Pocket ObGyn – Infertility Evaluation
See Abbreviations
Definitions and Epidemiology (Fertil Steril 2008;90:S60)
- Infertility: No Preg after 1 y of regular unprotected Consider eval & rx for woman >35 yo after 6 mo. Affects 7–8% of US women (Fertil Steril 2006;86:516). w/ age; >40 yo ® greatest infertility.
- Fecundity: Probability that a single menstrual cycle results in live birth
| Causes of infertility | |
| Dx | % affected |
| Ovulation disorders | 17 |
| Tubal dz | 23 |
| Endometriosis | 7 |
| Male factor | 24 |
| Unexplained | 26 |
| Other | 3 |
| From Smith S, Pfeifer SM, Collins JA. Diagnosis and management of female infertility. JAMA. 2003;290(13):1767–1770. | |
History (Fertil Steril 2004;82:S169)
- Gravidity, parity, Preg outcomes/assoc complications
- Age at menarche, cycle length & characteristics, dysmenorrheal moliminal sx
- Methods of contraception used in the past; frequency & timing of intercourse
- Duration of infertility & results of any prev eval & rx
- H/o thyroid dz, pelvic or abdominal pain, galactorrhea, hirsutism, dyspareunia
- Full medical & surgical Hx, including STIs & PID, prior abd/pelvic Surg
- Prev abn pap smears & any subseq rx
- Current meds including supplements & allergies
- Social history (SHx). Occupation, tobacco, EtOH, drug use
- Family history (FHx) of birth defects, mental retardation, or infertility
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- Partner’s reproductive Hx (conceptions/children in other pairings, testicular trauma, chronic medical conditions, & meds). Remember male factor on diff
Physical Examination
- Weight & Thyroid enlargement, nodule, or tenderness. Breast exam. Signs of androgen excess or acanthosis nigricans. Pelvic or abdominal tenderness, masses. Vaginal or cervical abnormality, secretions, or discharge. Uterine size, shape, position, & mobility. Adnexal mass or tenderness. Cul-de-sac mass, tenderness, nodularity.
Diagnostic Evaluation
- Ovulatory fxn: Oligomenorrhea (>35 d btw menses) or amenorrhea (>3 mo btw menses) ® no further w/u. Luteal phase (cycle day 21 or 7 d after ovulation) serum prog >6 ng/mL confirms ovulation. Urinary LH (commercial ovulation predictor kits) generally reliable & correlate w/ serum Serum FSH/LH ratio & estradiol (cycle day 3) or AMH (any time in cycle) indicate ovarian reserve. If ovulatory dysfxn ® TSH, prolactin, & FSH for etiology.
- Anatomy assessment: HSG evaluates tubal patency & uterine cavity, endometrial polyps, submucosal Schedule 2–5 d after last menses. Rx doxycycline 100 mg PO BID for 5 d if h/o PID or dilated tubes (Obstet Gynecol 2009;113(5):1180). Beware HSG contrast can ® tubal spasm (false + tubal blockage). TVUS shows uterine cavity contours & small intrauterine lesions. Sonohysterography (saline infusion sonogram) more accurate than HSG, as accurate as hysteroscopy for cavity assessment. 2D & 3D TVUS more sensitive than HSG for fibroids & polyps. Hysteroscopy for definitive dx + rx of cavity pathology. Laparoscopy definitive for tubal & pelvic pathology. Chromopertubation (the injection of indigo carmine dye through cervical canula w/ direct intra-abdominal observation of tubal spill for eval of tubal occlusion) & rx of mild dz (fimbrial agglutination, adhesion, endometriosis).
- See also male factor w/u & other diagnoses, below