Definitions
- Fecundability. The probability of conceiving during a single monthly cycle. In “normally fertile” couples it is 20–25%, with a cumulative 85–90% chance of pregnancy within 12 months.
- Infertility. The inability to conceive after 12 months of appropriately timed intercourse without contraception in women aged <35 years or after 6 months in women aged ≥35 years.
- Primary infertility refers to couples who have never achieved a pregnancy. Secondary infertility implies at least one previous conception.
Incidence
- 10–15% of reproductive age married couples are infertile.
- The prevalence of infertility has remained constant, but the number of office visits to physicians by “infertile” couples has tripled over the past 20 years. This “infertility epidemic” has been attributed primarily to elective postponement of childbearing and increased insurance coverage of elective fertility therapy.
Risk factors
- Fecundability begins to slowly decline after age 28 and usually declines at a more rapid rate after age 35.
- Cigarette smoking, recreational drug use, and certain occupational and environmental exposures decrease the fertility rate.
Initial assessment
- The primary goals of an infertility evaluation are to provide a rational approach to diagnosis, to present an accurate assessment of ongoing progress and prognosis, and to educate the couple about reproductive physiology.
- History. Relevant details include the female patient’s age, previous pregnancies, and duration of conception attempts, timing of intercourse, lubricant use, and erectile or ejaculatory dysfunction. A comprehensive gynecologic history should include menarche, menstrual intervals, prior history of sexually transmitted infections, prior tubal or pelvic surgery, prior pelvic infection or ectopic pregnancy, and prior abnormal Pap smears necessitating of the loop electrosurgical excision procedure (LEEP) or cryosurgery.
- Physical examination. Features of an endocrine disorder (hirsutism, hepatomegaly, thyromegaly) or gynecologic pathology (fibroids, endometriosis) may be evident.
- Laboratory tests.
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