infertility
INFERTILITY
Treatment Guideline Chart

Infertility is the failure to achieve pregnancy after a year of unprotected regular intercourse or therapeutic donor insemination in women <35 years old or within 6 months in women >35 years old.

It can be primary if no pregnancy has ever occurred or secondary if pregnancy has occurred irrespective of the outcome.

Ovulation induction is part of the patient's management for polycystic ovarian syndrome which aims to achieve development of a single follicle and subsequent ovulation in a woman with anovulation.

Infertility Diagnosis

History

  • Thorough medical, surgical, sexual, pregnancy and contraceptive history must be undertaken
    • Clinical history suggestive of ovulatory dysfunction includes the presence of premenstrual syndrome, abnormal cycle length, hot flushes, excessive physical exercise (eg athletes) and weight problems
  • History and physical signs of endocrine dysfunction must be elicited (eg thyroid disorders, diabetes mellitus, galactorrhea)
  • Inventory of medical treatments or intake of recreational drugs known for adverse effects on ovulation (eg steroids, neuroleptics, antidepressants)
  • Environmental and occupational risk factors for infertility

Physical Examination

  • Calculate BMI 
  • Thorough physical exam must be performed with emphasis on evaluation of secondary sex traits, external genitalia and bimanual exam of the pelvic area

Laboratory Tests

Diagnostic Assessment

  • Most couples will require the following diagnostic tests:

Semen Analysis

  • To exclude abnormalities in the semen and to rule out azoospermia
  • Confirmatory tests are ideally repeated after 3 months or as soon as possible if with gross deficiency

Assessment of Ovulatory Function

  • Ovarian reserve, which is the number of oocytes available for fertilization at a point in time, may be assessed through serum tests or ultrasonography
    • Presence of reduced ovarian reserve predicts future response to ovarian stimulation 
  • Inquire about frequency and regularity of menstrual cycles; women with regular cycles are likely to be ovulating
  • In women with regular menstrual cycles, perform a midluteal phase serum progesterone level (day 21 of a 28-day cycle) to confirm ovulation
  • In women with prolonged irregular cycles, serum gonadotropins (FSH and LH) and serum progesterone should be measured
    • Serum progesterone should be measured based on timing of menstrual periods which may be done later in the cycle and then repeated every week until the next menstrual cycle starts
  • Prolactin and thyroid function should only be evaluated in patients with signs and symptoms of thyroid dysfunction, ovulatory disorder, galactorrhea, or pituitary tumor
  • Testosterone level may also be checked for hyperandrogenism

Other Diagnostic Tests

  • Initial laboratory tests include CBC, urinalysis, screening for sexually transmitted infections (eg Chlamydia trachomatis), rubella and varicella titers, and Pap smear
  • Screening for other endocrine diseases is not routine and done only based on findings obtained from history and physical exam
  • Monitoring and charting of basal body temperature is unreliable and no longer recommended
  • Post-coital testing of cervical mucus has no predictive value

Evaluation

  • Women >35 years old should have expedited evaluation and treatment after 6 months of failed attempts to become pregnant
  • Women >40 years old require immediate evaluation and treatment
  • Immediate evaluation is indicated in the presence of:
    • Amenorrhea or oligomenorrhea
    • Suspected or known uterine, tubal, or peritoneal disease
    • Stage III-IV or severe endometriosis
    • Suspected or known male infertility

Assessment

Assessment of Tubal Patency

  • Prior to instrumental testing of tubal patency, women should be offered screening test for Chlamydia trachomatis
  • Hysterosalpingography (HSG)/Sonohysterogram
    • Usually preferred in women without known comorbidities (eg PID, previous ectopic pregnancy, endometriosis) to rule out tubal occlusion
  • Laparoscopy
    • May be preferred in women with known comorbidities so that tubal and other pelvic pathologies can be investigated
    • Considered when HSG suggests tubal disease that may be repaired

Assessment of Uterine Cavity

  • Not generally recommended as initial investigation since the effectiveness of surgical treatment of uterine pathologies and the improvement of pregnancy rates have not been investigated

Unexplained Infertility

  • A diagnosis of exclusion
  • Diagnosis is made after all tests are completed, including diagnostic laparoscopy with or without hysteroscopy
  • As many as 30% of women who undergo investigation for infertility are diagnosed with unexplained infertility
  • Investigations reveal normal semen analysis, ovulation, tubal patency, and normal uterine cavity
  • Clomifene citrate as a stand-alone treatment for unexplained infertility does not increase the chances of getting pregnant
  • Expectant management of 6-12 months prevents unwarranted treatment in couples with a good prognosis of naturally conceiving within 1 year (based on the Hunault prediction model) and is cost effective
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