HISTORY AND EVALUATION
1. Definition: Infertility is generally defined as the inability to achieve a conception after 1 year of unprotected intercourse.
a. Infertility affects 13% to 15% of married couples in the United States.
b. An episode of infertility will be experienced by 25% of women during their reproductive years.
3. Evaluation of the infertile female. a. History; A detailed patient history is important.
(1) Age of patient: fertility decreases with increasing age
(2) Exposure to chemicals, toxins, or radiation in the work environment
(3) Smokers: three to four times more likely to experience longer than a 1-year delay to conception when compared with non-smokers; a relative risk of 3:1 for an ectopic pregnancy when compared with control pregnant patients
(4) Caffeine: may be associated with an increased risk of miscarriage
(5) Alcohol use
(6) Current drugs or medications
(a) Antihistamines: can decrease mucus production and also diminish vaginal lubrication
(b) Nonsteroidal antiinflammatory drugs: can inhibit the luteinizing hormone (LH) surge
(c) Barbiturates: can decrease or inhibit gonadotropin-releasing hormone (GnRH) release
(7) Excessive physical activity: can lead to anovulatory cycles
(8) Marital history
(a) Number of years
(b) Contraception used
(9) Sexual intercourse
(a) Frequency: times per month
(b) Adequate penetration
(c) Ejaculation: retrograde, normal
(d) Difficulties: impotence
(e) Coital positions
(0 Use of lubricants: type
(g) Pain or discomfort: either partner
(i) Masturbation: frequency, especially by the male partner
(10) Pregnancy history
(a) All pregnancies: term, preterm, abortions
(g) Abortions: date, length of pregnancy, complications
(h) Number of natural children
(11) Previous marriages: all partners
(a) Number of years
(b) Contraception use: number of years, type
(12) Past workup
(a) Tests performed: repeating same tests should be avoided
(b) Dates, results, physician’s name
(13) Menstrual history
(a) Age at onset of menses
(b) Age of sexual development
(c) Present menstrual cycle
(i) Length: start to start
(ii) Duration of flow
(iii) Date of last menstrual period
(i) What was the age of onset?
(ii) Does it occur with each cycle?
(e) Vaginal discharge
(i) Color: Green or bright yellow is abnormal.
(ii) Odor: If odor present, it should be cultured.
(iii) Irritation: Wet mount and culture ate probably required.
(14) Medical history
(d) Blood transfusion
(e) Pelvic infection: syphilis, gonorrhea, Chlamydia
(f) Thyroid disease
(g) Other chronic medical problems b. Physical examination.
(1) Head, ears, eyes, nose, and throat.
(a) Clinicians should be alert for exophthalmos (Graves’ disease).
(b) The thyroid should be palpated to check for enlargement or nodules.
(a) A complete breast examination is necessary.
(b) Clinicians should be alert for galactorrhea; if present, prolactin and thyroid-stimulating hormone (TSH) should be checked.
(c) Of patients with polycystic ovaries (PCO), 25% will have hyperprolactinemia.
(a) Clinicians should palpate to check for masses.
(b) Often, myomas can be palpated abdominally.
(4) External genitalia: The size of the clitoris should be carefully examined. Enlargement is a sign of excessive androgens.
(a) A yearly Papanicolaou smear should be performed.
(b) Clinicians should observe for scarring secondary to cones, cryotherapy, and Loop electrosurgical excision procedure (LEEP).
(c) Observe the canal for signs of stenosis.
(6) Uterus, ovaries.
(c) Fixed vs. mobile
(d) Contour: smooth versus nodular