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 Signs and Symptoms


  • Infertility is defined as failure to achieve pregnancy after 1 year of unprotected regular intercourse or therapeutic donor insemination in women <35 years old or within 6 months in women >35 years old
  • It is also the period of time wherein the couple has been trying to conceive but without success after which investigation is performed and possible therapy applied 
  • Infertility can be primary (no pregnancy has ever occurred) or secondary (pregnancy has occurred irrespective of the outcome)
  • The prevalence rates of infertility are difficult to establish because of male and female factors that complicate any estimate which may only focus on the woman and the pregnancy outcome 
    • The difficulty of determining the prevalence of infertility is also associated with the lack of consistent definition use and tools for diagnosing, managing or reporting infertile couples


Ovulatory Disorders

  • Account for about 30% of infertility and manifest clinically with irregular menstruation or absence of periods

Hypogonadotropic Hypogonadism (WHO Class I) 

  • Characterized by low gonadotropins [follicle-stimulating hormone (FSH), luteinizing hormone (LH)], normal prolactin, low estradiol; hypothalamic amenorrhea
  • Common causes include excessive exercise and low body mass index (BMI); infiltrative diseases and tumors of the hypothalamus and pituitary may also cause hypogonadotropic hypogonadism due to decreased GnRH release or gonadotropin deficiency
  • Causes approximately 5-10% of ovulatory problems

Polycystic Ovarian Syndrome (PCOS) (WHO Class II) 

  • Most common cause of anovulatory infertility (70-85%); normogonadotropic normoestrogenic anovulation
  • Diagnosis is based on 2003 Rotterdam criteria:
    • 2 out of 3 of the following: Oligo-ovulation or anovulation, clinical or biochemical signs of hyperandrogenism, polycystic ovaries
    • Exclusion of other causes (congenital adrenal hyperplasia, androgen-secreting tumors, Cushing’s syndrome, thyroid disease, prolactinoma)

Ovarian Failure (WHO Class III) 

  • Characterized by hypergonadotropic hypoestrogenic anovulation
  • Cases are mostly primary gonadal failure (previously called premature ovarian failure) or gonadal dysgenesis 
    • Premature ovarian failure is irreversible and unsuitable for ovulation induction
  • Accounts for 10-30% of ovulation disorders


  • LH and FSH are usually at the lower end of the normal range and estradiol is low
  • Diagnosis is confirmed with a single measurement of serum prolactin level above 25 mcg/L
  • Many women present with secondary amenorrhea and occasionally, galactorrhea
  • Imaging of the pituitary fossa, eg MRI, may be needed to evaluate the cause of hyperprolactinemia
  • Prolactinomas or lactotroph adenomas are benign pituitary gland tumors that produce prolactin that causes higher than normal concentrations of prolactin in the blood

Other Causes of Infertility

Cervical Factors

  • Refer to abnormalities of the mucus-sperm interaction
  • May be due to stenosis of the cervical canal or presence of polyps in the cervical canal
    • Cervical canal stenosis prevents the production of normal cervical mucus which can impair fertility
    • Polyps obstruct normal sperm movement and delay sperm transport


  • Associated with reduced fertility, with most large series studies suggesting that young women with mild endometriosis spontaneously conceive at a rate of only 2-3% per month, far below the healthy monthly rate of 20%
  • Possible mechanisms for endometriosis-associated infertility include abnormalities in oocyte and embryo quality and utero-tubal transport, altered peritoneal, hormonal and cell-mediated function, distorted pelvic anatomy and impaired implantation 

Tubal Factors

  • 25-35% of female infertility is attributed to tubal factors
  • Most common cause of tubal infertility is proximal tubal obstruction
  • Semen analysis and ovulation assessment should be performed prior to testing for tubal patency
  • It is recommended that women be screened first for C trachomatis infection and treated accordingly prior to any uterine instrumentation
  • Chlamydial infection, a major cause of pelvic inflammatory disease (PID), can lead to tubal infertility
    • Elevated Chlamydia antibody titer (>1:256) is associated with high likelihood of tubal damage
  • Blocked tubal structures are diagnosed by HSG, sonohysterography and/or laparoscopy, and dye

Uterine Abnormalities

  • Polyps, adhesions, fibroids may be associated with infertility but exact role is unknown
Editor's Recommendations
Special Reports