid, varicocele assess।
  • Cause-specific referral: age ≥35, amenorrhea, severe male factor, tubal disease, endometriosis, recurrent miscarriage, known pelvic disease হলে early referral।

Pharmacological drugs — Bangladesh brandসহ

Important: Infertility drugs pregnancy test, baseline USG, semen report, tubal patency ও specialist monitoring ছাড়া দেওয়া উচিত নয়। Letrozole infertility-তে অনেক দেশে off-label; pregnancy exclude করে cycle-based use করতে হয়।

1) Letrozole — PCOS/anovulatory infertility first-line

  • Generic name: Letrozole
  • Therapeutic category: Ovulation induction agent
  • Pharmacological class: Aromatase inhibitor
  • Why used: Estrogen synthesis কমিয়ে FSH release বাড়ায় → follicular development ও ovulation। PCOS guideline 2023 anovulatory PCOS infertility-তে letrozole first-line বলে।
  • Dose: 2.5 mg PO daily for 5 days, usually cycle day 2–6 বা 3–7; response না হলে next cycle 5 mg/day, max 7.5 mg/day for 5 days।
  • Duration: usually 3–6 ovulatory cycles; response অনুযায়ী।
  • Side effects: headache, dizziness, fatigue, hot flush, nausea, ovarian cyst, multiple pregnancy rare।
  • Interactions: estrogen-containing drugs/tamoxifen effect কমাতে পারে; pregnancy হলে stop।
  • Bangladesh available brand with strength: Arofrez 2.5 mg, Endofree 2.5 mg, Femara 2.5 mg, Femzole 2.5 mg, Fezol 2.5 mg, Lenor 2.5 mg, Lerozol 2.5 mg, Letrol 2.5 mg, Letrogen 2.5 mg, Loreta 2.5 mg, Ovazol 2.5 mg, Zoleta 2.5 mg।

2) Clomiphene citrate — alternative ovulation induction

  • Generic name: Clomiphene citrate
  • Therapeutic category: Ovulation induction agent
  • Pharmacological class: Selective estrogen receptor modulator, SERM
  • Why used: hypothalamus-এ estrogen negative feedback block করে FSH/LH বাড়ায় → ovulation।
  • Dose: 50 mg PO daily for 5 days, cycle day 2–6 বা 3–7; ovulation না হলে 100 mg/day পর্যন্ত increase।
  • Duration: usually 3–6 cycles; prolonged unsupervised use avoid।
  • Side effects: hot flush, mood change, breast tenderness, ovarian enlargement, visual disturbance, multiple pregnancy, OHSS rare।
  • Interactions: gonadotrophin/HCG-এর সাথে OHSS/multiple pregnancy risk বাড়ে; liver disease, ovarian cyst, pregnancy-তে contraindicated।
  • Bangladesh available brand with strength: Fermid 50 mg, Fertil 50 mg, Ovajet 50 mg/100 mg, Ovuclon 50 mg, Ovulet 50 mg/100 mg, Reomen 50 mg।

3) Metformin — PCOS with insulin resistance/metabolic issue

  • Generic name: Metformin hydrochloride
  • Therapeutic category: Antidiabetic; PCOS adjunct
  • Pharmacological class: Biguanide
  • Why used: insulin resistance কমায়; PCOS-এ ovulation induction drug-এর adjunct হিসেবে use হতে পারে। PCOS guideline clomiphene + metformin combination ovulation/clinical pregnancy improve করতে পারে বলে।
  • Dose: 500 mg once daily with meal → 500 mg BD/TDS; XR 500–1000 mg daily; usual target 1500–2000 mg/day as tolerated।
  • Duration: 3–6 months or longer depending on PCOS/metabolic status।
  • Side effects: nausea, diarrhea, abdominal discomfort, metallic taste, vitamin B12 deficiency, lactic acidosis rare।
  • Interactions/precaution: eGFR low হলে avoid/adjust; iodinated contrast-এর আগে/পরে hold; alcohol excess avoid; B12 monitor।
  • Bangladesh available brand with strength: Glucomin 500/850 mg, Glucomin XR 500/1000 mg, Glunor 500/850 mg, Informet 500/850 mg, Informet XR 500/750/1000 mg, Insimet 500/850 mg, Meglu 500/850 mg, Met 500/850 mg, Metformin/Metform 500 mg, Metforal 500/850 mg, Radimet 500/850 mg, SB-Met 500/850/1000 mg।

