Female Infertility

Aka: Female Infertility, Infertility, Subfertility

1. See Also
   1. Female Infertility Causes
   2. Male Infertility
2. Definition
   1. No conception in 6 months in women over age 35 years
   2. No conception in 1 year without Contraception
      1. Primary Infertility: Nulligravida
      2. Secondary Infertility: Prior pregnancies
3. History
   1. History taken with both partners present
   2. Prior Pregnancy and outcomes
   3. General Factors
      1. Age
      2. Previous pregnancies
      3. Number of contiguous months attempting conception
   4. Symptoms of Sexually Transmitted Disease
      1. Vaginal Discharge
      2. Dysuria
      3. Abdominal Pain
      4. Fever
   5. Medications and substances
   6. Toxin exposures
   7. Menstrual History
   8. Sexual History
      1. Timing of intercourse in Menstrual Cycle
      2. Frequency of intercourse
         1. Optimally every day or every other day in Ovulation
      3. Lubricant use (spermatotoxic)
      4. History of Impotence
      5. Dyspareunia
      6. Technique
4. Exam
   1. Breast Exam
      1. Breast formation
      2. Galactorrhea
   2. Genitourinary Exam
      1. Uterine masses
      2. Vaginal Discharge
   3. Endocrine (Hyperandrogenism)
      1. Hirsutism
      2. Acne Vulgaris
      3. Clitoromegaly
5. Causes
   1. See Infertility Causes
6. Evaluation: Male Factor
   1. See Male Infertility
   2. Prior conceived children
   3. History of testicular surgery
   4. History of testicular infection (Mumps)
   5. Semen Analysis
   6. Test for Sexually Transmitted Disease
      1. Mandatory for in vitro fertilization
7. Evaluation: Female factor
   1. History related to Infertility Causes
   2. Confirm Ovulation
      1. Basal Body Temperature
      2. Urine Luteinizing hormone
   3. Evaluate for Anovulation causes
      1. Follicle Stimulating Hormone
      2. Serum Prolactin
      3. Thyroid Stimulating Hormone
   4. Evaluate for Premature Ovarian Failure (age >35)
      1. Serum Follicle Stimulating Hormone on Day 3 of cycle
         1. Increased FSH >15-29 IU/L on day 3 suggests decreased likelihood of conception
      2. Serum Estradiol on Day 3 of cycle
      3. Clomiphene Citrate (Clomid) challenge
      4. Transvaginal Ultrasound (assess follicle count)
   5. Consider Hyperandrogenism
      1. Serum 17a-Hydroxyprogesterone
      2. Serum Testosterone
   6. Assess tubal patency
      1. Transvaginal Ultrasound
      2. Hysterosalpinography
      3. Consider laparoscopy
8. Management
   1. Treat specific conditions if present
      1. Hyperprolactinemia
      2. Polycystic Ovary Syndrome (PCOS)
         1. Metformin (Glucophage)
         2. Laparoscopic Ovarian Drilling
      3. Tubal disease
         1. Tubal repair surgery
      4. Endometriosis
         1. Laparoscopic ablation
      5. Male Infertility
         1. Treat cause (e.g. Varicocele Repair)
         2. Artificial Insemmination, Intrauterine insemination
   2. Ovulatory Dysfunction management
      1. Clomiphene Citrate (Clomid)
         1. Use clomiphene in combination with Metformin if PCOS is present to improve efficacy in stimulating Ovulation
            1. Lord (2003) BMJ 327: 951
      2. Gonadotropins (for central Hypogonadism)
   3. Unexplained and refractory Infertility
      1. Ovulatory Dysfunction management (as above)
      2. Intrauterine insemination
      3. In-Vitro Fertilization
9. Prognosis
   1. Overall fertility rate with treatment: 50%
   2. Predictors of lower success rate
      1. Tubal causes of Infertility (20% fertility rate)
      2. Severe Endometriosis (17% fertility rate)
      3. Longer duration of Infertility
      4. No prior fertility history
      5. Women over age 30-35 years
   3. Reference
      1. Collins (2004) Hum Reprod Update 10:309-16
10. References
    1. Jose-Miller (2007) Am Fam Physician 75(6):849-58
    2. (2004) Fertil Steril 82(suppl 1):S169-72