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Infertility
is defined as at least one year of unprotected intercourse in which a pregnancy has not
been achieved. There are many causes of infertility including abnormalities of any portion
of the male or female reproductive systems. Infertility is due to a single cause in the
majority of couples, but more than one factor contributes to infertility in some couples,
and therefore a comprehensive diagnostic evaluation is recommended.
Causes
A. Causes in the case of males: A cause for infertility in the case of males occurs in
some couples. The most common male cause is a varicocele (dialated testicular vein).
Other causes include oligospermia (decrease in sperm count) or azoospermia (absence of
sperm in semen), disorders of sperm function or motility, and abnormalities in the sperm.
B. Causes in the case of women:
1. Ovulatory dysfunction. Causes of ovulation disorder may be grouped under four major
headings: (1) Hypothalamic anovulation, which includes anatomic defects, congenital
defects, psychological trauma, anorexia nervosa (loss of appetite), and pharmacologic
agents. (2) Ovarian anovulation, which includes ovarian tumors, pseudo-ovulation,
premature ovarian failure, and ovarian defects. (3) Pituitary anovulation, which includes
pituitary tumors and decreased blood flow. (4) Integrative anovulation, which includes
nonpsychogenic weight disturbances and a disease referred to as polycistic ovarian
syndrome.
C. Tubal damage: Infertility may be due to tubal damage or adnexal adhesions (when tissue
accumulates following surgery). Tubal obstruction may also be the result from inflammation
of the ovarian tubes, although often it may occur without the patient remembering any
previous episodes of tube inflammation.
D. Endometriosis: The chronic inflammation associated with endometriosis (when there is
uteral lining outside the uterus) may disrupt normal conception by interfering with ovum
(egg) capture and transport of the embryo, or by causing tubal damage.
E. Cervical mucus abnormalities: Insufficient quantity or poor quality cervical mucus is
an uncommon cause of infertility.
F. Infertility without a known cause.
Diagnosis
A. A full discussion (and survey) with the couple to evaluate each area of the
reproductive system.
A. A full medical history should be obtained. The initial assessment of the couple
consists of a thorough history of each partner, taken individually, to assess current and
past contributing symptoms, illness, medication, or surgery.
B. As with the history, a thorough physical examination of each partner is essential.
C. Each couple is evaluated with a few routine laboratory tests and appropriate studies to
assess each major reproductive factor that may contribute to the infertility.
1. The male is evaluated with a complete blood count, urinalysis, and at least two semen
analyses.
2. Ovulatory dysfunction. Anovulation (absence of ovulation) or inconsistent ovulation may
be diagnosed by history (irregular menses), abnormal body temperature pattern, abnormally
low serum progesterone levels when it should be high, or endometrial biopsy.
3. Tubal factors. The female partner must undergo an evaluation to determine whether the
ovarian tubes are open. A hysterosalpingogram (test to evaluate the uterus and tubes) is
performed if the history and physical examination show no evidence of tubal damage.
Otherwise, the patient is referred for laparoscopy (test to evaluate the abdominal cavity
contents by inserting a tube).
4. Cervical mucus factors. If many white blood cells are noted on cervical mucus samples
at the time of expected ovulation, then a specific bacteriologic diagnosis should be
sought.
Treatment
Treatment should not be initiated until the diagnostic survey is complete and the
infertility cause or causes identified. The diagnosis should be shared with the couple
together and the treatment options outlined. The workup, diagnosis, and treatment of
infertility can precipitate intense emotional reactions.
A. Treatment in the case of males: Consultation with a urologist is necessary to
coordinate treatment for a varicocele or other causes of sperm dysfunction.
B. Ovulatory dysfunction: Treatment with clomiphene should be considered for women
diagnosed with anovulation. Amenorrheic and oligomenorrheic (absence or decrease in
menstrual bleeding) women attempting to conceive are among the patients most suitable for
clomiphene. Patients with other causes of their anovulation respond best to specific
therapy, such as surgery.
C. Tubal damage: Tubal deformity or blockage often requires surgical correction.
D. Endometriosis: The management of infertile women with endometriosis depends on the
extent and location of the uteral lining outside of the uterus. Increase in ovulation with
clomiphene or human menopausal gonadotropins has also been shown to be effective in such
patients.
E. Cervical mucus abnormalities: Inflammation of the cervix should be treated with
antibiotics based on culture-results. Low-dose estrogens are often the best treatment for
poor cervical mucus that is not due to an infectious cause.
Prognosis
The specific prognosis of infertility is difficult to determine due to its multiple
causes. For most causes of infertility, conception will not occur without specific
treatment. The options for adoption should also be discussed with the couple if they
remain unable to have their own children.
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