Should I Upload Past Medical History Fertility
Evaluation and Handling of Infertility
Am Fam Doc. 2015 Mar ane;91(5):308-314.
Patient data: Run across related handout on infertility, written by the authors of this commodity.
Related alphabetic character: Natural Procreative Technology for Treating Infertility
This clinical content conforms to AAFP criteria for continuing medical education (CME). Meet the CME Quiz Questions.
Author disclosure: No relevant financial affiliations.
Commodity Sections
- Abstruse
- Evaluation of Men
- Evaluation of Women
- Treatment of Male Infertility
- Handling of Anovulatory Weather condition
- Treatment of Unexplained Infertility
- Lifestyle Factors
- References
Infertility is defined every bit the inability to achieve pregnancy after ane yr of regular, unprotected intercourse. Evaluation may be initiated sooner in patients who accept gamble factors for infertility or if the female partner is older than 35 years. Causes of infertility include male factors, ovulatory dysfunction, uterine abnormalities, tubal obstruction, peritoneal factors, or cervical factors. A history and physical examination tin help straight the evaluation. Men should undergo evaluation with a semen analysis. Abnormalities of sperm may exist treated with gonadotropin therapy, intrauterine insemination, or in vitro fertilization. Ovulation should be documented by serum progesterone level measurement at cycle solar day 21. Evaluation of the uterus and fallopian tubes can be performed by hysterosalpingography in women with no risk of obstacle. For patients with a history of endometriosis, pelvic infections, or ectopic pregnancy, evaluation with hysteroscopy or laparoscopy is recommended. Women with anovulation may be treated in the primary care setting with clomiphene to induce ovulation. Treatment of tubal obstruction generally requires referral for subspecialty care. Unexplained infertility in women or men may be managed with some other yr of unprotected intercourse, or may go along to assisted reproductive technologies, such every bit intrauterine insemination or in vitro fertilization.
Infertility is defined every bit the inability to go meaning afterwards 12 months of regular, unprotected intercourse. In a survey from 2006 to 2010, more than one.v meg U.Due south. women, or 6% of the married population 15 to 44 years of historic period, reported infertility, and 6.7 million women reported dumb power to get pregnant or behave a baby to term.1 Among couples 15 to 44 years of historic period, about vii million have used infertility services at some point.2 This encompasses couples with infertility and impaired ability to go meaning, but it does not capture those who are non married, and then actual numbers may be underestimated. These numbers are comparable to those of other industrialized nations.3,iv Infertility may arise from male person factors, female factors, or a combination of these (Table ane5–8).
SORT: Fundamental RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Confirmation of ovulation should exist obtained with a serum progesterone level on twenty-four hours 21 of a 28-twenty-four hours cycle or one week before presumed onset of menses. | C | half dozen, viii |
| Hysterosalpingography should be offered to screen for uterine and tubal abnormalities in women with infertility who have no history of pelvic infections, endometriosis, or ectopic pregnancy. | C | 8, 26, 27 |
| Women with unexplained infertility should not be offered ovulation induction or intrauterine insemination because these have non been shown to increase pregnancy rates. | C | 8, 45 |
| Women with a body mass alphabetize greater than 30 kg per m2 should be counseled to lose weight because this may restore ovulation. | B | 46 |
Best PRACTICES IN GYNECOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN
| Recommendation | Sponsoring organization |
|---|---|
| Do not perform immunological testing as part of the routine infertility evaluation. | American Society for Reproductive Medicine |
| Practice not routinely order thrombophilia testing on patients undergoing a routine infertility evaluation. | American Society for Reproductive Medicine |
Tabular array 1.
