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
- 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
- More common at older ages
II. Causes
- Male problems: azoospermia, etc.
- Cervical factors (infection, immunologic properties of mucus)
- Uterine abnormalities (fibroids, endometrial Ca, Asherman's sd., DES exposure)
- Tubes (h/o salpingitis)
- Pelvis (adhesions, endometriosis)
- Ovarian (luteal phase defect interfering with implantation, anovulation)
- 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
- BBT studies
- Px of male (hypospadias, varicocele)
- Sperm sample
Count > 20 million/ml Mobility > 50% Morphology > 4% nl Volume 2-6ml "Liquefaction" (?)
- Endometrial bx to identify luteal phase abnormalities
- HSP
- Laparoscopy as last resort
- 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
- For non-ovulation, meds to stimulate ovulation can be used:
- Clomiphene Citrate
- Human Menopausal Gonadotropins
- Possibly, metformin (see Am. J. Obs. Gynecol. 191:1580, 2004--AFP)