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GYN
CMECNE

Infertility Evaluation: Who, When and How

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Apply the appropriate infertility workup
2. Identify who should be evaluated for reduced ovarian reserve

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

Women who fail to achieve a successful pregnancy after 12 months of regular, unprotected intercourse should be evaluated with the diagnosis of infertility. Evaluation should be initiated after 6 months for women >35 years. If over 40 years of age, an even more rapid evaluation “is warranted”.

Indications for Immediate Evaluation Include 

  • History of oligo / amenorrhea | Known/ suspected uterine, tubal,  peritoneal disease | Endometriosis (stage III/IV) | Known/ suspected male factor subfertility

Definition of Unexplained Infertility (30% of infertile couples) 

  • Above definition of infertility is met
  • Infertility evaluation is normal
  • Minimum evaluation: Confirm ovulatory function | Tubal patency | Semen analysis

CLINICAL ACTIONS:

Relevant History

  • Infertility related
    • Menstrual history
    • Pregnancy history
    • Previous contraception
    • Frequency of intercourse
    • Previous evaluations and treatments
    • Family history of reproductive problems and birth defects
  • Surgical history
  • History of endocrine abnormalities such as
    • Hypothyroidism
    • Hyperprolactinemia
  • Abnormal cervical cancer screening and treatments
  • Medications and allergies including
    • Occupational exposures
    • Tobacco, alcohol, drugs

Physical Exam

  • Vital signs including BMI
  • Thyroid exam
  • Breast exam
  • Evaluation of androgen excess
    • Acne
    • Hirsutism
    • Male pattern balding
    • Clitoromegaly
    • Pelvic examination including evaluation of cul de sac masses / nodularity

Ovulatory Dysfunction Evaluation

  • Menstrual history of abnormal bleeding / oligo or amenorrhea
    • Regular menses likely to be ovulating
    • Cycles can be from 25 to 35 days, but if regular and especially if menstrual molimina is present, ovulatory function is likely to be normal
  • Serial basal body temperature
  • Serum progesterone approx. 1 week prior to menses
    • >3 ng/mL (15.9 nmol per L) indicates ovulation
  • Urinary LH (ovulation predictor kits)
  • Cervical mucous changes (clear, stretchy)

Note: Test TSH (thyroid function) and prolactin (hyperprolactinemia) in women with ovulatory dysfunction

Ovarian Reserve Assessment

  • Ovarian reserve testing may be of help in the following scenarios (higher risk for diminished ovarian reserve)
    • > 35 years
    • Unexplained infertility
    • Planning ART
    • Poor response to GnRH stimulation
    • Have family history of early menopause
    • At higher risk of diminished ovarian reserve (e.g., chemotherapy and/or pelvic irradiation; ovarian surgery for endometriomas)
  • Ovarian reserve can be measured by the following
    • Basal FSH and estradiol (E2) levels on days 2-5
      • FSH > 10 IU/L: Lesser response to ovarian stimulation
    • Serum anti-Mullerian hormone (AMH) levels (independent of day): <1 ng/mL
    • Antral follicle count on cycle day 2-5 (early follicular phase)
      • Low count: Fewer than 5 to 7 follicles
  • The best surrogate marker for oocyte quality is age
  • Note: Unexplained diminished ovarian reserve or elevated FSH <40 years: Offer Fragile X carrier screening for FMR1 premutation (associated with premature ovarian failure)

SYNOPSIS:

Evaluation of women for infertility should be timely, cost effective, and initially focused on the most common causes of infertility such as ovulatory dysfunction. If ovulatory function is normal, uterine anatomy and tubal patency should be investigated.  Tests for ovarian reserve can not predict failure to conceive and therefore should not be used to deny fertility treatment. Ovarian reserve testing should not be used to predict the likelihood of spontaneous conception or menopause.

KEY POINTS:

  • Cervical factors are rarely the primary cause of infertility
    • Treat cervicitis if noted
    • Post coital tests are no longer recommended
  • Uterine abnormalities can be evaluated with
    • Sonohysterography: Can detect abnormal intrauterine structures
    • Hysteroscopy: Definitive diagnosis under direct visualization
    • HSG: While lower sensitivity (e.g., only 50% sensitivity of polyps, can detect Müllerian anomalies
    • Ultrasound (3-D) & Pelvic MRI: Confirmation and diagnosis of Müllerian anomalies
  • Tubal Patency
    • Evaluate with with hysterosalpingogram (HSG)
    • Contrast sonohysterography
      • No FDA approved contrast agents available in the US | “Role of tubal patency is evolving as more data on its use are available”
  • Peritoneal factors (endometriosis / pelvic adhesions) requires laparoscopy for diagnosis
    • If assisted reproductive technology is warranted based on severe male factor infertility or known tubal occlusion, laparoscopy may not be necessary and it is not recommended for routine evaluation of the infertile woman without pelvic pathology
  • Male Factor
    • ACOG/ ASRM recommends evaluating both partners at the same time due to high percentage of infertility caused by male factor (40 to 50%)
    • Minimal evaluation: Reproductive history and semen analysis
  • Diagnostic code:
    • Female infertility associated with anovulation N97.0
    • Female infertility of tubal origin N97.1
    • Female infertilty of uterine origin N97.2
    • Female infertility of other origin N97.8
    • Female infertility, unspecified N97.9

Learn More – Primary Sources:

ACOG and ASRM Committee Opinion 781: Infertility Workup for the Women’s Health Specialist

ACOG Committee Opinion 773: The Use of Antimüllerian Hormone in Women Not Seeking Fertility Care

Locate a Reproductive Endocrinologist:

REI Locator – ASRM

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Related ObG Topics:

Managing Abnormal Uterine Bleeding with Ovulatory Dysfunction
Secondary Amenorrhea: Workup and Diagnosis  
Prolactinoma: Early Detection, Evaluation and Management
Do AMH Levels Truly Predict Ovarian Reserve in Women Over 30?

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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