A 27-year-old nulligravid woman comes to the office with her husband due to inability to conceive. The patient and her husband stopped using barrier contraception a year ago and have intercourse every other day. The patient has a period every 28 days that lasts 5 days with 2 days of heavy flow. She has brief pelvic pain approximately 14 days after her period starts, but intercourse is not painful. In her late teens, the patient was hospitalized for a pelvic infection; during that time she had pain with intercourse, discharge, and fever. She has no other medical or surgical history. Her sister has polycystic ovarian syndrome. The patient's husband is age 31; he has no children, and his semen analysis is normal. The patient's blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination shows no abnormalities. Which of the following is the best next step in management of this patient?

Question

A 27-year-old nulligravid woman comes to the office with her husband due to inability to conceive.  The patient and her husband stopped using barrier contraception a year ago and have intercourse every other day.  The patient has a period every 28 days that lasts 5 days with 2 days of heavy flow.  She has brief pelvic pain approximately 14 days after her period starts, but intercourse is not painful.  In her late teens, the patient was hospitalized for a pelvic infection; during that time she had pain with intercourse, discharge, and fever.  She has no other medical or surgical history.  Her sister has polycystic ovarian syndrome.  The patient's husband is age 31; he has no children, and his semen analysis is normal.  The patient's blood pressure is 128/76 mm Hg and pulse is 82/min.  Physical examination shows no abnormalities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient has primary infertility, defined as failure to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient age <35. (After age 35, infertility investigation can begin after 6 months). Because the patient's partner has a normal semen analysis, female factor infertility is the likely etiology. This patient's history of hospitalization during adolescence is likely due to pelvic inflammatory disease (PID), an important cause of infertility due to tubal scarring and obstruction. The first-line imaging test to assess fallopian tube patency is a hysterosalpingogram, which involves infusion of radiocontrast into the cervix under fluoroscopy. Hysterosalpingogram is minimally invasive and also can identify uterine cavity anomalies (eg, bicornuate uterus). (Choice B) A laparoscopy is useful for direct visualization and treatment of peritoneal adhesions and endometriosis. Laparoscopy with chromotubation can be performed to assess for PID-related scarring inside the fallopian tubes; however, it is invasive, expensive, and generally not used first-line. (Choice C) A mid-cycle LH level is used to test for ovulation. The LH surge occurs 36 hours prior to ovulation and can be detected in urine and serum. The patient has regular menstrual cycles accompanied by mid-cycle pelvic pain (mittelschmerz), which suggests ovulation. Therefore, an LH level would not be useful. (Choice D) Ovarian reserve typically begins to decline at age 35, and serum FSH levels are increased in women who have a declining capacity to ovulate. This patient is considerably younger with regular menses, and so a decrease in ovum quantity is unlikely to be the cause of infertility. (Choice E) Increased serum androgen levels can suppress ovulation by suppressing GnRH and FSH release by feedback inhibition. Although the patient's sister has polycystic ovarian syndrome, the patient has regular cycles and no hyperandrogenic symptoms (eg, hirsutism, irregular menses). Educational objective: Primary infertility is failure to conceive after a year of unprotected sexual intercourse in a nulliparous patient age <35. A hysterosalpingogram is used to diagnose an anatomic cause of infertility such as tubal obstruction from prior pelvic infection. References: Anatomical causes of female infertility and their management. (http://www.ncbi.nlm.nih.gov/pubmed/24119894) Subclinical pelvic inflammatory disease and infertility. (http://www.ncbi.nlm.nih.gov/pubmed/22678036)

A 27-Year-Old Nulligravid Woman Comes to the Office with Her