Infertility: What the Family
Physician Needs to Know
Heather L. Paladine MD, Med, FAAFP
January 23, 2016
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What You Need to Know
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Who to evaluate
Focused history and physical
Evaluation and treatment of women
Evaluation and treatment of men
Treatment side effects
Integrative medicine
Patient resources
Infertility Facts
- 85% of couples will conceive within 1 year,
therefore up to 15% may need evaluation
- Opportunity for preconception counseling
Sources: The Practice Committee of the American Society for Reproductive Medicine. Diagnostic
evaluation of the infertile female: a committee opinion. Fertil Steril 2012; 98(2): 302-7.
The Practice Committee of the American Society for Reproductive Medicine. Diagnostic evaluation of
the infertile male: a committee opinion. Fertil Steril 2015; 103: e18-25.
Who to Evaluate?
- No conception after 1 year of regular intercourse
- Consider evaluation after six months if the female partner
is >= age 35
- Also discuss options with same sex couples, transgender
patients, people who are lacking reproductive organs
(congenital or surgical)
History and Physical
Ask specifically about previous pregnancies/conceptions,
frequency of intercourse, STDs, medical history,
substance use/tobacco
- exam focusing on endocrine and reproductive systems
- for women: detailed menstrual history
Common Causes in Couples
• Female factors - 40-50%
• Male factors - 20%
• Joint or unknown - 30-40%
Women - Causes of Infertility
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Ovulatory dysfunction - most common
Tubal abnormalities - second most common
Uterine abnormalities
Peritoneal factors
(Cervical factors)
Ovulatory Dysfunction
- 15% of couples
- Usually identified on history
- Important to confirm ovulation as a first step
Ovulatory Dysfunction
Step 1: Confirm ovulation (or not)
• Anovulation may be obvious
• Ovulation should be confirmed with progesterone level
one week before next expected menses (level >3)
• BBT charting not recommended
• Can use at-home ovulation predictor kits
Step 2: Evaluate the cause of anovulation
• History and exam
• TSH, prolactin, FSH/estradiol on day #3 of menses
WHO Groups
I: Hypothalamic/pituitary insufficiency
II: Problems w/hypothalamic/pituitary/ovarian axis
III: Ovarian insufficiency
Source: ESHRE Capri Workshop Group. Health and fertility in World Health Organization group 2
anovulatory women. Human Reproduction Update 2012; 0(0):1 –14.
Group I: Hypothalamic/Pituitary
Insufficiency
• Low/normal FSH, low estradiol
• Underweight, excessive exercise, hyperprolactinemia
• Treatment depends on the underlying cause
Group II: Problems with the
Hypothalamic/Pituitary/Ovarian Axis
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Most common cause of ovulatory dysfunction
Normal FSH and estradiol
Primarily women with PCOS
Improved fertility with weight loss +/- metformin
Possible treatments:
– Ovulation induction (clomiphene citrate)
– Gonadotropin therapy
– IVF
Group III: Ovarian Insufficiency
• High FSH, low estradiol
• Congenital causes: Turner’s syndrome
• Acquired causes: premature ovarian failure,
chemotherapy
• May require ovum donation
Ovulatory Dysfunction - Treatment
• Treat the underlying cause when possible
• Clomiphene citrate - oral
– Blocks estrogen receptors in the
hypothalamus, resulting in upregulation of
GNRH
• Gonadotropin therapy - injectable GNRH or
FSH/LH analogs
• IVF - combined with ovulation induction
Clomiphene Citrate Use
• Use progesterone to induce menses
• Start with clomiphene 50mg daily for days 2-5
• Use home ovulation detection kit to confirm ovulation
(usually 5-12 days after last dose)
• Increase dose to 100mg if not effective
• Do not use for longer than 3-6 cycles
• Ultrasound not needed
Sources: The Practice Committee of the American Society for Reproductive Medicine. Use of
clomiphene citrate in infertile women: a committee opinion. Fertil Steril 2013;100:341–8.
https://www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/Practice_Guidelines/Co
mmittee_Opinions/use_of_clomiphene(1).pdf
Side Effects of Infertility Treatments
• Clomiphene citrate: mood swings, hot flashes, ovarian
cysts, multiple gestation (8-10%)
• Injectable gonadotropins: ovarian hyperstimulation
(vomiting, ascites, can be severe), multiple gestation
(33%)
• IVF: highest risk of multiple gestation (34% or higher),
perinatal morbidity/mortality, may need to consider
selective abortion
Tubal Abnormalities
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Also common
History: STDs/PID, ectopic pregnancy, tubal surgery
Traditionally evaluated by HSG
May require IVF
Uterine Abnormalities
• Uncommon
• Polyps, septa, etc.
