Referral of the male partner to a urologist for examination often is beneficial if historic information or subsequent evaluation suggests an abnormality. This initial encounter is an excellent time to outline the general causes of infertility and to discuss subsequent diagnostic and treatment plans (Figs. 32.1–32.3).
The basic investigations that ideally should be performed before starting any infertility treatment are semen analysis, confirmation of ovulation, and the documentation of tubal patency. Other noninfertility assessments should include rubella immunity testing (17). If a patient with severe systemic illness, such as renal failure, liver failure, or cancer, wishes to conceive, careful preconceptional assessment and counseling is advisable because the risks of fertility treatment and pregnancy can be substantial.
Causes of Infertility
The main causes of infertility include: 1.
2.
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Infertility one year or longer Initial evaluation, history, physical exam Irregular menses No ovulation by tests HSG  Unilateral or bilateral  tubal blockage Normal evaluation  History  Physical exam  Ovulation tests  HSG HSG or hysteroscopy  Structural abnormality of the endometrial cavity Abnormal semen analysis Unexplained infertility ± endometriosis  Counseling and Psychosocial support  If multiple factors present, investigate and manage concurrently
Figure 32.1 Diagnostic and treatment algorithm: infertility. HSG, hysterosalpingography. (From Yao M. Clinical management of infertility. Washington, DC: The Advisory Board: 2000, with permission.)
Factors from either or both partners may contribute to difficulties in conceiving; therefore, it is important to consider all possible diagnoses before pursuing invasive treatments. The relative prevalence of the different causes of infertility varies widely among patient populations (Table 32.1). In many cases, no specific cause is detected despite a thorough evaluation, and the couple’s infertility is categorized as unexplained.
Very few couples have absolute infertility, which can result from congenital or acquired irreversible loss of functional gametes in either partner or the absence of reproductive structures in either partner. In these specific instances, couples should be counseled regarding their options for adoption, use of donor gametes, or surrogacy.
Brain imaging (MRI is the gold standard) to exclude  Pituitary microadenoma  Pituitary macroadenoma  Other abnormal brain mass Hypothyroidism  Exclude secondary causes  Treat condition  Supplement with thyroid hormone if indicated  Spontaneous ovulation will occur when thyroid function normalizes  Treat underlying condition  When prolactin normalizes, spontaneous ovulation should occur Anovulation Normal or high day 3 FSH and LH Ovarian disorders (see Figure 30.3) Low LH, FSH, TSH, GH, ACTH High serum prolactin levels Abnormal TSH or T4Low FSH, LH, E2 Hypothalmic disorders Thyroid disease Hyperprolactinemia Panhypopituitarism Assess and treat condition Repeat test to exclude false positive Elevated prolactin If a pituatary microadenoma is diagnosed  Bromocriptine or cabergoline to normalize prolactin level  Spontaneous ovulation should occur when prolactin is normal Anorexia  Medical and psychiatric assessment  Treat condition  Aim to increase BMI to allow spontaneous ovulation  If female athlete triad, assess bone density, diet, caloric in take Hypogonadotropic hypogonadism  Congenital or acquired  Brain imaging Hyperthyroidism  Evaluate cause  Treat condition Ovulation induction  Pulsalite GnRH-agonist  Induce FSH and LH release Ovulation induction  FSH intrauterine insemination  FSH timed intercourse If no spontaneous ovulation, exclude irreversible damage to pituitary