Infertility

 

Clinical Background

Infertility is a common problem in the U.S., affecting millions of couples and creating significant cost for fertility treatments.

Epidemiology

  • Prevalence – 10-15% of couples in U.S., affects ~2 million couples
  • Definition – inability to conceive after 12 months of frequent, unprotected intercourse

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 – history of pelvic inflammatory disease (PID), tubal pregnancy, tubal or pelvic surgery
      • Endometriosis
    • Uterine/cervical factors (uncommon etiologies)
      • Congenital anomaly
      • Fibroids
      • Polyps
      • Poor cervical mucous quality
    • Lifestyle
      • Tobacco
      • Alcohol
      • Caffeine
      • Body mass
    • Endocrine/metabolic disorders
      • Congenital adrenal hyperplasia (CAH)
      • Virilizing tumors
      • Adrenal failure
      • Cushing syndrome
      • Hypo/hyperthyroidism
      • X chromosome abnormalities
  • Male factors – account for about 25% of the cases
    • Primary/secondary hypogonadism
    • Orchitis
    • Altered sperm
    • Y chromosome abnormalities/microdeletions
    • Trauma-related
    • Exposure to toxic agents (chemotherapy, radiation)
    • Testicular tumor
    • 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)
    • Obstruction/absence of the ejaculatory ducts
    • Testicular tumor

Treatment

  • Ovulation induction
  • Intrauterine insemination
  • In vitro fertilization (IVF)
    • Ovarian stimulation followed by egg retrieval
    • Egg fertilization, embryo culture
    • Embryo transfer to uterus
  • Intracytoplasmic sperm injection (ICSI)
  • Egg donation/ donor insemination