creation date: 2026-01-08 23:12
tags: Workups
Female Infertility
Background
Female infertility refers to the inability to achieve pregnancy after 12 months of unprotected intercourse in women younger than 35 or 6 months in women 35 or older.
This affects 15% of couples. Female factors account for 50% of cases, male factors for 40%, and combined factors for the remaining 10%.
Pathophysiology
Disruptions to the mechanisms required for pregnancy results in infertility.
Ovulatory dysfunction
Conditions which impair follicular development (eg. PCOS) result in oligo- or anovulation.
Oocyte transport/tubal factors
Conditions which damages the fallopian tubes (eg. PID) compromises ciliary motility and oocyte transport. This prevents the oocyte from migrating to the uterus and implanting.
Additionally, alterations to anatomy and chronic inflammation (eg. endometriosis) can impair oocyte quality and implantation potential.
Uterine factors
Anatomical abnormalities may distort the endometrial cavity deminishing vascularity and receptivity for implantation.
Subclinical abnormalities
In 20% of cases, no underlying factor is apparent. Such case may be due to:
- Oocyte aneuploidy
- Accelerated oocyte aging
- Environmental explosures (eg. phthalates and particulates)
Differential Diagnosis
This list is non-exhaustive.
Ovulatory dysfunction
Conditions that result in oligo- or anovulation:
- Primary hypothalamic-pituitary dysfunction (results in low FSH/LH)
- Polycystic ovary syndrome
- Cushing’s/nonclassic congenital adrenal hyperplasia (androgen and cortisol excess disrupts GnRH)
- Hypothyroidism and hyperprolactinemia (prolactin suppresses GnRH)
Others:
- Oocyte aging (due to maternal age or ovarian insults such as smoking)
- Ovarian cyst (inconclusive evidence)
Tubal factors
Conditions that result in disease and pelvic adhesions:
- Pelvic inflammatory disease
- Severe endometriosis
- Adhesions from prior surgery or nontubal infections
- Pelvic tuberculosis
- Salpingitis isthmica nodosa
- Tubal blockage from mucus of debris
Anatomical factors
- Submucosal or intracavitary uterine fibroids
- Uterine abnormalities (eg. septate uterus)
- Cervix stenosis/instability
Initial Evaluation
When applicable, evaluation of both partners should be performed concurrently.
History
Important points to include:
- Duration of infertility and results of previous evaluation and therapy
- Menstrual history (for ovulatory status)
- Medical, surgical, and gynecologic history
- Obstetric history and events that may contribute to subsequent infertility
- Sexual history (incl. timing of coitus)
- Family history
- Personal and lifestyle history
Physical Exam
This should include:
- BMI calculation and fat distribution
- Signs of endocrinopathy (thyroid, PCOS, adrenal, hyperprolactinemia)
- Vaginal/cervical structural abnormalities
- Uterine anomaly
Investigations
Pre-referral investigations include:
- TSH
- FSH/LH
- Ruling out common causes (eg. PCOS) - TVUS
- Semen analysis
Other testing (likely done by reproductive endocrinologist/specialist) include:
- Documentation of normal ovulatory function
- Testing for tubal occlusion/uterine cavity (eg. hysterosalpingogram)
- Test of ovarian reserve (eg. Cycle day 3 FSH, estradiol, AMH)