Etiology and Evaluation of Infertility

OB/GYN

Etiology of Infertility

  • Combined factors – 40% of cases
  • Male factors – 26 to 30% of cases
  • Ovulatory dysfunction – 21 to 25% of cases
  • Tubal factors 14 to 20% of cases.
  • Other (e.g., Uterine abnormalities, cervical factors, peritoneal factors) – 10 to 13 % of the cases.
  • Unexplained – 25 to 28% of cases.

The above stats are from AAFP (2015)

“The major causes of infertility include ovulatory dysfunction (20–40%), tubal and peritoneal pathology (30–40%), and male factors (30–40%); uterine pathology is relatively uncommon, and the remainder is largely unexplained. “(Fritz and Speroff)

ETIOLOGY & EVALUATION OF INFERTILITY IN FEMALES

Causes of infertility in females can be grouped into the following.

    1. Ovulation Factors (Ovarian disorders)
    2. Tubal Factors
    3. Uterine Factors
    4. Cervical Factors
    5. Peritoneal Factors
CONDITION H&P LAB & STUDIES COMMENTS

WHO Group 1 Ovulatory disorders
(Hypothalamic amenorrhea)

Amenorrhea or oligomenorrhea; low body mass index

Low to normal FSH level; low estradiol level
(Hypogonadotropic, hypogonadal anovulation)

Encourage weight gain

WHO group 2 Ovulatory disorders
+ hypothyroidism.

 Irregular menses; hirsutism; obesity (polycystic ovary syndrome); galactorrhea (hyperprolactinemia); fatigue; hair loss (hypothyroidism) Progesterone level < 5 ng per mL (15.9 nmol per L); elevated prolactin level; elevated TSH level.
(Normo-gonadotropic, normo-estrogenic anovulation)		 Check TSH and prolactin levels based on clinical symptoms
WHO group 3 Ovulatory disorder.

(Ovarian failure/insufficiency)

Amenorrhea or oligomenorrhea; menopausal symptoms; family history of early menopause; single ovary; chemotherapy or radiation therapy; previous ovarian surgery; history of autoimmune disease

Elevated FSH level; low estradiol level
(Hypergonadotropic, hypogonadal anovulation).

Consider additional tests of ovarian reserve (antral follicle count, antimüllerian hormone level, clomiphene [Clomid] challenge test)

Tubal Factors (blockage)

History of pelvic infections or endometriosis

Abnormal hysterosalpingography result

Refer to a specialist

Uterine abnormalities

Dyspareunia; dysmenorrhea; history of anatomic developmental abnormalities; family history of uterine fibroids; abnormal palpation and inspection

Abnormal hysterosalpingography or ultrasonography result

Refer to a specialist.

Endometriosis or pelvic adhesions

  History of abdominal or pelvic surgery; history consistent with endometriosis  Rarely helpful  Generally diagnosed on laparoscopy; consider in women with otherwise unexplained infertility
The above table is modified AAFP (2015)
http://www.aafp.org/afp/2015/0301/hi-res/afp20150301p308-t3.gif

Thyroid dysfunction: “Severe untreated thyroid dysfunction (both hyper- or hypothyroidism can cause menstrual irregularities and anovulatory infertility. The anovulatory effect of severe hypothyroidism is partly mediated by hyperprolactinemia because of the fact that elevated TSH acts as a release factor for prolactin.” (Ghumman)

Reference

Clinical Gynecologic Endocrinology and Infertility by Marc Fritz, MD, Leon Speroff, MD

http://www.aafp.org/afp/2015/0301/p308.html

Principles and Practice of Controlled Ovarian Stimulation in ART, edited by Surveen Ghumman
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2808395/
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