Infertility

Published on 10/03/2015 by admin

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Last modified 10/03/2015

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Chapter 22 INFERTILITY

Theodore O’Connell

Infertility affects one couple in six and becomes more common as people age. Clinical evaluation of infertility is indicated if a pregnancy has not occurred after 1 year of regular unprotected intercourse. An infertility work-up should also be initiated in female patients who complain of infertility and have any of the following abnormalities: irregular menses or amenorrhea, bleeding between periods, dyspareunia, history of upper genital tract infection, history of a ruptured appendix or other abdominal surgery, or age older than 35 years.

Because men account for approximately 40% of all cases of infertility, the male partner should be evaluated early in the infertility work-up. Historical factors affecting the male partner should also be considered in determining when to begin an infertility evaluation. The following historical factors in the male partner warrant an early investigation: difficulty achieving or maintaining an erection; inability to ejaculate during intercourse; history of testicular injury, mumps, or an undescended testicle; or history of infection in the prostate gland, epididymis, or testicles.

There are several tests that every infertile couple should have performed. The first is a semen analysis of the male partner, regardless of how many pregnancies he has caused, because sperm counts can change over time. The second test is hysterosalpingography, which helps determine whether the uterine cavity is normal in size and shape and whether the fallopian tubes are patent. Although hysterosalpingography is the initial test to evaluate tubal patency, patients at high risk for infection, such as those with a history of clinically diagnosed pelvic inflammatory disease, are best evaluated initially with laparoscopy and hysteroscopy. Laparoscopy is more invasive than hysterosalpingography, but it remains the best test for identifying endometriosis and peritubal adhesions.

Routine hormonal assessment, especially in a young and apparently ovulatory patient, is controversial. There is less disagreement about performing a hormonal assessment in women aged 35 years and older. The suggested work-up is outlined later in this chapter.

In approximately 5% to 10% of infertile couples who proceed through a complete infertility evaluation, no cause is identified; these couples are said to have unexplained infertility. Infertility clinics may perform additional specialized testing, such as ultrasonography, testing for antisperm antibodies, and sperm function assays. Empirical treatment regimens have been designed to treat subtle disorders that may not be diagnosed.

Causes of Female Infertility

Ovulatory dysfunction

• Hyperprolactinemia

• Oligomenorrhea

• Intrauterine synechiae (Asherman syndrome)

• Septate uterus

• Uterine fibroids

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