4) Cabergoline — hyperprolactinemia-related infertility

  • Generic name: Cabergoline
  • Therapeutic category: Antihyperprolactinemic drug
  • Pharmacological class: Dopamine D2 receptor agonist
  • Why used: prolactin কমায় → GnRH/FSH/LH normalize → ovulation restore। NICE 2026 hyperprolactinemia-related ovulatory disorder-এ cabergoline offer করতে বলে।
  • Dose: 0.25 mg twice weekly; prolactin অনুযায়ী 4-week interval-এ titrate; common 0.5–1 mg/week।
  • Duration: prolactin normalize ও ovulation restore হওয়া পর্যন্ত; pregnancy হলে endocrinologist/gynecologist decision অনুযায়ী usually stop/continue plan।
  • Side effects: nausea, dizziness, postural hypotension, headache, constipation; long-term high dose-এ valvular fibrosis risk।
  • Interactions: antipsychotic/metoclopramide/domperidone effect oppose করে; antihypertensive-এর সাথে hypotension বাড়তে পারে।
  • Bangladesh available brand with strength: Argolin 0.5 mg, Caber 0.5 mg, Cabergol 0.5 mg, Caberol 0.5 mg, Cabolac 0.5 mg, Cabolin 0.5 mg/1 mg, Ferticab 0.5 mg।

5) Bromocriptine — cabergoline alternative

  • Generic name: Bromocriptine mesylate
  • Therapeutic category: Antihyperprolactinemic drug
  • Pharmacological class: Dopamine agonist
  • Why used: hyperprolactinemia-induced anovulation/amenorrhea/infertility।
  • Dose: 1.25 mg at night with food, then 2.5 mg daily; gradually 2.5 mg BD if needed।
  • Duration: prolactin normalization/pregnancy plan অনুযায়ী।
  • Side effects: nausea, vomiting, dizziness, orthostatic hypotension, headache।
  • Interactions: dopamine antagonists reduce effect; alcohol/hypotensive drugs dizziness বাড়ায়।
  • Bangladesh available brand with strength: Bromergon 2.5 mg, Bromocriptine 2.5 mg, Bromodel 2.5 mg, Bromolac 2.5 mg, Bromotine 2.5 mg, Criptine 2.5 mg।

6) Gonadotrophins — specialist-supervised ovulation induction/ART & male HH

  • Generic name: Human menopausal gonadotrophin, HMG; FSH; Follitropin alfa
  • Therapeutic category: Drugs for infertility
  • Pharmacological class: Gonadotrophins / trophic hormones
  • Why used: follicle growth stimulate করে; oral ovulation induction fail হলে বা ART cycle-এ। PCOS guideline gonadotrophins second-line হিসেবে consider করে।
  • Female dose: HMG/FSH 50–75 IU SC/IM daily from cycle day 2–3; follicular monitoring করে dose adjust; mature follicle হলে HCG trigger।
  • Male hypogonadotropic hypogonadism: HCG ± FSH/HMG for spermatogenesis; semen response দেখতে 4–6 months or longer লাগে।
  • Side effects: OHSS, multiple pregnancy, abdominal pain, bloating, injection-site pain, ectopic pregnancy risk।
  • Interactions: clomiphene/letrozole/HCG combination response ও OHSS risk বাড়াতে পারে।
  • Bangladesh available brand with strength:
    • HMG: Gonagen 75 IU/vial, HMG 75/150 IU/vial, Menofactor 75 IU/vial, Menofin 75 IU/vial।
    • Follitropin alfa: Gonal-F 75, 300, 900, 1050 IU pre-filled syringe।
    • FSH/Urofollitropin examples: Foligest 75 IU/vial; Alfagon 75/150 IU pre-filled syringe।

7) HCG trigger

  • Generic name: Human chorionic gonadotrophin, HCG
  • Therapeutic category: Ovulation trigger / male HH support
  • Pharmacological class: Gonadotrophin; LH-like action
  • Why used: mature follicle rupture/ovulation trigger; male HH-তে Leydig cell testosterone production stimulate।
  • Female dose: 5,000–10,000 IU IM/SC once when follicle mature; intercourse/IUI timing specialist নির্ধারণ করবে।
  • Male dose: commonly 1,500–2,500 IU 2–3 times/week; testosterone ও semen response অনুযায়ী adjust।
  • Side effects: OHSS, multiple pregnancy, injection pain, gynecomastia, edema, mood change।
  • Interactions: other ovulation induction drugs with HCG → OHSS risk।
  • Bangladesh available brand with strength: Choriofactor 5000 IU, HCG 2500/5000/10000 IU, Ovugen 5000/10000 IU, Pregnyl 5000 IU, Prolific 5000 IU।

