Infertility resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[2]

Synonyms and keywords: Approach to Infertility, Approach to subfertility, Approach to impotence

Infertility Resident Survival Guide Microchapters


Infertility is defined as a failure to conceive after one or more years of unprotected intercourse. Infertility is divided broadly into primary and secondary infertility where primary infertility is failure to conceive and secondary infertility is failure to conceive after a previous pregnancy. Multiple factors play a role in conception and infertility such as healthy spermatozoa, regular ovulation, patent fallopian tubes, normal uterine cavity etc.


Common causes of female infertility are listed below.

Genetic causes

Endocrine causes

Ovarian causes

Tubal causes

Uterine causes

Cervical factors

Vaginal factors

Miscellaneous factors


Shown below is an algorithm summarizing the diagnosis of female infertility according to the American College of Gynecology and Obstetricians 2019 Committee Opinion on Infertility Workup for the Woman's Health Specialist and Evaluation, Global Infertility Guidelines published in 1992 by the WHO, updated in 2012, and The Treatment of Infertility Guidelines by the American Family Physician. [5][6][7][8]

Abbreviations: STD - Sexually transmitted disease, FSH - Follicle stimulating hormone, LH - Luteinizing hormone, TSH - Thyroid stimulating hormone, CT - Computed tomography, MRI - Magnetic resonance imaging, IVF - In vitro fertilization

Couple with infertility
Detailed history including
❑ Any history of abdominal or pelvic surgery?
Menstrual history
❑ History of contraceptive use
❑ Obstetric history
❑ Any history of diethylstilbestrol exposure
❑ Frequency of intercourse
❑ Any history of STDs in either partner
❑ History of acne, hirsutism or recent weight changes
Physical examination
Height, weight and BMI
Head and neck examination for
❑ Webbed neck
Epicanthal fold
❑ Presence of any neck swellings
Breast examination for any swellings or nipple discharge
❑ Any swellings in the abdomen
Thorough gynecological exam including
❑ Distribution of pubic hair
❑ If there is presence of any clitoral enlargement
❑ Signs of STDs
Bimanual exam might detect the presence of
Uterine fibroids
Cervical motion tenderness
❑ Presence of vaginal septae
Initial investigations
Urine examination
Complete blood count
❑ Fasting and post prandial blood sugar estimation
Semen analysis
Normal semen analysis
Ovarian causes
Endometrial causes
Cervical causes
Fallopian tube causes
Methods to detect ovulation
❑ Basal body temperature measurement throughout cycle
❑ Vaginal cytology
❑ Cervical mucus study
❑ Serum progesterone
❑ Serum Luteinizing hormone
❑ Serum estradiol
❑ Urine Luteinizing hormone level
Transvaginal ultrasound
Endometrial biopsy on day 21-23
Cervical mucus study/ Sperm cervical mucus contact test
Anovulatory cycle
Ovulatory cycle
Progressive motile sperm seen
Sperm antibodies
Investigate the following
❑ Serum FSH
❑ Serum LH
❑ Serum Prolactin
TSH level
❑ If hirsutism is present check testosterone levels and 17-Hydroxyprogesterone levels
❑ If FSH and LH levels are in the low-normal range, but with high prolactin, consider CT or MRI of the head
If age is >30 years, work up with all other investigations including day 3 FSH
Occasionally, IgG, IgA or IgM antibodies are found against sperm. Treating these anti-sperm antibodies have not shown an improved outcome in pregnancies. Treatment is along the lines of IVF
Non secretory endometrium
Secretory endometrium
Luteal phase defect
Confirmed by basal body temperature or repeat endometrial biopsy and serum progesterone estimated on 8th day


Shown below is an algorithm summarizing the treatment of infertility. [9][4]

Abbreviations: hMG- Human menopausal gonadotropin, FSH- Follicle stimulating hormone, CAH- Congenital adrenal hyperplasia, ART- Assisted reproductive technology, PCOS- Polycystic ovarian syndrome

