Master the board step 3

Gynecology
Infertility
A 35-year-old woman comes to the gynecologist’s office complaining of infertility
for 1 year. She and her husband have been trying to achieve pregnancy for > 1 year
and have been unsuccessful. There is no previous history of pelvic inflammatory
disease, and she had used oral contraception medication for 6 years. The pelvic
examination is normal. Semen analysis is low volume and shows decreased sperm
density and low motility. What is the next step in management?
a. Administer testosterone
b. Measure serum testosterone
c. Measure thyroid hormone
d. Repeat semen analysis
e. Refer for intrauterine insemination
Answer: D. Because semen samples are variable, an abnormal semen analysis is repeated
in 4–6 weeks to confirm findings.
Infertility is defined as inability to achieve pregnancy after 12 months of unprotected
and frequent intercourse.
Steps in workup for infertility:
1. The first step is semen analysis.
2. If semen analysis is normal, work up for anovulation.
3. If semen analysis is normal and ovulation is confirmed, work up for fallopian
tube abnormalities.
Step Diagnosis Management
1. Semen Analysis Normal values:
• Volume > 2 mL; pH
7.2–7.8; sperm density
> 20 million/mL; sperm
motility > 50%; and
sperm morphology >
50% normal.
2. Anovulation • Basal body temperature
(BBT) chart: NO
midcycle temperature
elevation
• Progesterone: Low
• Endometrial biopsy:
Proliferative histology
• If values are abnormal, repeat the semen analysis in 4–6
weeks.
• Abnormal semen analysis: Intrauterine insemination,
intracytoplasmic sperm injection (ICSI), and in vitro
fertilization (IVF) are fertility options.
• No viable sperm: Artificial insemination by donor may be
used.
• Hypothyroidism or hyperprolactinemia are causes of
anovulation that can be treated.
• Ovulation induction:
– Clomiphene citrate is the agent of choice.
– Human menopausal gonadotrophin (hMG) is used if
clomiphene fails
– Most common side effect = ovarian hyperstimulation.
Ovarian size must be monitored during induction.
3. Tube Abnormalities:
Hysterosalpingogram
and Laparoscopy
• Chlamydia Antibody: A
negative IgG antibody
test for chlamydia rules
out infection-induced
tubal adhesions.
• Hysterosalpingogram (HSG): No further testing is
performed if the HSG shows normal anatomy.
• Laparoscopy: Performed with an abnormal HSG to visualize
the oviducts and attempt reconstruction (tuboplasty). If
tubal damage is severe, IVF should be planned.
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