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Overview of Infertility

by Robert W. Rebar, MD

Infertility is usually defined as inability of a couple to conceive after 1 yr of unprotected intercourse.

Frequent, unprotected intercourse results in conception for 50% of couples within 3 mo, for 75% within 6 mo, and for 90% within 1 yr.

Infertility can be caused by the following:

  • Sperm disorders (≥ 35% of couples)

  • Decreased ovarian reserve or ovulatory dysfunction (20%)

  • Tubal dysfunction and pelvic lesions (30%)

  • Abnormal cervical mucus ( 5%)

  • Unidentified factors (10%)

Inability to conceive often leads to feelings of frustration, anger, guilt, resentment, and inadequacy.

Couples wishing to conceive are encouraged to have frequent intercourse for the few days when ovulation is most likely, probably midway between menstrual cycles. Measuring morning basal body temperature (BBT) daily can help determine when ovulation is occurring in women with regular menstrual cycles. A decrease suggests impending ovulation; an increase of 0.5° C suggests ovulation has just occurred. Commercially available luteinizing hormone (LH) prediction test kits, which identify the midcycle LH surge, can also help determine when ovulation occurs and are less disruptive than measuring BBT. BBT can be useful if women cannot afford or do not have access to LH prediction kits. Use of caffeine and tobacco, which can impair fertility, is discouraged.

If these measures do not result in pregnancy after ≥ 1 yr, both partners are evaluated. Evaluation begins with history, examination, and counseling. Men are evaluated for sperm disorders, and women are evaluated for ovulatory and tubal dysfunction and pelvic lesions. Evaluation is done sooner than 1 yr if

  • The woman is > 35.

  • The woman has infrequent menses.

  • The woman has a known abnormality of the uterus, fallopian tubes, or ovaries.

  • The man is known to be subfertile or is at risk of subfertility.

Support groups for couples (eg, American Fertility Association, RESOLVE) may help. A clinician should mention adoption if the likelihood of conceiving is low (usually confirmed after 3 yr of infertility, even in women < 35, or after 2 yr of treatment).

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