Inability to conceive after 12 months of regular unprotected intercourse (6 mo if >=35).
Also known as: infertility, subfertility, infertility workup, male infertility, female infertility
Overview
Failure to achieve clinical pregnancy after 12 months of regular unprotected intercourse in women <35, or 6 months in women >=35. Earlier evaluation if known risk factors (oligomenorrhea, prior pelvic surgery or PID, endometriosis, known male factor).
Epidemiology
Affects ~10-15% of reproductive-age couples. Causes are roughly distributed: female factor 30-40% (ovulatory 25%, tubal/peritoneal 20%, uterine/cervical 5%), male factor 30-40%, combined 10-15%, unexplained 10-15%.
Try two board-style Infertility questions
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Question 1ReproductiveEasy
A 24-year-old female with prior chlamydia trachomatis cervicitis presents 5 years later with infertility. In the year following that infection she was hospitalized for fever and lower abdominal pain. She and her partner have had regular unprotected intercourse for 18 months without conception. Which of the following complications does this represent?
ACervical stenosis affecting sperm transport
BAsherman syndrome with endometrial synechiae
CTubal factor infertility
DEndometriosis from chronic inflammation
Reveal answer & full explanation
Correct answer: C — Tubal factor infertility
ACervical stenosis affecting sperm transport
BAsherman syndrome with endometrial synechiae
CTubal factor infertility✓
DEndometriosis from chronic inflammation
Why Tubal factor infertility is correct
Untreated chlamydia or gonorrhea ascends to the upper genital tract, causing pelvic inflammatory disease (PID), tubal scarring and adhesions, and tubal factor infertility (the most common cause of infertility from STI).
Each PID episode increases infertility risk: 12% after 1 episode, 25% after 2 episodes, 50% after 3 or more episodes.
PID also increases ectopic pregnancy risk.
Why the others are wrong
Cervical stenosis affecting sperm transport — not a recognized sequela of PID; PID affects the fallopian tubes, not primarily the cervix.
Asherman syndrome with endometrial synechiae — Asherman syndrome is intrauterine adhesion formation that occurs after uterine instrumentation (e.g., dilation and curettage), not from PID.
Endometriosis from chronic inflammation — endometriosis is not caused by chlamydia or PID; it is a separate condition involving ectopic endometrial implants.
Additional high-yield points
Prevention of tubal infertility includes sexually transmitted infection (STI) screening, prompt treatment, and partner notification.
Question 2ReproductiveMedium
A 41-year-old woman and her 39-year-old partner present for evaluation after 8 months of regular unprotected intercourse without conception. Her menstrual cycles occur every 28 to 30 days, and a mid-luteal progesterone level was 11 ng/mL. She has never been pregnant, has no history of pelvic infection or surgery, and reports no dysmenorrhea or dyspareunia. She has a 5 pack-year smoking history and a BMI of 27 kg/m2. Her partner's semen analysis is normal. Which of the following is the strongest risk factor for infertility in this couple?
AHistory of nulliparity
BOverweight body habitus
CActive tobacco smoking
DAdvanced maternal age
Reveal answer & full explanation
Correct answer: D — Advanced maternal age
AHistory of nulliparity
BOverweight body habitus
CActive tobacco smoking
DAdvanced maternal age✓
Why Advanced maternal age is correct
Female fertility declines with age, driven primarily by falling oocyte quality and quantity, and this decline accelerates sharply after age 35.
At 41 she has the single most powerful risk factor present; her regular cycles with a confirmatory mid-luteal progesterone above 3 ng/mL indicate she is ovulating, and her partner's semen analysis is normal, so age-related diminished oocyte quality is the dominant contributor.
Guidelines (ACOG/ASRM) advise women 35 and older to seek evaluation after 6 months and women 40 and older after 3 months precisely because of this accelerating age effect.
