A 27-year-old woman, gravida 0 para 0, comes to the office with her husband for an infertility evaluation. The patient discontinued her combination oral contraceptive pills 14 months ago, and the couple has been trying to conceive since that time. The patient was initially placed on oral contraceptives at age 19 for dysmenorrhea. Her menstrual periods occur every 27 days; she has 3 days of light bleeding with painful cramping moderately controlled with aspirin, acetaminophen, and heating pads. For the last 8 months, the couple has had intercourse at least every other day from day 9 to day 16 of the patient's cycle. The patient has no chronic medical conditions and has had no surgery. She takes a daily prenatal vitamin. The patient has no history of abnormal Pap tests or sexually transmitted infections. She does not use tobacco, alcohol, or illicit drugs. Her husband is age 34 and has no children from previous relationships. He has no chronic medical conditions or previous surgery. He reports normal pubertal development. The patient's blood pressure is 120/70 mm Hg and pulse is 76/min. Height is 157.5 cm (5 ft 2 in) and BMI is 24 kg/m². Pelvic examination reveals a well-rugated vagina, a small anteverted uterus, and no adnexal masses. Physical examination of the husband shows normal secondary sexual characteristics and bilaterally descended testes. Which of the following is the most appropriate response to this couple's inability to conceive?

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Quizplus · Accepted Answer

Explanation: Infertility is defined as a couple's inability to conceive after >12 months of appropriately timed intercourse without contraception. For women age >35, evaluation occurs after >6 months of infertility. Male factor infertility is a common cause of infertility; the most common etiologies are testicular or genetic defects (eg, Klinefelter syndrome, varicocele) that result in changes in sperm quality and function. A semen analysis, a noninvasive, low-cost test, is the gold standard in evaluation of the male partner and is the first step in an infertility evaluation. Sperm volume, pH, concentration, motility, and morphology are assessed; if abnormal, infertility can be treated with intrauterine insemination or in-vitro fertilization. (Choice A) For most women, ovulation and fertility return within a month of discontinuing oral contraceptives. Patients unable to conceive for >12 months require investigation, regardless of prior methods of contraception. (Choice B) A history of regular menses suggests ovulation, and mid-luteal serum progesterone to confirm ovulation is not indicated. (Choice D) Chromosomal abnormalities may be suspected in cases of recurrent pregnancy loss (>3 spontaneous abortions) or cases of abnormal semen analysis (eg, azoospermia, oligospermia). Klinefelter syndrome (47, XXY) is the most common chromosomal cause of male infertility; typical examination findings include gynecomastia and cryptorchidism, not seen in this case. Klinefelter syndrome (Choice E) Laparoscopy is indicated if endometriosis (eg, chronic pelvic pain, immobile uterus, pelvic nodularity) is suspected, as resection improves pregnancy rates. However, it is not a first-line procedure for infertility, particularly in patients without findings suggestive of pelvic pathology. Educational objective: Infertility is defined as a couple's inability to conceive after >12 months of appropriately timed, unprotected intercourse. Initial evaluation includes a semen analysis, a noninvasive, low-cost test to detect male factor infertility. References: Trends of male factor infertility, an important cause of infertility: A review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/26752853)

A 27-Year-Old Woman, Gravida 0 Para 0, Comes to the Office