Infertility

Infertility

 

Infertility is defined as the failure to achieve a pregnancy during 12 months of frequent, unprotected intercourse.

Epidemiology

  • Prevalence – 10-15% of couples in U.S.

Etiology

  • Female factors – account for about 50% of the cases
    • Ovarian dysfunction
      • Aging
      • Endocrine disorders
      • Polycystic ovarian syndrome (PCOS)
      • Premature ovarian failure
    • Tubal factors
      • Obstruction
      • Endometriosis
    • Uterine/cervical factors
      • Congenital anomaly
      • Fibroids
      • Polyps
      • Poor cervical quality
    • Other
  • Male factors – account for about 25% of the cases
    • Primary/secondary hypogonadism
    • Orchitis
    • Altered sperm
    • Unknown
  • Unexplained – account for about 25% of the cases

Clinical Presentation

  • Female
    • Irregular menses
    • Galactorrhea
    • Signs of hyperandrogenism (eg, hirsutism)
  • Male
    • Varicocele or hydrocele
    • Signs of androgen deficiency (eg, small testes)
    • Signs of infection (eg, epididymitis)

Diagnosis

  • Indications for testing – inability to achieve pregnancy within 12 months
  • Female
    • Full physical examination including assessment of body mass index
    • Confirm rubella immunity
    • Cervical cytology and screening for sexually transmitted infections
    • Document ovulation – midluteal progesterone level, urinary luteinizing hormone
    • Determine etiology if ovulatory dysfunction is suspected – follicle stimulating hormone (FSH), prolactin, thyroid stimulating hormone, 17-hydroxyprogesterone, testosterone
    • Assess ovarian reserve – FSH and estradiol measures on day 3 of menstrual cycle 
    • Assess anatomic dysfunction-transvaginal ultrasound, hysterosalpingography, laparoscopy
  • Male
    • Assess androgen deficiency – LH, FSH, testosterone
    • Assess spermatic function – semen analysis (at least 2 specimens)

Click here for a list of Normal Semen Parameters

    • Consider infection evaluation – complete blood count (CBC), gonorrhea and chlamydia cultures and urinalysis

Treatment

  • Intrauterine insemination, ovulation induction
  • Highest pregnancy rate per cycle from in vitro fertilization (IVF)
    • Ovarian stimulation followed by egg retrieval
    • Egg fertilization, embryo culture
    • Embryo transfer to uterus

See Also