A 29-year-old woman comes to the office due to infertility. She has had unprotected intercourse with her husband regularly for the past year and has not become pregnant. The patient's last menstrual period was 3 weeks ago. Her menses occur every 28-30 days and last 4-5 days. The patient has severe lower abdominal pain that begins the day before her menses and is only partially relieved by ibuprofen. She was treated for gonococcal cervicitis at age 19. The patient takes a prenatal vitamin daily and does not use tobacco, alcohol, or illicit drugs. Her husband, age 31, recently had a normal semen analysis. The patient's blood pressure is 126/70 mm Hg and pulse is 85/min. BMI is 31 kg/m². Examination reveals a small uterus with a cervix that appears laterally displaced; there is pain with cervical manipulation. Which of the following is the most likely cause of this patient's infertility?

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11ec25c8_d9be_f4d9_bc81_e9e144b0557d_MD0003_00 This patient with severe dysmenorrhea and infertility (ie, no conception ≥12 months at age <35) most likely has endometriosis, ectopic endometrial implants within the abdomen and pelvis. Ectopic endometrial implants proliferate and shed with menses; because shedding occurs in the abdomen and has no outlet, patients can develop intraabdominal inflammation, fibrosis, and adhesions. ectopic endometrial implants Various implant locations (eg, uterus, bladder, bowel) can cause different presenting symptoms. Many patients have severe dysmenorrhea but seek medical attention only for infertility. In endometriosis, infertility is due to impaired tubal function (eg, tubal occlusion, decreased fimbrial mobility) from chronic inflammation and pelvic adhesion formation. Additional clinical findings include anatomic distortion (eg, lateral cervical displacement) and pain with cervical manipulation on examination (ie, cervical motion tenderness). Patients with dysmenorrhea and infertility due to suspected endometriosis require operative laparoscopy, which offers a definitive diagnosis (eg, visual inspection, biopsy) and improvement in pain symptoms and fertility. (Choice A) Endometrial polyps are benign growths of endometrial glands and stroma that can contribute to infertility; however, they typically present with painless intermenstrual spotting rather than dysmenorrhea and do not cause cervical motion tenderness. Endometrial polyps (Choice C) Endometritis (eg, untreated Neisseria gonorrhoeae cervicitis) may cause cervical motion tenderness and intrauterine adhesions that lead to infertility; however, patients typically have abnormal vaginal bleeding rather than regularly timed menses (eg, every 28-30 days). In addition, endometritis does not cause lateral cervical displacement. (Choice D) Submucosal fibroids may impinge on the endometrial lining and impair fertility; however, patients typically have heavy, prolonged menstrual bleeding rather than regular menses. In addition, submucosal fibroids do not cause cervical motion tenderness or lateral cervical displacement. fibroids (Choice E) A unicornuate uterus may cause obstetric complications but does not affect rates of conception. In addition, it does not cause pelvic pain. Educational objective: Endometriosis (ie, endometrial tissue implants outside of the uterus) can cause dysmenorrhea and infertility due to chronic intraabdominal inflammation and pelvic anatomy distortion. On examination, patients may have lateral cervical displacement or cervical motion tenderness. References: Endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/20573761) Clinical practice. Endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/20573927) Laparoscopic surgery for endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/24696265)

A 29-Year-Old Woman Comes to the Office Due to Infertility