8) Progesterone / Dydrogesterone — luteal support, ART/IUI

  • Generic name: Micronized progesterone / Dydrogesterone
  • Therapeutic category: Progestogen; luteal support
  • Pharmacological class: Natural progesterone / retro-progesterone
  • Why used: IUI/IVF/ART cycle-এ luteal phase support; routine natural infertility treatment হিসেবে নয়।
  • Dose:
    • Micronized progesterone: 200 mg vaginal/oral BD–TDS, ART protocol অনুযায়ী pregnancy test পর্যন্ত; pregnant হলে 8–12 weeks পর্যন্ত continue হতে পারে।
    • Dydrogesterone: 10 mg BD/TDS, protocol অনুযায়ী।
  • Side effects: drowsiness, dizziness, bloating, breast tenderness, mood change; vaginal route-এ discharge।
  • Interactions: CYP3A4 inducers যেমন rifampicin, carbamazepine, phenytoin effect কমাতে পারে।
  • Bangladesh available brand with strength:
    • Progesterone: Artigest 100/200 mg, Microgest 100/200 mg, Mygest 100/200 mg, Utrogest 100/200 mg, Utrogestan 100/200 mg।
    • Dydrogesterone: Caryon 10 mg, D-gest 10 mg, Divanor 10 mg, Duphaston 10 mg, Dydrogest 10 mg, Dydron 10 mg, Progest 10 mg, Rephaston 10 mg, Safyron 10 mg, Uphaston 10 mg।

9) Levothyroxine — infertility with hypothyroidism

  • Generic name: Levothyroxine sodium
  • Therapeutic category: Thyroid hormone replacement
  • Pharmacological class: Synthetic T4
  • Why used: overt hypothyroidism menstrual dysfunction, anovulation ও miscarriage risk বাড়াতে পারে; TSH normalize করা প্রয়োজন।
  • Dose: 25–50 mcg/day start; TSH অনুযায়ী every 4–6 weeks adjust। Pregnancy planning/pregnancy হলে target আলাদা, specialist follow-up দরকার।
  • Side effects: overtreatment হলে palpitation, tremor, insomnia, weight loss, heat intolerance।
  • Interactions: iron, calcium, antacid, sucralfate, PPI absorption কমায়; সকালে empty stomach, অন্য medicines থেকে 4 hours gap ভালো।
  • Bangladesh available brand with strength: Euthycin 50 mcg, Euthyrox 25/50/100 mcg, Leroid 25/50 mcg, Synroid 50 mcg, Synthox 25/50/75/100 mcg, T4 25/50 mcg, Thyrin 25/50/75/100 mcg, Thyrox 25/50/75/100 mcg।

10) Infection-associated infertility — only if infection confirmed

  • Generic name: Doxycycline
  • Therapeutic category: Antibiotic
  • Pharmacological class: Tetracycline
  • Why used: Chlamydia cervicitis/PID-related risk কমাতে; CDC uncomplicated chlamydia-তে doxycycline 100 mg BD for 7 days recommend করে।
  • Dose: 100 mg PO BD for 7 days; pregnancy হলে avoid, alternative needed।
  • Side effects: gastritis, photosensitivity, esophagitis।
  • Interactions: milk/iron/calcium/antacid absorption কমায়; warfarin effect বাড়াতে পারে।
  • Bangladesh brands: Doxacil 100 mg, Doxicap 100 mg, Doxibac 100 mg, Doxin 100 mg, Doxy-A 100 mg, Doxysina 100 mg etc.

