A 26-year-old woman comes to the office for infertility evaluation with her husband, age 30. They have been unable to conceive after 12 months of unprotected intercourse. The patient's menstrual periods are regular, occurring every 26 days with painful cramps the first day that are relieved with ibuprofen. Her last period began 6 days ago. She had 3 previous sexual partners without pregnancy. Both the patient and her husband report normal puberty, and neither have had any medical conditions or previous surgeries. The patient takes a daily prenatal vitamin. She is 155 cm (5 ft 1 in) tall and weighs 55 kg (121.3 lb). BMI is 23 kg/m². Blood pressure is 120/70 mm Hg and pulse is 70/min. Physical examination of the patient shows Tanner stage 5 breast development. Pelvic examination reveals a normal cervix; mobile, retroverted, nontender uterus; and no adnexal masses. Physical examination of the husband shows normal secondary sexual characteristics and bilaterally descended testes. Urine pregnancy test is negative. Which of the following is the best next step in evaluation of this couple's infertility?

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Quizplus · Accepted Answer

Infertility is defined as failure to achieve pregnancy after 12 months of unprotected sexual intercourse for a couple in which the woman is age <35. For women age >35, infertility evaluation can begin after 6 months without conception. This patient meets criteria for the diagnosis of infertility and should undergo further evaluation rather than reassurance alone (Choice G). The etiology of infertility is varied, with as many as 25% of cases due to male factor. Therefore, evaluation of an infertile couple includes identification of possible causes in both partners. The gold standard test for male factor infertility is semen analysis. It evaluates sperm concentration, motility, and morphology and allows for identification of azoospermia and severe oligospermia as obvious causes of infertility. Treatment of male factor infertility may include artificial insemination techniques and use of donor sperm. > (Choices A and E) A mid-luteal phase serum progesterone level and basal body temperature records are used to determine whether ovulation has occurred. These tests would be low yield as this patient has regular menses indicating regular ovulatory cycles. (Choice B) Endometrial biopsy was once used to confirm ovulation via sampling of secretory endometrium. This test is invasive and is not part of a routine evaluation of infertility. (Choice C) Evaluation for tubal factor infertility consists of hysterosalpingography. It is an invasive procedure performed if a patient has risk factors for tubal blockage (eg, pelvic inflammatory disease, endometriosis) and is not first-line evaluation. (Choice D) Karyotype analysis may reveal Turner syndrome in cases of abnormal pubertal development and ovarian failure, which are unlikely with regular menses and normal physical examination. (Choice F) Postcoital analysis of cervical mucus evaluates the interaction of sperm with cervical mucus; it is not routinely used due to its low diagnostic value. Educational objective: Infertility is failure to achieve pregnancy after 12 months of regular, unprotected sexual intercourse. Male factor infertility is the etiology in many couples; semen analysis is the gold standard test and is performed as part of the initial evaluation. References: What every gynecologist should know about male infertility: an update. (http://www.ncbi.nlm.nih.gov/pubmed/22392488) The male infertility office visit. (http://www.ncbi.nlm.nih.gov/pubmed/25604696)

A 26-Year-Old Woman Comes to the Office for Infertility Evaluation