STUDENT PROBLEM-BASED LEARNING SESSION

Infertility

Clinical Case:

A 37-year-old female and her 37-year-old husband present with the complaint of a possible fertility problem. The couple has been married for 2 years. The patient has a 4-year-old daughter from a previous relationship. The patient used birth control pills until one-and-a- half-years-ago. The couple has been trying to conceive since then and report a high degree of stress related to their lack of success. The patient reports good health and no problems in conceiving her previous pregnancy or in the vaginal delivery of her daughter. She reports that her periods were regular on the birth control pill, but have been irregular since she discontinued taking them. She reports having periods every 5-7 weeks. Past history is remarkable only for mild depression. Imipramine 150 mg qhs for the last 8 months is her only medication. She works as a cashier, runs 12-24 miles each week for the last 2 years, and has no history of STDs, abnormal Paps, smoking, alcohol or other drugs. She has had no surgery.

The patient's partner also reports good health and reports no problems with erection, ejaculation or pain with intercourse. He has had no prior urogenital infections or exposure to STDs. He has had unprotected sex prior to his current relationship, but has not knowingly conceived. He has no medical problems or past surgery. He works as a long-distance truck driver and is on the road 2-3 weeks each month. He smokes a pack of cigarettes a day since age 18 and drinks 2-3 cans of beer 3-4 times a week when he's not driving. He occasionally uses amphetamines to stay awake while driving at night. The couple has vaginal intercourse 3-5 times per week when he is at home.

The patient is 5'9 and weighs 130 pounds. Breast exam reveals no tenderness or masses, but bilateral galactorrhea on compression of the areola. Pelvic exam reveals normal genitalia, a well-estrogenized vaginal vault mucosa and cervical mucus consistent with the proliferative phase. The uterus is anteflexed and normal in size without masses or tenderness. Several tests were ordered.

Discussion questions:

  1. What is the definition of infertility?
  2. What are the etiologies of infertility?
  3. What is the initial work-up for infertile couples and what tests would you add for this particular couple?
  4. Studies were reviewed and showed a normal TSH, a prolactin of 60 ng/ml (normal range < 20 ng/ml) and a semen analysis with 2cc of semen, 4 million sperm per ml, 30% normal forms and 20% motility. Basal body temperature chart shows a monophasic temperature graph. What is the differential diagnosis at this point?
  5. What is the appropriate management for both these diagnoses?

References:

  1. Obstetrics and Gynecology by Beckmann 5 th Edition, 2006; Chapter 39 Infertility. Pages 384-395.
  2. Essentials of Obstetrics and Gynecology by Hacker and Moore 4 th Edition, 2004; Chapter 35 Infertility and Assisted Reproductive Technologies. Pages 413-421.

The evaluation and management of an infertile couple requires an understanding of the processes of conception and embryogenesis, as well as sensitivity to the emotional stress that can result from the inability to conceive.

The APGO Educational Objectives related to this topic are the following:

  1. Define infertility *
  2. Describe the causes of male and female infertility *
  3. Describe the evaluation and management of infertility
  4. List the psychosocial issues associated with infertility

*Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th Edition

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