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:

Overview

Infertility is defined as a failure to conceive after one or more years of unprotected intercourse[1]. 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.[2]

Causes

Common causes of female infertility are listed below.

Genetic causes

Endocrine causes

Ovarian causes

Tubal causes

Uterine causes

Cervical factors

Vaginal factors

Miscellaneous factors

Diagnosis

Shown below is an algorithm summarizing the diagnosis of female infertility [7].

 
 
 
 
 
 
 
Couple with infertility
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Detailed history including
❑ Any history of abdominal or pelvic surgery?
Menstrual history
❑ History of contraceptive use
❑ Obstetric history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 Lutenizing hormone
❑ Serum estradiol
❑ Urine Lutenizing 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

Treatment

Shown below is an algorithm summarizing the treatment of infertility.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Thorough history and initial investigations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ovulatory causes
 
 
 
Tubal causes
 
 
 
 
 
Cervical causes
 
 
 
 
 
 
Endocrinopathies
 
 
 
 
 
Uterine causes
 
 
 
 
 
Other causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anovulation
Induction of ovulation can be done by
Clomiphene citrate
❑ hMG
❑ Purified/recombinant FSH
Gonadotropin-releasing hormone and its analogues
 
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
 
 
 
 
 
 
 
 

Do's

  • The content in this section is in bullet points.

Don'ts

  • The content in this section is in bullet points.

References

  1. Gnoth C, Godehardt E, Frank-Herrmann P, Friol K, Tigges J, Freundl G (2005). "Definition and prevalence of subfertility and infertility". Hum Reprod. 20 (5): 1144–7. doi:10.1093/humrep/deh870. PMID 15802321.
  2. Dadhich P, Ramasamy R, Lipshultz LI (2015). "The male infertility office visit". Minerva Urol Nefrol. 67 (2): 157–68. PMID 25604696.
  3. Hovatta O (1999). "Pregnancies in women with Turner's syndrome". Ann Med. 31 (2): 106–10. PMID 10344582.
  4. 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.
  5. 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.
  6. Czernobilsky B (1978). "Endometritis and infertility". Fertil Steril. 30 (2): 119–30. doi:10.1016/s0015-0282(16)43448-5. PMID 354978.
  7. 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.


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