Etiology of Infertility
| Factors | Pct |
|---|---|
| Combined factors | 40 |
| Male factors | 26 to 30 |
| Ovulatory dysfunction | 21 to 25 |
| Tubal factors | 14 to 20 |
| Other (e.g., cervical factors, peritoneal factors, uterine abnormalities) | x to thirteen |
| Unexplained | 25 to 28 |
Considering 85% of couples conceive spontaneously inside 12 months if having intercourse regularly,5 information technology is of import to identify those who will do good from infertility evaluation. Generally, evaluation should be offered to couples who have not conceived later 1 yr of unprotected vaginal intercourse. Counseling virtually options should be offered to couples who are not physically able to excogitate (i.eastward., aforementioned-sex couples or persons lacking reproductive organs). Women older than 35 years or couples with known chance factors for infertility may warrant evaluation at six months.6,viii
Information technology is of import for chief care physicians to be familiar with the workup and prognosis for infertile couples. A British study found that patients valued primary care physicians who were well informed about infertility and the handling process.9 Because anxiety over infertility may cause increased stress and decreased libido, further compounding the problem, formal counseling is encouraged for couples experiencing infertility.viii
Evaluation of Men
- Abstruse
- Evaluation of Men
- Evaluation of Women
- Treatment of Male Infertility
- Treatment of Anovulatory Conditions
- Treatment of Unexplained Infertility
- Lifestyle Factors
- References
Causes of male infertility include infection, injury, toxin exposures, anatomic variances, chromosomal abnormalities, systemic diseases, and sperm antibodies. Additional run a risk factors may include smoking, booze use, obesity, and older historic period; nonetheless, the data are hampered past a lack of pregnancy-related outcomes.eight–sixteen One retrospective case-command study of 650 men with infertility and 698 control participants questioned the role of environmental risk; no association could be adamant after assessing for multiple factors including shift piece of work, stress, and pesticides.17
Evaluation of male infertility starts with a history and concrete exam focusing on previous fertility, pelvic or inguinal surgeries, systemic diseases, and exposures. The laboratory evaluation begins with a semen assay. Instructions for collecting the sample should include forbearance from ejaculation for 48 to 72 hours. Because sperm generation time is just over two months, information technology is recommended to wait iii months before repeat sampling.8 A normal sample according to the 2010 World Health System (WHO) guidelines is described in Table 2.18 If the semen analysis effect is abnormal, further evaluation is indicated (Table iii6–8,10,19,20). If oligospermia or azoospermia is noted, hypogonadism should be suspected. Obtaining morning levels of total testosterone (normal range = 240 to 950 ng per dL [eight.iii to 33.0 nmol per L]) and follicle-stimulating hormone (FSH; normal range = ane.5 to 12.4 mIU per mL [one.5 to 12.iv IU per 50]) can assistance differentiate between main and secondary disorders. A decreased testosterone level with an increased FSH level points to principal hypogonadism. A low testosterone level with a depression FSH level signals a secondary cause. Some causes, such every bit hyperprolactinemia, are reversible with proper treatment. Other testing may exist needed based on circumstances, including testicular biopsy, genetic testing, and imaging (Tabular array 36–8,10,19,20). Postcoital testing and antisperm antibody testing are no longer considered useful in this evaluation.21,22
Table 2.
Earth Health Arrangement 2010 Semen Analysis Reference Guidelines
| Characteristic | Normal reference |
|---|---|
| Morphologically normal | 4% |
| Motion (progressive) | 32% |
| Motility (full) | forty% |
| Sperm count | 39 million per ejaculate; 15 million per mL |
| Vitality | 58% |
| Volume | At least one.5 mL |
Table 3.
Etiology and Evaluation of Infertility
| Condition | History and physical test | Laboratory and radiologic testing | Comments | |
|---|---|---|---|---|
| Female person | ||||
| Endometriosis or pelvic adhesions | History of intestinal or pelvic surgery; history consequent with endometriosis | Rarely helpful | Generally diagnosed on laparoscopy; consider in women with otherwise unexplained infertility | |
| Hypothalamic amenorrhea | Amenorrhea or oligomenorrhea; depression body mass index | Low to normal FSH level; low estradiol level | Encourage weight gain | |
