Twenty-one percent of couples in the United States are expected to experience infertility in their lifetimes, with a current prevalence of 7.4% (6). In 2002, over 7 million US women age 22 to 44 reported using infertility services in their lifetimes (7). Once diagnosed, 13% of couples will not pursue treatment (8). The diagnosis of impaired fecundity has been rising, reaching 15% in 2002 and largely resulting from the trend toward delayed childbearing in developed countries (3). Worldwide, male factor accounts for 51.2% and tubal blockage for 25% to 35% of infertility and subfertility (conception after attempting for 1 year) (9,10). In Europe, ovulatory dysfunction accounts for 21% to 32%, male factor 19% to 57%, tubal factor 14% to 26%, unexplained 8% to 30%, endometriosis 4% to 6%, and combined male and female factors 34.4% of infertility (11–13). The odds of infertility increase with female age and in general among patients who have not graduated from college (14). The high cost of infertility treatment is a barrier for many in the United States where insurance typically does not cover these services (15). Language and other cultural barriers affect access for many minority groups (15,16). The women most likely to obtain specialized treatment are 30 years of age or older, white, married, and of relatively high socioeconomic status (7).
The physician’s initial encounter with the infertile couple is of primary importance because it sets the tone for subsequent evaluation and treatment. Ideally, both partners should be present at this first visit. It cannot be overemphasized that infertility is a problem of the couple. The presence of both partners, beginning with the initial evaluation, jointly involves them in the therapeutic process. This essential shared involvement demonstrates that the physician is receptive to the partner’s needs as well as those of the patient and offers the partner an opportunity to ask questions and voice concerns.
The physician should obtain a complete medical, surgical, and gynecologic history from the woman. Specifically, information regarding menstrual cycle regularity, pelvic pain, and previous pregnancy outcomes is important. Risk factors for infertility, such as a history of pelvic inﬂammatory disease (PID) or pelvic surgery, should be reviewed. A history of intrauterine exposure to diethylstilbestrol (DES) is significant. In addition, a review of systems relevant to pituitary, adrenal, and thyroid function is useful. Questions regarding galactorrhea, hirsutism, and changes in weight are particularly relevant. A directed history, including developmental defects such as undescended testes, past genital surgery, infections (including mumps orchitis), previous genital trauma, and medications should be obtained from the male partner. A history of occupational exposures that might affect the reproductive function of either partner is important, as is information about coital frequency, dyspareunia, and sexual dysfunction. Finally, information should be obtained on any family history of infertility, premature ovarian failure, congenital or developmental defects, mental retardation, and hereditary conditions relevant to preconceptional planning, such as cystic fibrosis, thalassemias, and Tay Sachs disease.
The initial interview provides the physician with the opportunity to assess the emotional impact of infertility on the couple. It presents a time for the physician to emphasize the emotional support available to the couple as they proceed with the diagnostic evaluation and suggested treatments. In some cases, referral to a trained social worker or psychologist may be beneficial.
The physical examination of the woman should be thorough, with particular attention given to height, weight, body habitus, hair distribution, thyroid gland, and pelvic examination.