Show Notes
Walking into your first infertility clinic visit and not sure what to expect? In this episode, Dr. Valdez-Sinon walks through the definition of infertility, how to take a thorough history for both partners, the key workup for ovulatory, tubal, uterine, and male factors, and when to refer to REI. Definition What is infertility?
Failure to achieve pregnancy after 12 months of regular unprotected intercourse — for patients under 35 Shorten to 6 months for patients 35 and older Anyone 40+ should be seen as soon as they start trying — don't wait Immediate evaluation warranted for:
Oligomenorrhea or amenorrhea Known uterine or tubal disease Stage III/IV endometriosis
Resource: ACOG Committee Opinion No. 781 and ASRM guidelines
History & Exam HISTORY — PATIENT
Comprehensive medical and surgical history Menstrual history — are cycles regular? (regular cycles suggest ovulation, but ~1/3 of regular cyclers can still be anovulatory) Full GYN history — pelvic infections, STIs, known fibroids, endometriosis Prior pregnancies with previous partners? (establishes primary vs. secondary infertility) Ask about: thyroid disease, galactorrhea, hirsutism, pelvic/abdominal pain, dyspareunia Family history: developmental delay, early menopause, reproductive problems Social history: tobacco, alcohol, recreational drugs
HISTORY — PARTNER
Obtain medical and reproductive history — pregnancy takes two Prior pregnancies with previous partners? Intercourse frequency — ideally unprotected sex ~2x/week
PHYSICAL EXAM
Vitals, weight and BMI — extremes affect fertility Thyroid exam; breast exam (look for galactorrhea if indicated) Signs of androgen excess — acne, hirsutism, male-pattern hair Pelvic exam — uterine size, shape, mobility; adnexal masses or tenderness
Ovarian & Ovulatory Evaluation COMMON CAUSES
PCOS — most common cause of ovulatory-related infertility Primary ovarian insufficiency (POI) Thyroid disease, hyperprolactinemia
WORK-UP
Mid-luteal progesterone — obtain ~day 21 of a 28-day cycle; value >3 ng/mL suggests ovulation For PCOS evaluation: LH, FSH, testosterone Thyroid function studies and prolactin as indicated Ovarian reserve:
Antral follicle count on early-cycle ultrasound AMH — value 16% of patients with infertility have a uterine abnormality on sono Saline infusion sonogram (SIS) — preferred over standa...
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