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For further information, see CMDT Part 18-20: Infertility

Key Features

Essentials of Diagnosis

  • Pregnancy does not result after 12 months of normal sexual activity without contraceptives

General Considerations

  • About 25% of couples experience infertility at some point

  • The incidence increases with age, with a decline in fertility beginning in the early 30s and accelerating in the late 30s

  • The male partner contributes to about 40% of cases of infertility, and a combination of male and female factors is common

Clinical Findings

Symptoms and Signs

  • Obtain history of sexually transmitted disease or prior pregnancies

  • Discuss ill effects of cigarettes, alcohol, and other recreational or prescription drugs on male fertility

  • Discuss factors that may lead to scrotal hyperthermia, such as tight underwear or frequent use of saunas or hot tubs

  • The gynecologic history should include

    • The menstrual pattern

    • Use and types of contraceptives

    • Libido

    • Sexual practices

    • Frequency and success of coitus

    • Correlation of intercourse with time of ovulation

  • Family history should inquire about family members with repeated abortions

  • General physical and genital examinations for both partners

Differential Diagnosis

  • Male factor infertility (hypogonadism, varicocele, alcohol or drug use, immotile cilia syndrome)

  • Polycystic ovary syndrome

  • Premature ovarian failure

  • Hyperprolactinemia

  • Hypothyroidism

  • Inadequate luteal progesterone or short luteal phase

  • Endometriosis

  • Uterine leiomyomas (fibroids) or polyps

  • Prior pelvic inflammatory disease

  • Pelvic adhesions, eg, pelvic surgery, therapeutic abortion, ectopic pregnancy, septic abortion, intrauterine device use

Diagnosis

Diagnostic Procedures

INITIAL TESTING

  • Complete blood count, urinalysis, cervical culture for Chlamydia, rubella antibody determination, and thyroid function tests

  • A luteal phase serum progesterone above 3 ng/mL establishes ovulation

  • Ovulation predictor kits have largely replaced basal body temperatures for predicting ovulation

  • While basal body temperature charting is a natural and inexpensive way to identify most fertile days, it cannot predict ovulation but rather only retrospectively confirm that ovulation occurred

  • Coitus resulting in conception occurs during the 6-day period ending with the day of ovulation

  • Before additional testing, an ejaculate from the male partner for semen analysis is obtained after sexual abstinence for at least 3 days

  • Semen should be examined within 1–2 h after collection

    • Normal semen: volume, 2 mL; concentration, 20 million sperm per milliliter; motility, > 50% forward progression, > 25% rapid progression; and ≥ 30% normal forms

    • If the sperm count is abnormal, search for exposure to environmental and workplace toxins, alcohol or drug abuse, and hypogonadism

FURTHER TESTING

  • Gross deficiencies of sperm (number, motility, or appearance) require a repeat semen analysis

  • A screening pelvic ultrasound and hysterosalpingography to identify uterine cavity or tubal anomalies should be performed

  • Obstruction of the uterine tubes requires either microsurgery or in vitro fertilization

  • Absent or infrequent ovulation requires additional laboratory evaluation

    • Elevated ...

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