| Fecundity | Ability to become pregnant |
|---|---|
| Fecundability | Probability of pregnancy per menstrual cycle |
| Primary **Infertility | |
| (**nulliparous) | • Age <35: No pregnancy in ≥12 months of unprotected sex |
| • Age ≥35: No pregnancy in ≥6 months of unprotected sex |
<aside> 💡 In healthy couples, the probability of pregnancy (ie, fecundability) is 15%-30% per menstrual cycle, and 80%-90% will conceive within a year of unprotected intercourse.
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<aside> 💡 The unprotected intercourse should be regular or apropiately timed
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Other factors that warrant immediate evaluation of infertility include menstrual cycle abnormalities, endometriosis, history of uterine, tubal, or peritoneal disease, and suspected or known male partner infertility. This 32-year-old woman has regular menses, an unremarkable medical history, and no abnormalities on physical examination. Her husband has a history of successfully managed gonorrhea 10 years ago and shows no abnormalities on physical examination. They both appear to be healthy and have only been trying to conceive for 6 months, so they do not meet the criteria for infertility evaluation. At this time, the couple only requires reassurance and a follow-up in 6 months if the issue persists.
Up to 40% of cases are due to male factor infertility; therefore, men are evaluated with semen analysis ( noninvasive and low-cost)
<aside> 💡 Male factor infertility is a common cause, and the initial evaluation for infertility includes semen analysis.
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A normal semen analysis makes female factor infertility most likely. which most commonly occurs due to anatomic disorders (eg, fallopian tube obstruction), ovulatory dysfunction (eg, anovulation), or diminished ovarian reserve. Therefore, the initial evaluation includes assessments of tubal patency, ovulation, and ovarian reserve
noninvasive testing (eg, AMH level) is performed prior to invasive testing.
| Etiology | Diagnostic test |
|---|---|
| Male factor | • Semen analysis |
| Ovulatory function | • Midluteal phase (day 21) progesterone level |
| • Menstrual history (regular + molimina syx) | |
| Ovarian reserve | • Day 3 FSH & estradiol levels |
| • Clomiphene citrate challenge test | |
| • Antral follicle count | |
| • Antimüllerian hormone | |
| Fallopian tube patency | • Hysterosalpingogram |
| Uterine cavity evaluation | • Sonohysterogram |
Ovarian reserve refers to the quantity and quality of a patient's remaining oocytes (ie, primordial follicle pool), which naturally diminish with age. A serum marker of ovarian reserve is antimüllerian hormone (AMH), which is released by small preantral ovarian follicles as they are recruited from the primordial pool and mature. Therefore, in patients with infertility, low AMH levels typically reflect a smaller primordial pool and diminished ovarian reserve.