Infertility: Clinical

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Infertility: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 25-year-old nulligravida woman comes to the office because of difficulty getting pregnant. She has no medical conditions, no history of sexually transmitted infections, and no other complaints except for mild chronic pelvic pain. She has been having regular intercourse for the past 12 months and has a regular 28-day cycle. Pelvic examination shows a tender right adnexal mass which shows up as a 3 x 2 cm homogenous cystic mass on ultrasonography. A working diagnosis of endometriosis is established. Which of the following treatment options would be most appropriate for this patient?

Memory Anchors and Partner Content


Infertility is classically defined as the inability of a couple to conceive after 12 months of sexual intercourse without using contraception. Sometimes, the evaluation for infertility begins at 6 months, depending on female and male factors. Female factors include age over 35, other gynecologic conditions like endometriosis, prior pelvic inflammatory disease or suspected uterine pathology, like in women who have undergone uterine surgery in the past. Evaluation should also start at 6 months in females with risk factors for premature ovarian failure, like previous ovarian surgery, chemotherapy or pelvic radiation therapy, autoimmune disease, smoking, or a family history. Male factors include history of testicular surgery or radiation, chemotherapy, adult mumps, impotence or other sexual dysfunction, or history of fertility issues with a prior partner.

The infertility work-up is done for both partners at the same time. In males, the semen analysis can identify most causes of infertility. This is when semen is collected in a sterile cup after 2 to 7 days of ejaculatory abstinence - meaning no semen release through sexual intercourse or masturbation - and then analyzed under a microscope. Because sperm concentrations tend to vary a lot between semen samples, at least two samples should be collected at least one week apart. The standard semen analysis can give information about semen volume, as well as sperm count, motility and morphology.

Semen volume is normally greater than 2 milliliters, sperm concentration should be above 15 million spermatozoa per milliliter of ejaculate, and total sperm count should be over 40 million spermatozoa per ejaculate. Total sperm motility should be over 40%, meaning over 40% of sperm should be moving, with at least 32% showing forward motility. The last parameter is morphology - at least 4% of sperm should have a head, a neck, and a single tail. That may sound like a low bar, but that’s all it takes.


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