PRACTICE RECOMMENDATIONS
• Evaluate the fallopian tubes and their patency when menstruation is normal. Also, consider arranging for a hysterosalpingogram. B
• Suspect polycystic ovarian syndrome when adiposity, acne, and hirsutism with menstrual irregularity are factors. B
• Suspect androgen deficiency when a man’s arm span is >2 cm longer than his height, or when he has experienced a loss of pubic, axillary, or facial hair. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
During an annual visit, a patient confides in you that she and her husband have been trying to get pregnant for a year, but haven’t had any success. She tells you that she’s starting to get worried.
How do you advise her? What are your next steps?
The approach to evaluating infertility complaints is usually straightforward and can lead to a positive outcome. Not surprisingly, the dialogue often begins with you, the family physician. Your attention to clues in each partner’s history can do much to get to the heart of the problem. And even if a couple requires a specialty referral, it’s best to be familiar with the more extensive evaluation and management options they’ll encounter to help them anticipate likely discussions in their consultations. In this article, we review the best evidence for the care of your patients who want to conceive.
Who’s affected?
Infertility difficulties may be attributable to one or both partners, may be multifactorial, or may be unexplained (TABLE).
In women, infertility is the inability to conceive after 1 year of unprotected regular intercourse in those younger than 35 years, and after 6 months in those 35 years and older.1 Fecundability is the probability of achieving pregnancy in 1 menstrual cycle. Normal fecundability with a single menstrual cycle is ~20%, peaking between the ages of 20 and 24 years.2 Fecundability decreases slightly at age 32 and declines progressively and more rapidly after age 40. Spontaneous miscarriage is a factor; its rate in younger women is ~10% and in women >40 years is ~40%.2 Overall, approximately 13% of women between the ages of 15 and 44 have fecundity impairment, with more than 6 million women in the United States affected.2
About 24% of all cases of infertility are due to male factors—seminiferous dysfunction, including problems with motility, morphology, and volume of sperm; primary hypogonadism; posttesticular defects; and hypothalamic pituitary disease.3 Recent observational trends show declines in fertility among men older than 40, and among men from different areas in the country, thus raising the issue of the role that environmental pollutants or toxins may play. Supposed increases in urogenital abnormalities and testicular cancers may also contribute to declining fertility rates.4,5
TABLE
Consider these factors in cases of suspected infertility3,6,21,23,40,41
| Major causes of infertility | Infertility risk factors | |
|---|---|---|
| Female | ||
| Cause | Contribution | |
| Endocrine factors | 45%-55% |
|
| PCOS Thyroid Diabetes mellitus Prolactinemia | 21%-28% 10%-20% 10%-20% 7% | |
| Tubal and peritoneal pathology | 30%-40% | |
| Ovulatory dysfunction* | 15% | |
| Cervical and uterine factors | <5% | |
| Male | ||
| Cause | Contribution | |
| Seminiferous tubule dysfunction | 60%-80% |
|
| Posttesticular defects | 10%-20% | |
| Primary hypogonadism | 10%-15% | |
| Hypothalamic pituitary disease | 1%-2% | |
| *Assuming appropriate ovarian reserve, indicated by follicle-stimulating hormone (FSH) level <10 mIU/mL, FSH-to-luteinizing hormone ratio <2, and estradiol level <50 pg/mL. GU, genitourinary; PCOS, polycystic ovarian syndrome; STIs, sexually transmitted infections | ||
Zero in on these areas of the history
As with any diagnostic work-up, the most important aspect of an infertility evaluation is the history. Document menstrual cycle length and regularity and the timing of intercourse. (Ideally, this would be done when a couple first decides to conceive.) It’s important to know how long the couple has been trying to become pregnant. More time may be all they need to achieve pregnancy. Educate them on reproductive cycles and optimal timing to achieve pregnancy. Some women experience lower abdominal pain (mittelschmerz) signifying release of an egg from the ovary, which can help identify the time of ovulation.
Remember, too, the role that a couple’s psychological state can play; worries over suspected infertility may cause anxiety, anger, depression, and marital troubles.
Is it her?
Regular menstrual cycles—menses occurring every 21 to 35 days—carry an ovulation probability of 95% with each cycle.6 With normal menses, ovulatory dysfunction is an unlikely cause of infertility. If menstrual cycles are irregular, ovulatory function is not normal and cyclical. Explore the woman’s medical, surgical, and gynecologic histories, looking particularly for thyroid disease, galactorrhea, hirsutism, pelvic or abdominal pain, dysmenorrhea, dyspareunia, pelvic inflammatory disease (PID), and abdominal or pelvic surgery.