Snapshot A couple presents to the specialist clinic after a 12-month history of failure to conceive with regular unprotected vaginal sexual intercourse. They are both in their late thirties. Introduction Defined by failure to conceive after a 12-month period of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility 10-15% of couples have infertility Causes include abnormal spermatogenesis (40%) anovulation (30%) anatomic defects of female reproductive tract (20%) unknown (10%) Male Dysfunction (40%) Initially work up male most common, less expensive workup Normal semen excludes male cause in 90% of couples Look for varicoceles in males Ovulatory Problems (30%) Symptoms suggestive of anovulation amenorrhea irregular menses hirsutism acne galactorhea Evaluation: r/o prolactinoma basal body temperture evaluation (excellent screening test for ovulation) FSH measurement serum progesterone endometrial biopsy Treatment: restore ovulation with ovulation inducing medications clomiphene as first line an estrogen antoagonist that relieves negative feedback on FSH and allows follicle development 40% get pregnant 10% multiple births FSH as second line 70% get pregnant 20% multiple births Anatomic Factors (20%) PID especially acure salpingitis secondary to N. gonorrhoaeae or C. trachomatis Endometriosis Asherman's Syndrome Intrauterine adhesions result from scar formation after uterine surgery (D&C most common) Evaluation Hysterosalpingogram to rule out anatomic abnormality Treatment surgical lysis of pelvic adhesions assisted fertilization (in vitro) if endosalpinx not intact and ovum transport not possible 20% success