Infertility

Clinical description

Infertility is the inability for a couple to conceive after regular, unprotected sexual intercourse for one year.

Aetiologies of infertility may be found in the female partner, male partner, and/or both partners, or may be unexplained.

Signs and symptoms

History

• Both partners: prior pregnancies, history of STIs, drug history (alcohol, tobacco), occupational history,

frequency of intercourse

• Female: age (≥ 35 years old), height/weight/BMI, previous pelvic and/or abdominal surgery, contraceptive

use, menstrual history and any menstrual abnormalities

• Male: previous urogenital or hernia surgery, varicocele and/or genital pathology, mumps

Exam/Investigations - as indicated

• Female: menstrual calendar, pelvic US, HSG; if available: basal body temperature graph, TSH, PRL, day 3

FSH and oestrogen, day 21 progesterone or ovulation predictor kits,diagnostic laparoscopy

• Male: semen analysis (2 samples should be submitted)

Treatment

• Pre-conception management includes weight loss if female BMI > 30 and female rubella and syphilis

status.

• HIV testing for both partners.
• Couples should be advised to have regular intercourse 2 - 3 times per wk or can be counseled to use timed

intercourse around the time of ovulation if the woman has predictable menstrual cycles.

• To calculate the day of ovulation, calculate the woman’s menstrual cycle lengthand subtract 14.
• The couple should start having intercourse every other day for 7 days, beginning 5 days before her

anticipated date of ovulation.

• If woman is overweight, counsel about weight loss as a strategy to improve fertility.
• If woman has abnormal TSH or PRL noted, treat underlying etiology.
• If woman has anovulatory cycles, may consider using clomiphene citrate (Clomid 50 mg) on days 5-9 of

cycle if structural and semen abnormalities have been ruled out.

• Counsel patient about increased risk of multiple gestation and ovarian hyperstimulation syndrome with

Clomid.

• If structural or semen abnormalities are noted, patient may need referral for surgery, intrauterine

insemination (IUI), or in vitro fertilization (IVF).