Female infertility is the next topic.
One should always suspect this when there is failure to
become pregnant after one year of unprotected intercourse,
in an average, on average twice weekly
in women younger than 35 years of age
and after six months
in women over age 35.
The history and physical exam has a
numerous clues that one should look for.
First of all, a menstrual history should
be obtained to determine ovulatory status,
the state of previous pregnancies, if they have
occurred and have been successful should be determined.
Has the patient been on prior
cancer therapy particularly agents
that are toxic to the gonads and
reproductive system and ovaries?
Has the patient had
prior substance abuse?
Do they have any sexually transmitted infections
or history of sexually transmitted infections?
Have they had pelvic
Have they also had any prior
that may have led to abnormalities
of the uterus or fallopian tubes.
And finally, the gynecological
procedures provide important information
about the anatomy of the patient in terms
of where to go with the further work-up.
Assessment of symptoms include
ruling out any thyroid dysfunction,
ruling out any galactorrhea
or abnormal milk production.
Assessing for hirsutism, determining whether
there is the presence of pelvic pain
and then any dysmenorrhea
There after, one should go on to do
an assessment for any clinical signs.
Firstly, is there any evidence of
Is the patient hirsute?
Do they have any features on the exam
that suggest that they are androgenized?
Also look for evidence of
estrogen deficiency clinically,
Do they have vaginal
Hyperprolactinemia, the clinical findings usually present
as galactorrhea which is excess milk production.
And then finally, do they have signs
clinically of thyroid dysfunction.
Is there a goiter, for
instance, in the the neck?
Here is an algorithm that helps you assess the female
reproductive axis and we'll go through this slowly.
First of all, we begin with pulses
of gonadotropin releasing hormone
that drive luteinizing
hormone and FSH production.
Luteinizing hormone affects the theca cells to
stimulate androgens, principally androstenedione.
Androstendione is metabolized to
estradiol in the granulosa cells.
FSH acts on the granulosa cells
to enhance follicle maturation.
And granulosa cells produce negative feedback
regulation through inhibin to regulate FSH production.
Ovulatory status is then assessed using
a midluteal phase progesterone level
obtained 1 week before
A progesterone level that is greater than
3 ng/mL is evidence of recent ovulation.
If anovulatory cycles are suspected, evaluation
including a prolactin level, a TSH and FSH measurement
with subsequent assessment for
polycystic ovary syndrome is warranted.
A hysterosalpingogram is used to assess for tubal
occlusion and to evaluate the uterine cavity.
This would be particularly important
in the case of Asherman syndrome
where the patient has undergone
prior currettages of the uterus.
An exploratory laparoscopy may be used if
endometriosis or pelvic adhesions are suspected.
In this manner, a laparoscope is
induced, is inserted into the peritoneum
to look for any areas of endometriosis that
may be contributing to the infertility.
If no abnormalities are found, fertility treatments will be
offered under the direction of a reproductive endocrinologist.
These treatments could include a variance stimulation with
clomiphine or letrozole or intrauterine insemination.
Also, in-vitro fertilization can be offered to women
age 40 years or older as the first line therapy.