Remember, if a woman in trying to get pregnant, she should be on at least 400ug/d of folate to reduce risk of neural tube defects!

I. Epidemiology and definitions

  1. Definitions = no pregnancy after 12 mos of unprotected sex; 15% of couples fall under this definition; 1/3 will get pregnant in the next year
  2. More common at older ages

II. Causes

  1. Male problems: azoospermia, etc.
  2. Cervical factors (infection, immunologic properties of mucus)
  3. Uterine abnormalities (fibroids, endometrial Ca, Asherman's sd., DES exposure)
  4. Tubes (h/o salpingitis)
  5. Pelvis (adhesions, endometriosis)
  6. Ovarian (luteal phase defect interfering with implantation, anovulation)
  7. Smoking by either partner ass'd with delays in conception (Fertil. Steril. 74:725, 2000--JW)

III. Hx: menstrual function, coital timing, smoking/drinking/exercise (all may decrease fertility), hot baths in male (ditto), h/I PID in woman, STD's in man, endometriosis sx

IV. Workup

  1. BBT studies
  2. Px of male (hypospadias, varicocele)
  3. Sperm sample
  • Count > 20 million/ml
  • Mobility > 50%
  • Morphology > 4% nl
  • Volume 2-6ml
  • "Liquefaction" (?)
    1. Endometrial bx to identify luteal phase abnormalities
    2. HSP
    3. Laparoscopy as last resort
    4. Postcoital test (examination of cervical mucus postcoitally for presence of motile sperm)--thought to give info on cervical "hostility" to sperm--falling out of use as of 1998; probably doesn't offer any useful prognostic information

    V. Treatment

    1. For non-ovulation, meds to stimulate ovulation can be used:
      1. Clomiphene Citrate
      2. Human Menopausal Gonadotropins
      3. Possibly, metformin (see Am. J. Obs. Gynecol. 191:1580, 2004--AFP)