Female Infertility
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Introduction
Infertility affects 10-15% of couples. Normally, 75% of couples become pregnant within 6 months, 85% within one year, and 90% within two years.
Infertility investigations must include both female and male.
Infertility is the
50% female, 35% male, 15% unexplained
The Case of...
Differential Diagnosis
Ovulatory dysfunction is responsible for 15-20% of infertility. Causes include:
- hypothalamic amenorrhea
- pituitary prolactinoma or hypopituitarism
- ovary: PCOS, premature ovarian failure, luteal phase defect
- systemic diseases: thyroid, Cushing's syndrome, renal or hepatic failure
- congenital: Turner syndrome, gonadal dysgenesis, gonadotropin deficiency
- stress
- poor nutrition
- excessive exercise, even with menstruation
Outflow tract abnormality can include:
- Fallopian tubes in 20-30%: PID, adhesions, endometriosis, occlusion by previous ectopic pregnancy
uterus
- congenital anomalies
- intrauterine adhesions
- infection (endometritis, TB)
- fibroids or polyps
- endometrial ablation
cervix
- acidic cervical mucous
- anti-sperm antibodies
- structural abnormalities: biopsy, laser, cryotherapy
Endometriosis
Multiple factors (30%)
idiopathic (10-15%)
History and Physical Exam
- history
- physical exam
History
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Ovulatory investigations include:
- beta-HCG
- assess basal body temperature fluctuations
- Day 3 FSH, LH, TSH, free T4, PRL
- +/- DHEA and free testosterone if hirsutism present
- Day 21-23 serum progesterone
- lipid profile, lasting insulin
- 17-OH progesterone (for CAH)
- progesterone withdrawal test
- enodometrial biopsy because of unopposed estrogens
Outflow tract investigations include:
- hysterosalphingogram
- sonohysterogram
- laparoscopy with dye insufflation
- hysteroscopy
Karyotype analysis may also be considered
Lubricants can be detrimental for fertility (but not adequate for conception)
Diagnostic Imaging
Management
Education should be provided regarding monthly cycles and ovulation.
Ovulation may be induced using various medications.
Procedures include:
- tuboplasty
- adhesion/endometriosis ablation
- sperm washing
- IVF
Pathophysiology
Resources and References
Topic Development
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