Why the others are wrong
Active tobacco smoking — Smoking is a genuine modifiable risk factor that lowers fecundity, but a modest 5 pack-year history is far weaker than her age in this scenario.
Overweight body habitus — A BMI of 27 is only mildly overweight; extremes of weight impair fertility, often through ovulatory dysfunction, but she is clearly ovulating and this confers minimal added risk.
History of nulliparity — Never having been pregnant is a descriptor of her reproductive history, not an independent causal risk factor for infertility, and carries little predictive weight relative to age.
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Reproductive success requires ovulation, sperm production and transport, fallopian tube patency, normal uterine cavity, and synchronized fertilization and implantation. Disruption at any step impairs fertility. Age-related decline in fertility is driven primarily by oocyte quality and quantity, accelerating after 35.
Clinical presentation
Symptoms
Inability to conceive over the defined interval
Menstrual history is critical — regular cycles 21-35 days suggest ovulation; irregular cycles suggest ovulatory dysfunction
Male factor — Abnormal semen analysis — first-line male evaluation
Unexplained infertility — Normal workup; treatment options include expectant, IUI with ovulation induction, or IVF
Diagnostic workup
Diagnostic criteria
Clinical: failure to conceive over the defined interval with sufficient evaluation to identify ovulation, tubal patency, uterine cavity, and male factor.
Ovarian reserve: AMH, day-3 FSH and estradiol, antral follicle count by transvaginal ultrasound — used to counsel regarding response to ovarian stimulation, NOT to predict spontaneous fertility
TSH, prolactin (universal); testosterone, DHEA-S, 17-OHP if hyperandrogenism suspected
Male: semen analysis after 2-5 days of abstinence — repeat if abnormal (volume >=1.5 mL, concentration >=15 million/mL, total motility >=40%, normal morphology >=4% by Kruger or >=30% WHO criteria)
Male further workup if abnormal: FSH, LH, testosterone (morning), prolactin, TSH; karyotype and Y-microdeletion if severe oligospermia or azoospermia
Hysterosalpingogram (HSG) — assesses tubal patency and uterine cavity; performed days 5-12 of the cycle
Saline-infusion sonohysterography (SIS) — superior for cavity (polyps, submucosal fibroids, septum)
Scrotal ultrasound in men with abnormal exam or semen analysis (varicocele)
Diagnostic algorithm
flowchart TD
A[Couple presents with infertility] --> B[Detailed history + exam]
B --> C[Semen analysis]
B --> D[Ovulation assessment<br/>menstrual hx, mid-luteal P4]
B --> E[Tubal/uterine: HSG or SIS]
B --> F[Ovarian reserve: AMH, AFC]
C --> G{Semen abnormal?}
G -->|Yes| H[Repeat + endocrine + scrotal US<br/>Urology referral]
D --> I{Ovulatory?}
I -->|No| J[Identify cause<br/>PCOS, HPRL, hypothalamic, thyroid]
J --> K[Ovulation induction<br/>letrozole > clomiphene; cabergoline if HPRL]
E --> L{Tubal/cavity normal?}
L -->|No| M[Hysteroscopic repair or IVF]
G & I & L -->|All normal| N[Unexplained infertility]
N --> O[IUI + stimulation x 3-4 cycles, then IVF]
Initial workup and treatment pathway for the infertile couple.
- PCOS: letrozole (first-line per ASRM; superior to clomiphene for live birth in PCOS); clomiphene citrate alternative; metformin alone or adjunctive in insulin-resistant patients
- Hypogonadotropic hypogonadism: pulsatile GnRH or exogenous gonadotropins (FSH/LH); restore weight/reduce exercise stress in hypothalamic amenorrhea
- Hyperprolactinemia: dopamine agonist (cabergoline preferred over bromocriptine)
Tubal disease: in vitro fertilization (IVF); salpingectomy of hydrosalpinx improves IVF success
Uterine factor: hysteroscopic polypectomy, myomectomy, septum resection, lysis of adhesions
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