Snapshot A 27-year-old G0P0 female presents with difficulty with becoming pregnant. She and her husband have been trying to conceive for around 6 months, but have been unsuccessful. On physical exam, she has a short stature with a stocky habitus and broad chest. Labs reveal decreased estrogen, increased LH, and increased FSH. Introduction Inability to conceive after 1 year of unprotected sex in the absence of any known causes of infertility after 6 months if the woman is > 35 years of age or in couples with known risk factors for infertility Epidemiology 10-15% of reproductive-aged couples in the US more common in developing countries Etiologies ovulatory disorder tubal disease uterine or cervical disorders endometriosis idiopathic or advanced maternal age Disorders Category Ovulation Tubal Uterine Pathogenesis Ovaries fail to produce mature oocyte on a regular basis Fallopian tubes fail to capture ovulated ova and/or transport sperm and embryo Uterus fails to allow embryo to implant or support growth/development Risk factors Increasing age Cytotoxic chemotherapy Radiation therapy Diminished ovarian reserve Smoking Endocrine disorders Pelvic inflammatory disease Pelvic tuberculosis Pelvic surgery Complicated abdominal surgery Ectopic pregnancy Uterine leiomyoma Uterine polyps Etiologies Primary ovarian insufficiency Endocrine disorders Polycystic ovarian syndrome Turner syndrome Asherman's syndrome Uterine growths (leiomyoma, polyps) Congenital uterine anomaly Treatment Ovulation induction Oocyte donation Dopamine agonists for hyperprolactinemia Assisted reproductive technology Tubal microsurgery Laparoscopic tubal surgery Assisted reproductive technology Surgery Assisted reproductive technology Presentation Symptoms: etiology dependent and thus patients may report hot flashes chronic pelvic or abdominal pain irregularity of menstrual cycle psychological distress Physical exam - etiology dependent depending on etiology, may find body habitus body mass index > 25 kg/m2 or < 17 kg/m2 note, both extremes have been associated with infertility short, stocky, or square-shaped chest may suggest Turner syndrome excessive hair growth acne galactorrhea thyromegaly pelvic exam immobile or mobile uterus discharge from cervix tenderness Evalution Diagnosis typically based on history and physical both members of the couple must be evaluated Further testing for female infertility ovulatory function mid-luteal phase serum progesterone level if abnormal, evaluate for causes of anovulation serum prolactin, thyroid-stumlating hormone (TSH), and follicle-stimulating hormone (FSH) assess for polycystic ovarian syndrome (PCOS) ovarian reserve diminished oocyte quality, oocyte quantity, or reproductive potential test ovarian reserve with a day 3 (of menstrual cycle) FSH and estradiol levels other tests clomiphene citrate challenge test provocative test for measurement of FSH anti-Müllerian hormone biochemical marker of ovarian function declines as follicle pool decline fallopian tube patency hysterosalpingogram (HSG) - first-line tubal occlusion or anatomic abnormality contrast spillage into the peritoneal cavity is a normal finding uterine cavity saline infusion sonohysterography - preferred unless HSG already being done better for diagnosing intrauterine adhesions, polyps, and congenital anomalies hysterosalpingography hysteroscopy - definitive method to evaluate abnormalities of uterine cavity also offers opportunity for treatment at the time of diagnosis Differential Use of contraception Insufficient time to conceive Male infertility Treatment Depends on the cause of infertility (see chart above) Ovulation induction weight change (either lose or gain weight) clomiphene citrate metformin for PCOS Oocyte donation for primary ovarian insufficiency Assisted reproductive technology in vitro fertilization intrauterine insemination Surgery to correct anatomic abnormality, obstruction, and endometriosis Prognosis, Prevention, and Complications Prognosis better chance of fertility with < 32-year-old women presence of ovulatory cycle general treatment efficacy 50% pregnancy rate following treatment for infertility best success with ovulatory dysfunction causing infertility less success with severe endometriosis Complications psychiatric complications depression anxiety sexual dysfunction