Infertility: Clinical sciences

Infertility is defined as the inability to become pregnant after 12 months of timed, unprotected intercourse or donor insemination when the biologically female partner is under 35 years of age; or after 6 months when they’re older than 35.

When evaluating a patient with a chief concern suggesting infertility your first step is to obtain a focused history and physical.

Key history findings include intercourse for 6 to 12 months that is regular, timed, and unprotected without pregnancy; history of previous infertility treatment; irregular menses; history of STIs, such as cervical infections with gonorrhea or chlamydia; pelvic infection such as pelvic inflammatory disease, or PID; galactorrhea; and hirsutism.

Additionally, when taking a history you should consider their prior pregnancies and birth control, presence of sexual dysfunction, family history of birth defects, developmental delay or early menopause, substance use including tobacco and alcohol; and occupational exposure to environmental hazards.

You should also ask about important information like surgical history, focusing on prior surgeries involving the pelvis, previous serious illness or hospitalization, and current medications including supplements.

Here’s a clinical pearl! Timed intercourse means having unprotected intercourse during the most fertile time of the menstrual cycle or “fertile window”. This is during the 3 to 5 days leading up to ovulation. So if your patient has a 28-day cycle, you can predict they ovulate on day 14 and thus calculate their fertile window as days 10 through 14, with day 1 of their cycle being the first day of their period.

Alright, if you found any of the key findings in history, you should suspect infertility and see if your patient meets the criteria for infertility. Now, if your patient is less than 35 years old and has not become pregnant after 12 months of regular, timed, unprotected intercourse or donor insemination, or if they are at least 35 years old and have not become pregnant after 6 months, you can diagnose infertility. The next step is to perform a basic infertility evaluation. That being said, if your patient doesn’t fit these criteria, but has at least one identifiable infertility factor, they still qualify for a basic infertility workup.

The first infertility factor is the age of 40 years or more. This is important because oocyte quantity and quality decline over time. Next up, there is infrequent menstrual bleeding, or amenorrhea, meaning no menstrual bleeding for 3 months in individuals with previously regular cycles or 6 months in those with previously irregular cycles. Then, known or suspected uterine, tubal, or peritoneal disease might also be present from previous infections, such as PID, or prior surgeries involving the pelvis. Another important factor is stage 3 or 4 endometriosis, which can cause inflammation and scarring that alter pelvic anatomy. Finally, there might be known or suspected male factor infertility.

Okay, let’s discuss the basic infertility workup. The four main categories are testing for male factor infertility; ovulatory function; structural abnormalities; and ovarian reserve.

Alright, male factor infertility can cause up to half of infertility in heterosexual couples, so it is really important to test this along with female factors. Male factor testing is completed by obtaining a semen analysis.

Next, testing ovulatory function includes assessing for regular, monthly ovulation, which is a good sign if present. However, specific testing for ovulation may be completed, which includes a midluteal serum progesterone that rises after ovulation, or home ovulation predictor kits. These kits test the urine for a surge in the luteinizing hormone, or LH, that occurs about 24 hours prior to ovulation.

Next up, structural abnormalities, also known as tubal or uterine factors, include tubal occlusion; peritubal adhesions; endometrial polyps; submucosal fibroids, which can distort the endometrial cavity; and uterine synechiae, such as adhesions.

Testing can include a hysterosalpingogram, which is done by injecting radiopaque dye through the cervix into the uterus while using fluoroscopy to determine tubal patency.

Another test you can do is a transvaginal ultrasound with or without 3D imaging. This is often more readily available than other options and can evaluate for uterine fibroids and some Mullerian anomalies. The benefits include being able to evaluate the adnexa as well. Limitations include difficulty differentiating submucosal fibroids from endometrial polyps.

Sonohysterogram is another option that’s performed by injecting saline through the cervix into the uterus during a transvaginal ultrasound. The saline distends the endometrial cavity and provides contrast to evaluate the endometrium. This is a great tool to check for uterine factors. A combination of air and saline can also be injected, called the “bubble test”, in which bubbles are followed from the cornua through the fallopian tubes to evaluate tubal patency.