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[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
- Turner's syndrome[3]
- Mayer-Rokitansky-Kuster-Hauser syndrome
- Kallmann syndrome
- Primary ciliary dyskinesia
Endocrine causes
- Hypothyroidism[4]
- 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[5]
- Fibroids
- Endometriosis[6]
- 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 [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 | ||||||||||||||||||||||||||||||||||||
| 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
- ↑ 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.
- ↑ Dadhich P, Ramasamy R, Lipshultz LI (2015). "The male infertility office visit". Minerva Urol Nefrol. 67 (2): 157–68. PMID 25604696.
- ↑ Hovatta O (1999). "Pregnancies in women with Turner's syndrome". Ann Med. 31 (2): 106–10. PMID 10344582.
- ↑ 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.
- ↑ 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.
- ↑ Czernobilsky B (1978). "Endometritis and infertility". Fertil Steril. 30 (2): 119–30. doi:10.1016/s0015-0282(16)43448-5. PMID 354978.
- ↑ 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.