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A couple is said to be infertile if pregnancy does not result after 1 year of normal sexual activity without contraception. Up to 20% of couples experience infertility at some point in their reproductive lives; the incidence of infertility 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 factors is common. The most recent data from the CDC National Survey of Family Growth noted that 12% of women in the United States aged 15–44 have impaired fecundity.

A. Initial Testing

During the initial interview, the clinician can present an overview of infertility and discuss an evaluation and management plan. Private consultations with each partner separately are then conducted, allowing appraisal of psychosexual adjustment without embarrassment or criticism. Pertinent details (eg, sexually transmitted infection history or prior pregnancies) must be obtained. The ill effects of cigarettes, alcohol, and other recreational drugs on male fertility should be discussed. Prescription medications that impair male potency and factors that may lead to scrotal hyperthermia, such as tight underwear or frequent use of saunas or hot tubs, should be discussed. The gynecologic history should include the menstrual pattern, the use and types of contraceptives, frequency and success of coitus, and correlation of intercourse with time of ovulation. The American Society for Reproductive Medicine provides patient information on the infertility evaluation and treatment (

General physical and genital examinations are performed on the female partner. Basic laboratory studies include assessment of ovarian reserve (eg, antimüllerian hormone, and day 3 FSH and estradiol) and thyroid function tests. If the woman has regular menses with moliminal symptoms, the likelihood of ovulatory cycles is very high. A luteal phase serum progesterone above 3 ng/mL establishes ovulation. Couples should be advised that coitus resulting in conception occurs during the 6-day window prior to the day of ovulation. Ovulation predictor kits have largely replaced basal body temperatures for predicting ovulation, but temperature charting may be used to identify most fertile days. Basal body temperature charts cannot predict ovulation; they can only retrospectively confirm that ovulation occurred.

A semen analysis should be completed to rule out a male factor for infertility (see Chapter 29). Men must abstain from sexual activity for at least 3 days before the semen is obtained. Semen should be examined within 1–2 hours after collection. Semen is considered normal with the following minimum values: volume, 2.0 mL; concentration, 20 million sperm per milliliter; motility, 50% or more forward progression, 25% or more rapid progression; and normal forms, 30%. If the sperm count is abnormal, further evaluation includes physical examination of the male partner and a search for exposure to environmental and workplace toxins and alcohol or drug use.

B. Further Testing

  1. Gross deficiencies of sperm (number, ...

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