Infertility

Infertility is the inability of a sexually active couple
who desire a child to become pregnant within one
year.
Impact
1. Approximately 10 to 15% of couples have
difficulty becoming pregnant. Approximately
9 million American women have impaired
fertility, either primary (never having a child)
or secondary (trouble having as many children
as desired).
2. Family and general physicians can work with
couples to help them achieve a pregnancy.
Consultation to fertility specialists may be needed
sooner or later.
Etiology
1. Infertility is a couple’s problem. Most couples
conceived within 6 months of trying.1 Infertility
increases with age (Figure 8.1).
2. Half of the couples who have failed to get
pregnant in six months conceive within the next
six months.2
3. In retrospect, approximately 40% of infertility is
caused by ovulation problems. Ten to thirty
percent may be caused by multiple factors, and
male factors make up the remaining of the causes
(Table 8.1).
4. Chronic disease of either partner may cause
infertility.
5. Women’s causes of infertility include ovarian and
tubal or mechanical factors.
a. Ovarian failure may be caused by
malnutrition, anorexia, diabetes, or renal
failure.
b. Ovarian failure can be temporary or
permanent and can be caused by an
endocrinopathy or polycystic ovarian
syndrome or can be idiopathic.
c. Tubal factors include scarring from
endometriosis, PID or infections, especially
gonorrhea or chlamydia.
d. Cervical and uterine factors can include an
abnormally shaped uterus (bifid, bicornuate,
or anatomy changed by fibroids) or inimical
cervical mucus.
e. Use of certain medications, smoking, alcohol,
and obesity all reduce a woman’s fertility.
A recent retrospective study of more than 400
Danish couples found that drinking as little as
one to five alcoholic drinks weekly
significantly decreased the likelihood of
pregnancy (RR ¼ 0.6) and more than five
drinks weekly decreased the likelihood to less
than one-third (RR ¼ 0.3).3
6. Male causes of infertility include erective
dysfunction and other sexual dysfunction, a low or
absent sperm count, abnormal sperm, epidydimal
scarring from infection, or medication use.
Antidepressant use can cause reduced sperm
numbers and motility.4
Evaluation
1. The duration of the infertility and the age of the
woman are the most important factors influencing
the success rate for fertility5 (Figure 8.2).
2. The history of medications and alcohol use are
important factors.
3. Contraceptive history is important. After
hormonal contraception, return to normal ovulation patterns can take months. After
stopping OCPs, amenorrhea and anovulation can
last 6–12 months. After use of depot
Medroxyprogesterone acetate (DMPA),
anovulation can last 12–24 months (Figure 8.3).
4. Sexual history is important. Approximately 5% of
infertility is caused by sexual dysfunction.
5. A complete physical examination of both men and
women is essential.
a. In the woman, medical and medication
history, sexual history, gynecological and
obstetrical history including pregnancies,
abortion, surgeries, episodes of PID, and
menstrual history. Physical examination of
women includes gynecological exams
including vaginal, uterine and bimanual
examination. Examining hair and skin for
changes of a hormonal disorder or PCOS is
important.
b. In the man, medical and medication history,
sexual history and history of infections or
surgery are important. Physical examination
of scrotum, testes and penis is important.
Phimosis, balanitis, small testes, or varicoeles
may interfere with fertility. Varicoeles do not
interfere with normal sperm counts and
assessment; how they reduce fertility is not
well defined.
c. Both partners should be examined and
cultured for sexually transmitted disease,
especially chlamydia.
Counseling
Counseling the couple about the normal menstrual
and ovulation cycle, about the effects of medications
and alcohol on fertility, and about expectations about
coming pregnant is important. A survey study of
approximately 250 women who were trying to
become pregnant found that many were having intercourse
at times other than ovulation. After teaching
these women how to use a “fertility monitor,” almost
half conceived in the first month, and 90% within
three months.6 Other important counseling includes
the following.

Woman’s use of folic acid prophylactically to
reduce incidence of spina bifida is suggested.

Reducing or quitting smoking and decreasing
alcohol consumption should be advised. Smoking
reduces fertility. Medications should be reduced
or changed as needed (Table 8.2).

Weight should be lost if possible.

Vaginal lubricants or gel that may cause sperm
immobility and impede infertility should not be
used.
Treatment
1. The woman should start a three to six month basal
body temperature log, or use LH predictors to determine whether she is ovulating. Although this
seems simple, an accurate record takes
thoroughness and consistency. A biphasic curve
with a 0.4 to 0.5 degree elevation is consistent with
the day of ovulation. Over the counter LH surge
predictors cost $35–50 per cycle.
2. The man should have a semen analysis. Examined
within 60 minutes of ejaculation, normal semen
contains 2 mL or more of 20 million motile sperm
per mL, or more. The motility of sperm should
show that more than half progress in a forward
direction, with more than 25% progressing
rapidly. Thirty percent or more should have
normal shape. One study of more than 100 fertile
men undergoing vasectomy found that the mean
volume was 3.31 ml (range 0.6–11 mL), with
a sperm count average of 81 million per mL
(range 4–318 million). The percent of active
sperm averaged 63% (range 10 to 95%).7
3. If these tests are normal, a postcoital test is
suggested, although its prognostic value has been
questioned by a meta-analysis.8 Within eight
hours after coitus, a cervical specimen is analyzed
for sperm motility and morphology. One RCT
found that postcoital tests increased the number
of tests, but not the overall pregnancy rate.9
4. If the woman is not ovulating, the family
physician (if she stays up-to-date on the literature
and treatment) or a consultant can help induce ovulation with clomiphene, Pergonal®,
gonadotropin agonists or pulsatile gonadotropin
releasing hormone administration. Only
physicians experienced in using these drugs
should attempt ovulation induction.
a. Clomiphene, a selective estrogen receptor
modulator (SERM), is contraindicated in
women with liver failure, ovarian cysts, PCOS,
and undiagnosed abnormal uterine bleeding
or pregnancy. It is associated with an increase
in multiple births. There may be severe
menstrual and intermenstrual pain, nausea,
bloating and premenstrual syndrome
associated with its use.
b. The next step may be the use of menotropins
incluing human menopausal gonadotropins
(hMG, Pergonal). These can cause high serum
estradiol concentrations and ovarian
hypertrophy with multiple follicles. These
follicles can rupture and cause
hemoperitoneum, ascites, and hypovolemia in
as many as 25% of women using the
medication.
5. If the semen analysis is abnormal, there are
methods of increasing the concentration, number
and motility of sperm, called “capacitating.”
6. Alternatively, the sperm can be introduced
directly into the uterus with a catheter, especially
if the postcoital test is abnormal.
7. Women with PCOS may be treated with
metformin which induces ovulation in
approximately 50%, as it reduces insulinemia,
improves glucose control, and decreases weight
and hirsuitism. In early studies metformin was
given to 43 women who were hyperinsulinemic
and euglycemic. Ninety-one percent resumed
menses.

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