-Definition: Infertility is defined as the inability to conceive after one year of regular unprotected intercourse. For women ≥ 35 years of age, the timeframe to define
-Will approach infertility as a problem that affects couples instead of individuals and do H&P for both partners.
-See HPI.
-PE: Weight and BMI reviewed. No thyroid enlargement, nodule, or tenderness. No breast secretions. No signs of androgen excess (like acne, hirsutism, baldness, virilization). No pelvic or abdominal tenderness, organ enlargement, or mass. No Vaginal or cervical abnormality, secretions, or discharge. No mass, tenderness, or nodularity in the adnexa or cul-de-sac.
–Causes of infertility reviewed with the patient.
-Will work up both males & females since combined factors are responsible for 40% of the cases.
-Semen analysis after 72 hours of abstinence. If done < 72 h may result in a low sperm count. If > 72 h, may result in decreased sperm motility. “Because sperm generation time is just over two months, it is recommended to wait three months before repeat sampling,” if needed.
-Hysterosalpingogram (HSG) to screen for tubal and uterine factors (abnormalities) in this woman with infertility who has no history of pelvic infections, endometriosis, or ectopic pregnancy. If she reveals a history of endometriosis, pelvic infections, or ectopic pregnancy we will do a hysteroscopy or laparoscopy instead of HSG.
-FSH / Estradiol (E2) on day 3 of her cycle to evaluate ovarian reserve.
-Luteal-phase serum progesterone level on day 21 of a 28-day cycle or one week before presumed onset of menses to confirm ovulation.
-TSH and Prolactin to r/o thyroid dysfunction and hyperprolactinemia.
-Consider PCOS eval.
-Will get CBC, CMP, lipid panel, etc.
-Blood type, Rh factor, and antibody screening (if she is Rh-negative).
-Will check for STIs.
Counseling:
-Lifestyle modification: Keep BMI between 20 and 25. Avoid smoking and illicit drug use and limit alcohol consumption to 4 or fewer drinks per week since these negatively impact fertility in both males and females. Recommend moderate exercise and decreasing stress and limit caffeine intake to less than 250 mg/day.
-Recommend intercourse every other day during the most fertile period which is the six days preceding ovulation and the day after ovulation.
-Approximately 85–90% of healthy young couples conceive within 1 year, most within 6 months. Infertility, therefore, affects approximately 10–15% of couples. Patient informed that 50% of couples who have not conceived in the first year of trying will conceive in the second year. “Couples with unexplained infertility may want to consider another year of intercourse before moving to more costly and invasive therapies, such as assisted reproductive technology.”AAFP
-Folic acid (vitamin B9) 0.4 to 0.8 mg (400 to 800 μg) daily to decrease neural tube defects, per USPSTF. Usually as part of a multivitamin or single supplement.
-Will refer the couple to formal counseling because anxiety over infertility may cause increased stress and decreased libido, further compounding the problem.
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AMH (Anti-mullerian Hormone) is another way to check ovarian reserve.
“For most couples, the simple recommendation for intercourse approximately twice per week can avoid an unnecessary source of stress while also helping to ensure that coitus occurs during the interval of highest fertility.348 However, timed coitus may be a reasonable recommendation for couples having infrequent intercourse, by preference or because of circumstance.” Fritz and Speroff)
“The largest majority of spontaneous pregnancies occur within 3 years; thereafter, the prognosis for success without treatment is relatively poor. Couples that have conceived before generally have a better prognosis than those who have never achieved pregnancy. The cause of infertility also affects the prognosis for success without treatment but, of course, cannot be determined without evaluation. Predictably, the diagnoses of anovulation and unexplained infertility have the best prognosis. The likelihood for success without treatment for couples with male factors, tubal disease, and endometriosis varies widely with the severity of disease; the prognosis is reasonably good for mild oligospermia, tubal adhesions, and mild endometriosis, and quite poor for severe male factors, tubal obstruction, and severe endometriosis.
Evaluation should be offered to all couples who have failed to conceive after a year or more of regular unprotected intercourse, but a year of infertility is not a prerequisite for evaluation. Earlier evaluation is justified for women with irregular or infrequent menses, history of pelvic infection or endometriosis, or having a male partner with known or suspected poor semen quality, and also is warranted after 6 months of unsuccessful effort for women over the age of 35 years.”
-Will consider screening for cystic fibrosis (CF) “The American College of Obstetricians and Gynecologists and the American College of Medical Genetics recommend that screening for cystic fibrosis (CF) be offered to individuals with a family history of CF, reproductive partners of individuals with CF, and couples planning a pregnancy or seeking prenatal care wherein one or both partners are Caucasian or of Ashkenazi Jewish descent, and that the test be made available to all patients on request.362 Sequential screening (testing one partner, and the second only if the first partner is identified as a carrier) is most cost effective. Interestingly, a 2007 study found that only 22/1,006 (2%) infertile non-Hispanic Caucasian couples offered counseling and screening (carrier frequency 1/25, detection rate 88%) chose to be tested, most citing the cost of screening” (Fritz and Speroff)
Progesterone level > 3 ng/ml confirms ovulation. (Fritz and Speroff). An AAFP article uses 5 as a cutoff. Investigate.
Infertility is defined as the inability to conceive after one year of regular unprotected intercourse. “Some prefer the term subfertility to describe women or couples who are not sterile but exhibit decreased reproductive efficiency. Approximately 85–90% of healthy young couples conceive within 1 year, most within 6 months. Infertility, therefore, affects approximately 10–15% of couples.” Fritz and Speroff
“A 30-year-old female reports that she and her husband have not been able to conceive after trying for 15 months. She takes no medications, has regular menses, and has no history of headaches, pelvic infections, or heat/cold intolerance. Her physical examination is unremarkable. Her husband recently had a normal semen analysis. Which one of the following would be the most appropriate next step?
- Observation for 1 year
- TSH, free T4, and prolactin levels
- Hysterosalpingography
- An estradiol level
- A luteal-phase progesterone level
Rationale:
“Although infertility issues may be very complex, the primary care physician can initiate an appropriate workup. For women who are having regular menstrual cycles, ovulation is very likely. Ovulation can be confirmed by a progesterone level >=5 ng/mL on day 21 of the cycle. If this is the case, tubal patency should be confirmed with hysterosalpingography or laparoscopy. Obstruction or adhesions would require surgical correction, but if there are none, referral for assisted reproductive technology would be appropriate. Should the progesterone level be <5 ng/mL, anovulation should be investigated with TSH, estradiol, FSH, and prolactin levels. Treatment can be initiated if findings reveal the cause of the problem, but if they are unremarkable it is reasonable to try clomiphene to induce ovulation. If this is unsuccessful, referral would be the next step.” ABFM
“Normal sperm can survive in the female reproductive tract and retain the ability to fertilize an egg for at least 3 and up to 5 days, but an oocyte can be fertilized successfully for only approximately 12–24 hours after ovulation. Consequently, virtually all pregnancies result from intercourse occurring sometime within the 6-day interval ending on the day of ovulation.” (Fritz and Speroff)
Reference
Clinical Gynecologic Endocrinology and Infertility by Marc Fritz, MD, Leon Speroff, MD
Am Fam Physician. 2015 Mar 1;91(5):308-314. http://www.aafp.org/afp/2015/0301/p308.html
Am Fam Physician. 2007 Mar 15;75(6):849-856. http://www.aafp.org/afp/2007/0315/p849.html