Infertility
Differential Overview
Female Factors
❑ Anovulation
❑ Tubal obstruction
❑ Endometriosis
❑ Polycystic ovary disease
❑ Luteal phase dysfunction
❑ Cervical factors
❑ Uterine leiomyoma
❑ Testicular feminization
Male Factors
❑ Genitourinary infection
❑ Erectile dysfunction
❑ Drugs
❑ Retrograde ejaculation
❑ Varicocele
❑ Germinal compartment failure
❑ Partial androgen resistance
❑ Hypogonadotrophic hypogonadism
❑ Primary hypogonadism
Diagnostic Approach
Couples should be encouraged to attempt to conceive (unprotected intercourse) for 1 year before undergoing evaluation. Ovulation usually occurs if there have been spontaneous, regular, cyclic menses, but this can be confirmed by daily measurement of basal body temperature. The sperm count and motility can be ascertained to be adequate only by semen analysis. Male factors account for about 25% of infertility.
Interpersonal issues such as career stress, differences in desire for children (a clue is that one partner only seeks evaluation), or unacknowledged homosexual preference may interfere with effective coitus.
Clinical Findings
Anovulation Absence of a cyclical rise in basal temperature suggests lack of ovulation, the cause of 30% of female infertility.
Tubal obstruction Infertility caused by pelvic inflammatory disease may occur in 10% of patients following a single episode. Repeated episodes may increase the percentage to 75%.
Endometriosis Typical symptoms are pelvic pain with dysmenorrhea, and multiple, tender nodules along the uterosacral ligament on rectovaginal exam, a posteriorly fixed uterus, and enlarged, cystic ovaries.
Polycystic ovary disease Virilization, menstrual abnormalities, and large cystic ovaries are clues.
Luteal phase dysfunction Ovulation occurs, as documented by basal temperature records, but there may be evidence of inadequate estrogen production by the dominant follicle, preventing implantation.
Cervical factors The cervical mucous should be examined for viable sperm, following coitus, ideally just before ovulation.
Uterine leiomyoma The uterus has knobby projections on examination.
Testicular feminization The patient has well-developed breasts but lacks pubic and axillary hair, ovaries, and a uterus.
Genitourinary infection Occult prostatitis with mild prostate tenderness should be sought. Qualitative sperm changes and leukocytes appear in the semen.
Erectile dysfunction This is evident by history.
Drugs Alcohol or marijuana is often associated with testicular atrophy. Antihypertensive medications may produce problems via impotence.
Retrograde ejaculation The male partner will experience orgasm without ejaculation. Look for sperm on urinalysis. Diabetes and prior urologic surgery are common underlying causes.
Varicocele A “bag of worms” is visible and palpable in the scrotum. Testicular size may be reduced. A Valsalva maneuver with the patient examined standing may uncover a subtle varicocele.
Germinal compartment failure A history of adult mumps, trauma, cryptorchidism, or irradiation will be elicited. One or both testes will be atrophic.
Partial androgen resistance Gynecomastia is present.
Hypogonadotrophic hypogonadism Because it is usually due to hypopituitarism, other endocrine deficiencies are present. Androgen deficiency is suggested by spare pubic, axillary and facial hair, decreased oiliness of the skin and soft artophic testicles.
Primary hypogonadism Klinefelter syndrome is recognized by the presence of long limbs, azoospermia, and small testes.
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Infertility
Read excerpts from these other book chapters related to Infertility:
Medical Books Excerpts
- AMENORRHEA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Amenorrhea
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Amenorrhea
- "A Pocket Manual of Differential Diagnosis" (1999)
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- Amenorrhea
- "Professional Guide to Diseases (Eighth Edition)" (2005)
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- Amenorrhea
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Amenorrhea
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Amenorrhea
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
More About Causes of Infertility
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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» Next page: Secondary Amenorrhea (Field Guide to Bedside Diagnosis)
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