ETIOLOGY

Infertility is defined as the inability to conceive after 12 months of unprotected sexual intercourse. The causes of infertility are outlined in Fig. 178-4. Male infertility is discussed in Chap. 177: Disorders of the Male Reproductive System.

FIGURE 178-4

Causes of infertility. FSH, follicle-stimulating hormone; LH, luteinizing hormone.

CLINICAL FEATURES

The initial evaluation includes discussion of the appropriate timing of intercourse, semen analysis in the male, confirmation of ovulation in the female, and, in the majority of situations, documentation of tubal patency in the female. Abnormalities in menstrual function constitute the most common cause of female infertility (Fig. 178-1). A history of regular, cyclic, predictable, spontaneous menses usually indicates ovulatory cycles, which may be confirmed by urinary ovulation predictor kits, basal body temperature graphs, or plasma progesterone measurements during the luteal phase of the cycle. An FSH level <10 IU/mL on day 3 of the cycle predicts adequate ovarian oocyte reserve. Tubal disease can be evaluated by obtaining a hysterosalpingogram or by diagnostic laparoscopy. Endometriosis may be suggested by history and examination, but is often clinically silent and can only be excluded definitively by laparoscopy.

Treatment: Infertility

The treatment of infertility should be tailored to the problems unique to each couple. Treatment options include expectant management, clomiphene citrate with or without intrauterine insemination (IUI), gonadotropins with or without IUI, and in vitro fertilization (IVF). In specific situations, surgery, gonadotropin therapy, intracytoplasmic sperm injection (ICSI), or assisted reproductive technologies with donor egg or sperm may be required.

Outline

• Disorders of the Female Reproductive System
  • AMENORRHEA
  • PELVIC PAIN
  • HIRSUTISM
  • MENOPAUSE
  • CONTRACEPTION
  • INFERTILITY