8) Prevention / কীভাবে infertility risk কমাবেন

  • Age delay সম্পর্কে counselling: female fertility age-related decline হয়।
  • STI prevention: condom, screening, early treatment; Chlamydia/PID untreated রাখবেন না।
  • Smoking, alcohol, anabolic steroid/testosterone avoid।
  • Healthy BMI maintain।
  • Diabetes, thyroid disease, PCOS early control।
  • Pelvic pain, irregular period, galactorrhea, ED/ejaculation problem হলে early evaluation।
  • Cancer therapy/chemotherapy/radiotherapy-এর আগে fertility preservation counselling।
  • Male: heat exposure, tight underwear, sauna, occupational toxin কমানো।
  • Unnecessary uterine instrumentation/unsafe abortion avoid।

Real clinical examples

Example 1: PCOS infertility
28-year-old female, irregular period, hirsutism, BMI 31, semen normal, tubes patent → lifestyle + weight reduction + letrozole ovulation induction first-line; metformin add if insulin resistance/metabolic issue।

Example 2: Male varicocele
Couple 1.5 years infertile, wife evaluation normal, semen count/motility low, clinical grade varicocele → urologist referral; varicocele repair consider।

Example 3: Unexplained infertility
Female ovulating, tubes patent, semen normal, 2 years trying → NICE অনুযায়ী IVF-এর আগে up to 4 cycles stimulated IUI consider বা IVF offer করা যায়।

Overview / Summary

Infertility হলো couple-based disease—শুধু female problem নয়। Main causes: PCOS/anovulation, tubal disease, endometriosis, uterine factor, age-related ovarian reserve decline, male sperm abnormality, varicocele, hypogonadism, obstruction। Diagnosis-এর core হলো semen analysis + ovulation confirmation + tubal patency + uterine assessment + targeted hormone tests। Treatment always cause-specific: PCOS-এ letrozole, hyperprolactinemia-তে cabergoline, hypogonadotropic hypogonadism-এ gonadotrophins, tubal/endometriosis/varicocele-এ surgical/ART options।

Actionable Plan / Steps

  1. Couple দুজনের history + examination করুন।
  2. Male partner: semen analysis; abnormal হলে repeat।
  3. Female: mid-luteal progesterone, TVS, targeted TSH/prolactin/FSH-LH, PCOS workup।
  4. Tubal patency: HSG/HyCoSy; high-risk হলে laparoscopy + dye।
  5. Cause-specific treatment: PCOS → letrozole; hyperprolactinemia → cabergoline; tubal/endometriosis/male factor → specialist referral।
  6. Age ≥35, amenorrhea, severe male factor, endometriosis, tubal disease, recurrent pregnancy loss থাকলে early fertility specialist referral।

Reference List

Textbooks

  1. Berek & Novak’s Gynecology, 16th ed. Chapters: Infertility; Reproductive Endocrinology.
  2. Williams Gynecology, 4th ed. Chapters: Infertility; Endometriosis; PCOS.
  3. Harrison’s Principles of Internal Medicine, 21st ed. Chapters: Pituitary disorders, reproductive endocrinology, thyroid disease.
  4. Davidson’s Principles and Practice of Medicine, 24th ed. Endocrinology and reproductive medicine sections.
  5. Robbins & Cotran Pathologic Basis of Disease, 10th/11th ed. Male and female genital tract pathology.
  6. Guyton and Hall Textbook of Medical Physiology, 14th ed. Female physiology before pregnancy; male reproductive physiology.

Guidelines

  1. WHO. Infertility fact sheet, updated 28 Nov 2025.
  2. NICE NG257. Fertility problems: assessment and treatment, 31 Mar 2026.
  3. ASRM. Fertility evaluation of infertile women: committee opinion, Fertility and Sterility 2021.
  4. AUA/ASRM. Diagnosis and Treatment of Infertility in Men guideline, 2021; 2024 amendment.
  5. International Evidence-based Guideline for PCOS, 2023.
  6. CDC STI Treatment Guidelines, 2021.

Peer-reviewed DOI

  1. Legro RS et al. Letrozole versus Clomiphene for Infertility in PCOS. NEJM. 2014;371:119–129. DOI: 10.1056/NEJMoa1313517.
  2. Marcoux S et al. Laparoscopic surgery in infertile women with minimal/mild endometriosis. NEJM. 1997;337:217–222. DOI: 10.1056/NEJM199707243370401.

3.Teede HJ et al. Recommendations from the 2023 International Evidence-based Guideline for PCOS. Human Reproduction. 2023;38(9):1655–1679. DOI: 10.1093/humrep/dead156

Md.Rafiqul Islam Lipu,Date:-27-05-2026 Wednesday,Time:-05-26-49 Pm

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