| Ovarian failure/insufficiency | Amenorrhea or oligomenorrhea; menopausal symptoms; family unit history of early menopause; single ovary; chemotherapy or radiations therapy; previous ovarian surgery; history of autoimmune disease | Elevated FSH level; low estradiol level | Consider additional tests of ovarian reserve (antral follicle count, antimüllerian hormone level, clomiphene [Clomid] challenge test) | |
| Ovulatory disorder | Irregular flow; hirsutism; obesity (polycystic ovary syndrome); galactorrhea (hyperprolactinemia); fatigue; hair loss (hypothyroidism) | Progesterone level < 5 ng per mL (fifteen.9 nmol per 50); elevated prolactin level; elevated TSH level [ corrected] | Check TSH and prolactin levels based on clinical symptoms | |
| Tubal blockage | History of pelvic infections or endometriosis | Aberrant hysterosalpingography result | Usually necessitates subspecialist referral for treatment | |
| Uterine abnormalities | Dyspareunia; dysmenorrhea; history of anatomic developmental abnormalities; family history of uterine fibroids; abnormal palpation and inspection | Aberrant hysterosalpingography or ultrasonography result | May necessitate subspecialist referral for treatment | |
| Male | ||||
| Genetic etiology: | Both syndromes result in normal semen volume but low sperm count | Y deletions can be passed to offspring if intracytoplasmic sperm injection is used with in vitro fertilization; genetic counseling is indicated | ||
| Y deletions | Y deletions: small testes | Y deletions may nowadays as normal hormone levels or have an elevated FSH level | ||
| XXY (Klinefelter syndrome) | Klinefelter phenotype: small testes, tall, gynecomastia, learning disabilities | Klinefelter syndrome typically results in low testosterone level and an elevated FSH level | ||
| Other genetics: | Absence of the vas deferens | Low volume semen assay | Because of the inheritance pattern, genetic testing of the partner is warranted, and counseling is indicated if she is a carrier | |
| CFTR gene (cystic fibrosis) | ||||
| 5T allele (cystic fibrosis) | ||||
| Obstruction of the vas deferens or epididymis Ejaculatory dysfunction | History of infection, trauma, or vasectomy; normal testicular examination | Low volume semen analysis; transrectal ultrasonography can place obstacle | Rare cause of infertility; evaluation reserved for fertility specialist | |
| Systemic disease (non all-inclusive): | — | Depression FSH level; low testosterone level; check prolactin level and, if elevated, perform imaging for pituitary tumor | Infiltrative processes that cause a small number of infertility cases; however, effective treatment is available | |
| Hemochromatosis | ||||
| Kallmann syndrome | ||||
| Pituitary tumor | ||||
| Sarcoidosis | ||||
| Unclear etiology | Normal testicular examination | Normal FSH level; normal semen volume; depression sperm count | Subspecialist may consider testicular biopsy to determine obstructive vs. nonobstructive azoospermia | |
Evaluation of Women
- Abstract
- Evaluation of Men
- Evaluation of Women
- Treatment of Male Infertility
- Treatment of Anovulatory Conditions
- Treatment of Unexplained Infertility
- Lifestyle Factors
- References
The etiology of female infertility can exist cleaved down into ovulation disorders, uterine abnormalities, tubal obstruction, and peritoneal factors. Cervical factors are also thought to play a minor office, although they are rarely the sole cause. Evaluation of cervical fungus is unreliable; therefore, investigation is not helpful with the management of infertility.six
The initial history should cover menstrual history, timing and frequency of intercourse, previous use of contraception, previous pregnancies and outcomes, pelvic infections, medication apply, occupational exposures, substance abuse, alcohol intake, tobacco use, and previous surgery on reproductive organs. A review of systems and physical exam of the endocrine and gynecologic systems should be performed. Other considerations include preconception screening and vaccination for preventable diseases such equally rubella and varicella, sexually transmitted infections, and cervical cancer, based on advisable guidelines and risk.
WHO categorizes ovulatory disorders into three groups: group I is acquired past hypothalamic pituitary failure (10%), group II results from dysfunction of hypothalamic-pituitary-ovarian axis (85%), and group Three is caused by ovarian failure (5%).8 Women in group I typically present with amenorrhea and low gonadotropin levels, most usually from low body weight or excessive exercise. Women in grouping Two include those with polycystic ovary syndrome and hyperprolactinemia. Women in group III can conceive just with oocyte donation and in vitro fertilization.
