A 32-year-old nulligravid woman comes to the office for evaluation of possible infertility. The patient underwent removal of a progestin-releasing intrauterine device (IUD) 13 months ago, and since then she has been having unprotected intercourse 3 or 4 times per week with her husband. The patient's menstrual cycles occur every 28-31 days with 3-5 days of light to moderate bleeding and no associated fatigue, cramping, or bloating. Her last menstrual period was 3 weeks ago. BMI is 28 kg/m². Vital signs are normal. Pelvic examination and transvaginal ultrasonography reveal an anteverted uterus and normal, bilateral adnexa. The remainder of the examination is normal. Her husband's semen analysis is normal. Hysterosalpingogram shows a normal uterine cavity and bilateral tubal patency. Which of the following is the best next step for this patient?

Question

A 32-year-old nulligravid woman comes to the office for evaluation of possible infertility.  The patient underwent removal of a progestin-releasing intrauterine device (IUD) 13 months ago, and since then she has been having unprotected intercourse 3 or 4 times per week with her husband.  The patient's menstrual cycles occur every 28-31 days with 3-5 days of light to moderate bleeding and no associated fatigue, cramping, or bloating.  Her last menstrual period was 3 weeks ago.  BMI is 28 kg/m².  Vital signs are normal.  Pelvic examination and transvaginal ultrasonography reveal an anteverted uterus and normal, bilateral adnexa.  The remainder of the examination is normal.  Her husband's semen analysis is normal.  Hysterosalpingogram shows a normal uterine cavity and bilateral tubal patency.  Which of the following is the best next step for this patient?

Quizplus · Accepted Answer

11ec25c8_d9c6_6ef5_bc81_fb16978fef2b_MD0003_00 Initial infertility evaluation includes male factor (eg, semen analysis) and female factor infertility testing (eg, testing for tubal patency, ovulatory function, ovarian reserve). This patient's hysterosalpingogram shows a normal uterine cavity and patent fallopian tubes. Her menstrual cycles occur monthly, which typically indicates normal ovulation. hysterosalpingogram Ovulation (ie, oocyte release) occurs on day 14 of the menstrual cycle, which is the end of the follicular phase characterized by increasing estrogen. After releasing the oocyte, the dominant ovarian follicle becomes the corpus luteum and secretes progesterone, marking the beginning of the luteal phase. The increasing progesterone level after ovulation causes molimina symptoms (eg, fatigue, bloating, premenstrual breast tenderness). Ovulation Menstrual bleeding accompanied by no molimina symptoms, as in this patient, could indicate an anovulatory menstrual cycle (with clinically normal menstrual bleeding); therefore, these patients should undergo ovulation testing. For example, patients with polycystic ovary syndrome are typically anovulatory but have elevated estrogen levels that cause endometrial thickening and shedding (menstrual bleeding) once the lining becomes too thick. To confirm ovulation, a serum midluteal phase progesterone level (ie, sample drawn on day 21 or 7 days before expected menses) is obtained. An elevated level (>3 ng/mL) reflects progesterone secretion by the corpus luteum and confirms recent ovulation; a low level suggests an anovulatory cycle. too thick (Choice A) In contrast to this patient, those with a hysterosalpingogram showing tubal occlusion may benefit from diagnostic laparoscopy to visualize and treat the underlying etiology (eg, intrapelvic adhesions, endometriosis). tubal occlusion (Choice B) Karyotyping can identify maternal chromosomal abnormalities that cause infertility, such as Turner syndrome (45,X) and primary ovarian insufficiency. However, these diagnoses are unlikely in this patient who has normal bilateral adnexa and no additional clinical features (eg, shield chest, premature menopause). Turner syndrome (Choice D) Removal of a progestin-releasing intrauterine device (IUD) typically causes a return to baseline fertility level within days to weeks. This patient's IUD was removed >1 year ago. (Choice E) Testosterone and dehydroepiandrosterone sulfate (DHEAS) levels can be used to diagnose polycystic ovary syndrome, which causes ovulatory dysfunction, hyperandrogenism (eg, cystic acne, hirsutism), and enlarged polycystic ovaries. This patient has normal-appearing ovaries on ultrasound, making this diagnosis less likely. Educational objective: The initial infertility evaluation includes a semen analysis in men and tests for tubal patency (eg, hysterosalpingogram), ovulatory function, and ovarian reserve in women. An elevated midluteal phase (ie, day 21) progesterone level confirms recent ovulation. References: Evaluation and treatment of infertility. (http://www.ncbi.nlm.nih.gov/pubmed/25822387) Proven and unproven methods for diagnosis and treatment of infertility. (http://www.ncbi.nlm.nih.gov/pubmed/31923772) Ovulation prevalence in women with spontaneous normal-length menstrual cycles-a population-based cohort from HUNT3, Norway. (http://www.ncbi.nlm.nih.gov/pubmed/26291617)

A 32-Year-Old Nulligravid Woman Comes to the Office for Evaluation