Infertility, Female

Key Features

Essentials of Diagnosis

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

General Considerations

• About 20% 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

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