Diagnosing infertility:

Epidemiology and initial

work-up

Anatte E. Karmon, MD

Disclosures- Anatte Karmon, MD

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•No financial relationships to

disclose

Objectives

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•Understand the prevalence of infertility

and its common causes

•Understand the disparities associated

with infertility care in the United States

•Follow evidence based practices

regarding the diagnosis and work-up of

infertility

At the end of this presentation, participants will be able to:

The definition of infertility

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• Inability of a couple, practicing frequent

intercourse and not using

contraception, to conceive a child

within 1 year

1 month – 25% conceive

6 months – 70%-80% conceive

1 year – 90% conceive

Fertility is highest in the first 3 months of attempting pregnancy

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• 80% will achieve pregnancy within 6

months

• Relative fertility decreased to about half

comparing women in late 30s to early

20s

• Semen parameters decline after 35, no

detectable decrease in fertility until 50

in men

ASRM. Fertil Steril. 2017 Jan;107(1):52-58.

Infertility is

common

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Treatments include:

• Oral medications

• Injectable medications

• In Vitro Fertilization (IVF)

• Intrauterine insemination (IUI)15-20%

What are the common causes of infertility?

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Male30%

Female35%

Unexplained25%

Combined10%

Age-related decline in fertility

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ASRM. Fertil Steril. 2017 Jan;107(1):52-58.

Access to ART services in the United States

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Adashi EY, Dean LA. Fertil Steril. 2016 May;105(5):1113-1118.

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Disparities in access to fertility care

ASRM. Fertil Steril. 2015 Nov;104(5):1104-10

Who seeks an infertility evaluation?

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Farland LV. Fertil Steril. 2016 May;105(5):1274-1280

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History

Day 3 endocrine labs, AMH

TSH and Prolactin

Pelvic ultrasound

Saline infusion Sonohysterography (SIS), HSG

Initial testing for female factor Initial testing for male factor

History

Semen analysis

TSH and Prolactin

Gonadotropins, estradiol, total T

Reasons for female infertility

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1 2

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Female

infertility

Egg quality/quantity Ovulatory

Uterine/Tubal Endometriosis

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• Day 3: Elevated FSH, elevated

estradiol

• Low AMH

• Low antral follicle count

• If premature ovarian insufficiency is

suspected:

• Fragile X, Karyotype, anti-adrenal

antibodies

Diminished ovarian reserve

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• Saline ultrasound or hysteroscopy:

• Mullerian anomaly, polyps, fibroids

• MRI in certain instances of

mullerian anomaly or fibroids

• 3D ultrasound

• HSG or saline sonoHSG: tubal patency

Uterine/ tubal factor

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• History

• Day 21 progesterone

• LH surge

• No evidence for current evaluation of

luteal insufficiency

• TSH, prolactin

Ovulatory

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• History

• Pelvic exam

• Pelvic ultrasound

• Laparoscopy

Endometriosis

1 9

• History

• Semen analysis

• Lab work

• Urology referral

Male factor

2 0

Take home message

• Infertility is common

• Clinicians should be aware of the

barriers to fertility care

• A basic evaluation can often diagnose

etiology of infertility and help guide

when a referral to a specialist is

necessary

Questions

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