Thorough history and initial investigations
Ovulatory causes
Tubal causes
Cervical causes
Uterine causes
Other causes
Induction of ovulation can be done by
Clomiphene citrate
❑ Purified/recombinant FSH
Gonadotropin-releasing hormone and its analogues
Assisted reproductive techniques such as
In vitro fertilization
❑ cryopreservation of gametes or fertilized embryos
Intracytoplasmic sperm injection
❑ Egg donation via donors
Correction of biochemical abnormalities
Hyperinsulinemia or insulin resistance - Metformin
Hyperprolactinemia - Bromocriptine
Cervicitis is treated with doxycycline or other antibiotics
❑ Quality of cervical mucus is improved with oral estrogen
Uterine fibroids are treated by myomectomy
Uterine septum is corrected by a metroplasty
Polyps are treated by polypectomy
❑ Hysteroscopic adhesiolysis in cases of synechiae
❑ Uncontrolled diabetes must be treated before exploring other options
Hyperthyroidism and Grave's disease causing infertility can be corrected with antithyroid drugs
Hypothyroidism induced infertility is corrected when euthyroid state is achieved
CAH causes infertility which can be corrected with clomiphene and other ovulation induction techniques
ARTs are used when ovulation stimulation fails
❑ Treating infertility in PCOS is a multidisciplinary approach and involves
Glycemic control with metformin
Reduction of weight when applicable
Oral contraceptive pills
Ovulation induction with clomiphene
Antiandrogens such as flutamide and spironolactone for acne and hirsutism
Hyperprolactinemia induced infertility is treated with dopamine agonists such as cabergoline
Pelvic inflammatory disease - Identify the infecting agent and start appropriate antibiotic therapy
Treat sexual partner for any STIs
Adhesions- surgical correction
In vitro fertilization
Unexplained infertility is a diagnosis of exclusion after semen analysis and all other tests are normal
Treatment can include the following
Ovulation induction with clomiphene
Intrauterine insemination
Invitro fertilization




  1. Hovatta O (1999). "Pregnancies in women with Turner's syndrome". Ann Med. 31 (2): 106–10. PMID 10344582.
  2. Luciano AA, Lanzone A, Goverde AJ (2013). "Management of female infertility from hormonal causes". Int J Gynaecol Obstet. 123 Suppl 2: S9–17. doi:10.1016/j.ijgo.2013.09.007. PMID 24139473.
  3. Abrao MS, Muzii L, Marana R (2013). "Anatomical causes of female infertility and their management". Int J Gynaecol Obstet. 123 Suppl 2: S18–24. doi:10.1016/j.ijgo.2013.09.008. PMID 24119894.
  4. 4.0 4.1 Tanbo T, Fedorcsak P (2017). "Endometriosis-associated infertility: aspects of pathophysiological mechanisms and treatment options". Acta Obstet Gynecol Scand. 96 (6): 659–667. doi:10.1111/aogs.13082. PMID 27998009.
  5. Smith S, Pfeifer SM, Collins JA (2003). "Diagnosis and management of female infertility". JAMA. 290 (13): 1767–70. doi:10.1001/jama.290.13.1767. PMID 14519712.
  6. "Infertility Workup for the Women's Health Specialist: ACOG Committee Opinion, Number 781". Obstet Gynecol. 133 (6): e377–e384. 2019. doi:10.1097/AOG.0000000000003271. PMID 31135764.
  7. Lindsay TJ, Vitrikas KR (2015). "Evaluation and treatment of infertility". Am Fam Physician. 91 (5): 308–14. PMID 25822387.
  8. "Recent advances in medically assisted conception. Report of a WHO Scientific Group". World Health Organ Tech Rep Ser. 820: 1–111. 1992. PMID 1642014.
  9. Macer ML, Taylor HS (2012). "Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility". Obstet Gynecol Clin North Am. 39 (4): 535–49. doi:10.1016/j.ogc.2012.10.002. PMC 3538128. PMID 23182559.
  10. Haggerty CL, Ness RB (2006). "Epidemiology, pathogenesis and treatment of pelvic inflammatory disease". Expert Rev Anti Infect Ther. 4 (2): 235–47. doi:10.1586/14787210.4.2.235. PMID 16597205.
  11. Messi E, Pimpinelli F, Andrè V, Rigobello C, Gotti C, Maggi R (2018). "The alpha-7 nicotinic acetylcholine receptor is involved in a direct inhibitory effect of nicotine on GnRH release: In vitro studies". Mol Cell Endocrinol. 460: 209–218. doi:10.1016/j.mce.2017.07.025. PMID 28754351.
  12. Shah JS, Roman T, Viteri OA, Haidar ZA, Ontiveros A, Sibai BM (2018). "The Relationship of Assisted Reproductive Technology on Perinatal Outcomes in Triplet Gestations". Am J Perinatol. 35 (14): 1388–1393. doi:10.1055/s-0038-1660457. PMID 29883983.
  13. Nelson SM (2017). "Prevention and management of ovarian hyperstimulation syndrome". Thromb Res. 151 Suppl 1: S61–S64. doi:10.1016/S0049-3848(17)30070-1. PMID 28262238.