Women with regular menstrual cycles are probable to exist ovulating and should be offered serum progesterone testing at day 21 to confirm ovulation.viii If a woman has irregular cycles, the testing should be conducted afterward in the cycle, starting vii days earlier presumed onset of menses, and repeated weekly until menstruum.vi,8 A progesterone level of 5 ng per mL (15.9 nmol per L) or greater implies ovulation.half-dozen,23 Anovulatory women should have farther investigation to determine treatable causes such as thyroid disorders or hyperprolactinemia based on symptoms.eight A high serum FSH level (greater than 30 to 40 mIU per mL [xxx to xl IU per L]) with a depression estradiol level can distinguish ovarian failure from hypothalamic pituitary failure, which typically reveals a low or normal FSH level (less than x mIU per mL [ten IU per L]) and a low estradiol level. Basal body temperatures are no longer considered a reliable indicator of ovulation, and are non recommended for evaluating ovulation.6,8,23
A high FSH level (x to 20 mIU per mL [10 to 20 IU per 50]) drawn on twenty-four hours iii of the menstrual bike is associated with infertility. A high serum estradiol level (greater than 60 to 80 pg per mL [220 to 294 pmol per L]) in conjunction with a normal FSH level has also been associated with lower pregnancy rates. This combination of laboratory test results may indicate ovarian insufficiency or diminished ovarian reserve.24 Other tests of ovarian reserve, such as the clomiphene (Clomid) claiming test, antral follicle count, and antimüllerian hormone level, are also generally performed to predict response to ovarian stimulation with exogenous gonadotropins and assisted reproductive engineering. Even so, these tests have only poor to moderate predictive value despite widespread use.25
Women with no clear risk of tubal obstruction should be offered hysterosalpingography to screen for tubal occlusion and structural uterine abnormalities.8,26,27 As opposed to laparoscopy or hysteroscopy, hysterosalpingography is a minimally invasive procedure with potentially therapeutic effects and should exist considered before more than invasive methods of assessing tubal patency.6 Women with hazard factors for tubal obstruction, such as endometriosis, previous pelvic infections, or ectopic pregnancy, should instead be offered hysteroscopy or laparoscopy with dye to assess for other pelvic pathology.8 These studies are more sensitive and may delineate an abnormally formed uterus or structural problems, such as fibroids. This allows for the diagnosis and treatment of conditions such as endometriosis with one procedure. Treatment of tubal obstruction generally requires referral for subspecialty care.
Endometrial biopsy should be performed only in women with suspected pathology (chronic endometritis or neoplasia). Histologic endometrial dating is not considered reliable nor is it predictive of fertility.half-dozen,28 Additionally, postcoital testing of cervical mucus is no longer recommended considering it does not bear upon clinical direction or predict the inability to conceive.22
Treatment of Male Infertility
- Abstract
- Evaluation of Men
- Evaluation of Women
- Treatment of Male Infertility
- Treatment of Anovulatory Weather
- Treatment of Unexplained Infertility
- Lifestyle Factors
- References
Underlying etiology determines the therapeutic course, although male person infertility is unexplained in 40% to 50% of cases.29 When the semen analysis is abnormal, referral to a male fertility specialist or reproductive endocrinologist is warranted. When anatomic variance or obstruction is suspected, referral for surgical evaluation and treatment is appropriate. If an endocrinopathy, such every bit hyperprolactinemia, is diagnosed, the underlying crusade should exist treated. In patients with varicocele, in that location is insufficient testify to suggest corrective surgery will increment alive birth rates, despite improvement in semen analysis results.30–32 Other handling options include antiestrogens and gonadotropin therapy, which showed a tendency toward increased live nascency rates in a Cochrane review.33 Use of antioxidants such as zinc, vitamin E, or fifty-carnitine showed increased live nascency rates in iii pocket-sized randomized controlled trials in couples undergoing assisted reproductive technology.34 Although intrauterine insemination has been shown to exist as constructive as timed intercourse in unstimulated cycles, in that location is a modest increment in alive birth rates when combined with ovarian stimulation.8,33,35,36 Lastly, in vitro fertilization, with or without intracytoplasmic sperm injection, is the mainstay of assisted reproductive technology for male gene infertility.
