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Infertility

Infertility is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

Definition: failure of a couple to conceive after ≥12 months of regular unprotected intercourse or after ≥6 months if the woman is ≥35 years. Primary: Couple has never been pregnant. Secondary: Couple has been pregnant. Fecundability: the probability of achieving pregnancy in one menstrual cycle

Epidemiology

Incidence
Incidence is the probability of achieving a pregnancy within 1 year. ~85% of couples will conceive within 12 months of unprotected intercourse.


Prevalence
  • In the United States, 5–15% of women currently trying to conceive are infertile.
  • ~11.5% of married couples between ages 15 and 34 years and 42% between ages 35 and 44 years meet the criteria for being infertile.
  • May increase as more women delay childbearing; 20% of women in the United States have their first child >35 years.

Etiology and Pathophysiology

  • Most cases multifactorial: Approximately 50% of cases due to female factors (of which 20% are due to ovulatory dysfunction and 30% due to tubal and pelvic pathology); 30% due to male factors; and 20% are of unknown etiology.
  • Acquired: Most common cause of infertility in the United States is pelvic inflammatory disease (PID) secondary to chlamydia (1), endometriosis, polycystic ovary syndrome (PCOS), premature ovarian failure, and increased maternal age.
  • Diminished ovarian reserve (DOR): low fertility due to low quantity or functional quality of oocytes
  • Congenital: anatomic and genetic abnormalities

Genetics
  • Higher incidence of genetic abnormalities among infertile population, including Klinefelter syndrome (47XXY), Turner syndrome (45X or mosaic), and fragile X syndrome
  • Y chromosomal microdeletions are associated with isolated defects of spermatogenesis → found in 16% of men with azoo-/severe oligospermia.
  • Cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation causing congenital bilateral absence of vas deferens (CBAVD)

Risk Factors

  • Female
    • Gynecologic history: irregular/abnormal menses, sexually transmitted infections (STIs), dysmenorrhea, fibroids, prior pregnancy
    • Medical history: endocrinopathy, autoimmune disease, undiagnosed celiac disease, collagen vascular diseases, thrombophilia, obesity, and cancer
    • Surgical history: appendicitis, pelvic surgery, intrauterine surgery, tubal ligation
    • Social history: smoking, alcohol/substance abuse, eating disorders, exercise, advanced maternal age
  • Male
    • Medical history: STI, prostatitis, medication use (i.e., β-blockers, calcium channel blocker, antiulcer medication), endocrinopathy, cancer
    • Surgical history: orchiopexy, hernia repair, vasectomy with/without reversal
    • Social: smoking, alcohol/substance abuse, anabolic steroids, environmental exposures, occupations leading to increased scrotal temperature

General Prevention

Normal diet and exercise, avoid smoking and other substance abuse, prevention of STIs

Commonly Associated Conditions

  • Sexual behavior increasing risk for STIs
  • Pelvic pathology: endometriosis, ovarian cysts, endometrial polyps, and uterine fibroids
  • Endocrine dysfunction (thyroid, glucose metabolism, menstrual cycle abnormalities, prolactin)
  • Anovulation is commonly associated with hyperandrogenism and PCOS.

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Citation

Stephens, Mark B., et al., editors. "Infertility." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116320/all/Infertility.
Infertility. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116320/all/Infertility. Accessed April 19, 2019.
Infertility. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116320/all/Infertility
Infertility [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 19]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116320/all/Infertility.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Infertility ID - 116320 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116320/all/Infertility PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -