Infertility resident survival guide

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. 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.

Causes

Common causes of female infertility are listed below.

Genetic causes

• Turner's syndrome
• Mayer-Rokitansky-Kuster-Hauser syndrome
• Kallmann syndrome
• Primary ciliary dyskinesia

Endocrine causes

• Hypothyroidism
• Hypopituitarism
• Hyperprolactinemia
• Polycystic ovarian syndrome
• Congenital adrenal hyperplasia
• Hypogonadotropic hypergonadism

Ovarian causes

• Anovulation
• Luteal phase defect
• Luteinised unruptured follicle

Tubal causes

• Pelvic inflammatory disease causing adhesions and endosalpingeal damage
• Previous tubal surgery
• Tubal endometriosis

Uterine causes

• Polyps
• Fibroids
• Endometriosis
• Congenital uterine anomalies such as septate uterus
• Uterine hypoplasia

Cervical factors

• Congenital elongation of cervix
• Uterine prolapse
• Cauterization of cervix

Vaginal factors

• Vaginal atresia
• Transverse vaginal septum
• Septate vagina
• Vaginitis

Miscellaneous factors

• Advanced age
• Anxiety
• Dyspareunia
• Contraceptive use

Diagnosis

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

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

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

❑ Hysterosalpingography ❑ Laproscopy

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

Don'ts

• The content in this section is in bullet points.

References

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