female infertility
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Introduction
Inability to conceive within 1 year or regular unprotected sexual intercourse (6 months if > 35 years of age).
Etiology
- ovarian failure*
- polycystic ovary syndrome is the most common cause of anovulatory infertility[1]
- thyroid disease
- hyperprolactinemia
- viral infection may play a role in unexplained infertility, especially HHV6-A[7]
- ciliary dyskinesia
- cystic fibrosis
* regular menses correlates with regular ovulation
Pathology
- antibodies associated with infertility include:
- anti-SPAG8
History
- medical history of both partners
- menstrual history
- history of sexually-transmitted disease
- pelvic surgery
- history of obstetric complications
Laboratory
- serum TSH
- serum prolactin
- semen analysis of male partner
- serum progesterone (mid-luteal phase) 1 week prior to expected menses
- serum FSH on day 3 of the menstrual cycle
- LH in urine 24-48 hours prior to ovulation
- serum antimullerian hormone
- see ARUP consult[3]
Diagnostic procedures
- pelvic ultrasound
- hysterosalpingography 6-10 days into the menstrual cycle to evaluate for uterine or fallopian tube abnormalities
- especially with history of pelvic inflammatory disease[1]
- endometrial biopsy NOT useful[2]
Management
- both partners should be evaluated concurrently as multiple factors may be present[1]
- refer to reproductive endocrinologist if
- weight reduction in obese women does not improve chances of delivering a healthy baby vaginally[6]
- assisted reproduction technology
- clomiphene citrate may be useful if testing is negative
- gonadotropins (GnRH agonists & GnRH antagonists) also used
- letrozole superior to clomiphene for anovulatory infertility[8]
- intrauterine insemination with ovarian stimulation superior to expectant management[9]
Notes
- gonadotropins associated with more multiple gestations & triplet pregnancies than clomiphene
- live birth rate is 23% with clomiphene, & 32% with gonadotropins
- letrozole with 19% live birth rate otherwise similar to clomiphene, but is not FDA-approved or recommended[4]
More general terms
More specific terms
Additional terms
References
- ↑ Jump up to: 1.0 1.1 1.2 1.3 1.4 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2022.
- ↑ Jump up to: 2.0 2.1 Journal Watch 24(12):95-96, 2004 Murray MJ, Meyer WR, Zaino RJ, Lessey BA, Novotny DB, Ireland K, Zeng D, Fritz MA. A critical analysis of the accuracy, reproducibility, and clinical utility of histologic endometrial dating in fertile women. Fertil Steril. 2004 May;81(5):1333-43. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15136099
- ↑ Jump up to: 3.0 3.1 ARUP Consult: Infertility The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/infertility
- ↑ Jump up to: 4.0 4.1 Diamond MP et al Letrozole, Gonadotropin, or Clomiphene for Unexplained Infertility. N Engl J Med 2015; 373:1230-1240. September 24, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26398071 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1414827
- ↑ Maheux-Lacroix S, Boutin A, Moore L et al Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review with meta-analysis. Hum Reprod. 2014 May;29(5):953-63. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24578476 Free Article
- ↑ Jump up to: 6.0 6.1 Mutsaerts MAQ et al Randomized Trial of a Lifestyle Program in Obese Infertile Women. N Engl J Med 2016; 374:1942-1953May 19, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27192672 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1505297
- ↑ Jump up to: 7.0 7.1 Marci R, Gentili V, Bortolotti D et al Presence of HHV-6A in Endometrial Epithelial Cells from Women with Primary Unexplained Infertility. PLoS One. 2016 Jul 1;11(7):e0158304. eCollection 2016. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27367597 Free PMC Article
- ↑ Jump up to: 8.0 8.1 Wang R et al. Treatment strategies for women with WHO group II anovulation: Systematic review and network meta-analysis. BMJ 2017 Jan 31; 356:j138 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28143834 Free full text <Internet> http://www.bmj.com/content/356/bmj.j138
- ↑ Jump up to: 9.0 9.1 Farquhar CM, Liu E, Armstrong S et al Intrauterine insemination with ovarian stimulation versus expectant management for unexplained infertility (TUI): a pragmatic, open-label, randomised, controlled, two-centre trial. Lancet. Nov 23, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29174128 <Internet> http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)32406-6/fulltext
Nandi A, El-Toukhy T Stimulated intrauterine insemination for unexplained subfertility. Lancet. Nov 23, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29174130 <Internet> http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)33038-6/fulltext - ↑ Jump up to: 10.0 10.1 10.2 10.3 NEJM Knowledge+
Cox L, Liu JH. Primary ovarian insufficiency: an update. Int J Womens Health. 2014 Feb 20;6:235-43. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24591848 PMCID: PMC3934663 Free PMC article. Review.