• Should be evaluated with US, HSG, or
sonohysterography
• Treatment is via hysteroscopy
Peritoneal Factors
• Suspect endometriosis or adhesions by history/exam
• May need laparoscopy for evaluation and treatment
Cervical Factors
• Uncommon
• Thought to be incompatibility between sperm
and cervical mucous
• No specific test
Evaluation of the Male Partner
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Should begin at the same time
History and physical exam
Semen analysis
Oligospermia or azoospermia: check testosterone and
FSH to differentiate between primary and secondary
hypogonadism
• Look for structural causes, like congenital absence of the
vas deferens (almost all men with CF)
Primary Hypogonadism
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Genetic: Klinefelter’s syndrome
Cryptorchidism
Testicular trauma
Mumps
Varicocele
Autoimmune
Alcohol
Basaria S. Male hypogonadism. Lancet 2014; 383 (9924): 1250-1263.
Secondary Hypogonadism
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Obesity
Diabetes
Hyperprolactinemia
Infection/infiltration (TB, sarcoid,
hemochromatosis)
• Medications (opioids, steroids)
• Excessive exercise or underweight
Varicocele
• Examine pt while standing, Valsalva
• Indications for surgical treatment:
– Couple with infertility
– No female cause or treatable female cause
– Varicocele is palpable on exam
– Abnormal semen analysis
Source: Practice Committee of the American Society for Reproductive Medicine. Report on
varicocele and infertility: a committee opinion. Fertility and Sterility 2014; 102(6): 1556-1560.
Treatment of the Male Partner
• Referral to Urology or Reproductive Endocrinology if
semen analysis or exam are abnormal and no reversible
cause is found
• Treatment may include IVF
Integrative Medicine and Infertility
• Traditional Chinese Medicine: meta-analysis showed
increased pregnancy rate in women with ovulatory
dysfunction, but studies were low quality
• Acupuncture is used with IVF but Cochrane review found
no benefit
Sources: Tan L, Tong Y, Sze SCW et al. Chinese Herbal Medicine for Infertility with Anovulation:
A Systematic Review. Journal of Alternative and Complementary Medicine 2012; 18(12): 10871100.
Cheong YC, Dix S, Hung Yu Ng E, Ledger WL, and Farquhar C. Acupuncture and assisted
reproductive technology. Cochrane Database of Systematic Reviews 2013; Issue 7.
Patient Support
Higher levels of stress, anxiety, and depression
Psychosocial interventions can decrease stress and may
increase pregnancy rate
Sources: Vahratian A, Flynn H, Dorman M, Smith YR. Infertility treatment and psychosocial health
status. Fertility and Sterility 2008; 90: S383.
Frederiksen Y, Farver-Vestergaard I, Skovgård N, Ingerslev HJ, Zachariae R (2015) Efficacy of
psychosocial interventions for psychological and pregnancy outcomes in infertile women and
men: a systematic review and meta-analysis.
Patient Resources
• Resolve.org - national advocacy group, can search for
local support groups by zip code
• Womenshealth.gov - fact sheets for patients in English
and Spanish
• Familydoctor.org - patient handout on male infertility in
English and Spanish
• Reproductivefacts.org - ASRM patient education site
• Be Fruitful by Victoria Maizes - book on integrative
medicine and fertility
Practice Recommendations
• Couples should be evaluated if they have not become
pregnant after one year of regular intercourse. Consider
evaluation after six months if the female partner is >=
35 (SORT: C)
• Evaluation of the male and female partner should begin
at the same time (SORT: C)
• Recommended tests to confirm ovulation are
progesterone levels or urinary LH/ovulation detection
kits (SORT: C)
Contact Information
Heather L. Paladine, MD, Med, FAAFP
hlp222@gmail.com
@paladineh on Twitter