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Updated: Jul 7 2019

Female Infertility

  • 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
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