Treatment of Anovulatory Weather condition
- Abstract
- Evaluation of Men
- Evaluation of Women
- Treatment of Male Infertility
- Treatment of Anovulatory Conditions
- Handling of Unexplained Infertility
- Lifestyle Factors
- References
Women with WHO group I ovulatory disorders should exist counseled to accomplish a normal body weight. They may do good from referral to a doc comfy with prescribing pulsatile administration of gonadotropin-releasing hormone or gonadotropins with luteinizing hormone activity to induce ovulation.eight,37
Women in WHO group II, including those who are overweight and who have polycystic ovary syndrome, can benefit from weight loss, exercise, and lifestyle modifications to restore ovulatory cycles and achieve pregnancy.37 Clomiphene has also proven effective for ovulation consecration in women with polycystic ovary syndrome.37,38 The improver of 1,500 to 1,700 mg of metformin (Glucophage) daily may increase ovulation and pregnancy rates, only information technology does not significantly improve live nascence rates over clomiphene solitary.38,39
Family physicians may choose to attempt ovulation induction in anovulatory women (WHO group Ii) with clomiphene. Ovulation induction agents increase the gamble of multiple pregnancy, ovarian hyperstimulation syndrome, and thrombosis, and they may increment the risk of ovarian cancer in women who remain nulliparous.40 Patients using these agents should be counseled about these risks. The initial dosage of clomiphene is 50 mg daily for five days starting on twenty-four hour period 3 to 5 of the menstrual wheel. This should be followed by documentation of ovulation via serum progesterone. If this is unsuccessful, the dosage may be increased to 100 mg daily. Patients who exercise non achieve ovulation after 3 to 6 cycles should be referred to an infertility specialist for further treatment. Couples who do not conceive after treatment for six cycles with documented ovulation should also consider referral to an infertility specialist.41
Treatment of Unexplained Infertility
- Abstract
- Evaluation of Men
- Evaluation of Women
- Treatment of Male Infertility
- Treatment of Anovulatory Weather condition
- Handling of Unexplained Infertility
- Lifestyle Factors
- References
Couples who have no identified crusade of infertility should be counseled on timing of intercourse for the about fertile period (i.e., the six days preceding ovulation).42 Urinary luteinizing hormone kits indicate the midcycle luteinizing hormone surge that precedes ovulation past one to two days. These may be purchased over the counter and allow couples to predict the most fertile days in the cycle.half dozen Accuracy may be improved past use on midday or evening urine specimens, which correlate better with the top in serum luteinizing hormone levels.43 Other low-cost methods of monitoring for ovulation, although less effective, include basal torso temperature measurements and cervical fungus changes.42 Withal, none of these methods has been proven to increment pregnancy rates when used to predict timing of intercourse. Additionally, at that place is concern that the stress of a strict schedule for intercourse may lead to reduced frequency of intercourse.44 Therefore, a unproblematic recommendation is for vaginal intercourse every two to three days to optimize the risk of pregnancy.8
Patients should be counseled that 50% of couples who have non conceived in the first year of trying will conceive in the 2d year.8 Couples with unexplained infertility may want to consider another year of intercourse earlier moving to more costly and invasive therapies, such as assisted reproductive technology.viii Intrauterine insemination and ovulation induction do not result in increased pregnancy rates in women with unexplained infertility.8,45
Figure one provides an algorithmic arroyo to the evaluation of infertility.
Infertility Evaluation
Effigy 1.
Algorithm for infertility evaluation. (ART = assisted reproductive engineering.)
Lifestyle Factors
- Abstract
- Evaluation of Men
- Evaluation of Women
- Handling of Male Infertility
- Treatment of Anovulatory Atmospheric condition
- Handling of Unexplained Infertility
- Lifestyle Factors
- References
All couples should be counseled to abjure from tobacco use, limit alcohol consumption, and aim for a trunk mass index less than 30 kg per k2 to improve their chances of natural conception or using assisted reproductive engineering.viii,46 Obesity impairs fertility and the response to fertility treatments, including in vitro fertilization; therefore, it is advisable to counsel patients who are obese to lose weight before conception or infertility treatments.8 Interest in group counseling and exercise is more effective than weight loss communication solitary.8 Counseling on lifestyle modifications is reasonable because exposures to tobacco and alcohol are associated with lower rates of fertility.47 Motivational interviewing techniques for modifiable chance factors, such as obesity, tobacco, illicit drugs, and alcohol, can decrease the targeted hazard factor.48 Notwithstanding, there is no business firm testify that preconception counseling leads to increased live birth rates, in role because no studies on this topic take been performed.10
Data Sources: A PubMed search was completed using the key terms infertility, subfertility, handling, etiology, and diagnosis. It was cleaved down into male person and female categories. The search included meta-analyses, randomized controlled trials, clinical trials, and systematic reviews. Limits were placed on language and homo race equally well. Likewise searched were the Cochrane database, the National Guideline Clearinghouse database, Dynamed, and Essential Prove Plus. Search dates: January 6, 2014; Jan 28, 2014; Feb 5, 2014; and November 18, 2014.
The views expressed in this material are those of the authors, and exercise not reflect the official policy or position of the U.Southward. Government, the Section of Defense, or the Department of the Air Forcefulness.
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Source: https://www.aafp.org/afp/2015/0301/p308.html
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