Medico

Med Clin N Am
92 (2008) 1163–1192

Basic Infertility Including Polycystic
Ovary Syndrome
Maryse Brassard, MDa, Youssef AinMelk, MDb,
Jean-Patrice Baillargeon, MD, MSca,*
a

Division of Endocrinology, Department of Medicine, Universite´ de Sherbrooke,
3001, 12th North Avenue, Sherbrooke, QC J1H 5N4, Canada
b
Department of Obstetrics and Gynecology, Universite´ de Sherbrooke, 3001,12th North Avenue, Sherbrooke, QC J1H 5N4, Canada

Infertility is the inability of a couple to conceive after 12 months of
unprotected and frequent intercourse. It affects about 10% to 15% of couples [1]. Cycle fecundability is the probability that a single cycle will result in
pregnancy and is approximately 20% in normal couples [2]. It typically
decreases with age. The fertility rate indeveloped countries has declined
in recent years and can be attributed mainly to delayed childbearing.
The effect of aging on female fertility is clear: In women, the fertility peak
is between the ages of 20 and 24 years, decreases slightly by age 32, and then
declines progressively and more rapidly after age 40 [3,4]. Decreasing
fertility is associated with increasing pregnancy wastage. Spontaneousmiscarriage increases from 10% in younger women to 40% at age 40, even with
assisted reproductive technology. This increase is due to progressive follicular depletion and a high incidence of abnormalities in aging oocytes, mainly
aneuploidy.
In addition to age, other factors that influence fertility include lifestyle
(smoking, alcohol, caffeine, drugs, and body mass index) and the timing
andfrequency of intercourse. Normal sperm can survive at least 3 days,
but an oocyte can be fertilized for only 12 to 24 hours.
The major causes of infertility include tubal and peritoneal pathology
(30%–40%), ovulatory dysfunction (15%), and male factor (30%–40%)
[5]. Uterine and cervical factors are uncommon. Patients without an

This work was supported by Personal Award #12131 to Jean-PatriceBaillargeon from
´
´
the Fonds de la recherche en sante du Quebec.
* Corresponding author.
E-mail address: jp.baillargeon@usherbrooke.ca (J-P. Baillargeon).
0025-7125/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.mcna.2008.04.008
medical.theclinics.com

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BRASSARD

et al

identifiable cause are classified as unexplained infertility (10%).Ovulatory
dysfunction and unexplained infertility have the best prognosis. This article
reviews the evaluation and treatment of female infertility.

Initial evaluation
The evaluation should be initiated after 12 months of unprotected intercourse, at which time 85% of couples attempting conception will have been
successful [6]. In women between 35 and 40 years of age, assessment should
beconsidered after 6 months. In such females with oligomenorrhea or
amenorrhea, or a history of pelvic infection or chemotherapy [1], assessment
should be considered sooner.
Initial evaluation includes a complete medical history, physical examination, and screening tests for cervical dysplasia and sexually transmitted
infections, including gonorrhea and chlamydia. Basic testing consists of
semenanalysis, documentation of ovulation (eg, midluteal phase progesterone level above 6.5 ng/mL followed by menstrual bleeding within 2 weeks),
and a hysterosalpingogram to assess possible tubal factors. If an obvious
cause, such as oligoanovulation, is determined during initial clinical evaluation, semen analysis and hysterosalpingogram can be postponed until after
resolution of this condition,assuming that infertility persists. The next steps
in the evaluation of female infertility are based on the most probable causes
initially identified. These are discussed in this article and summarized in
Fig. 1.

Tubal and peritoneal pathology
Tubal factors
Approximately 20% of female infertility results from tubal disease. This
disease can be suspected by a history of pelvic infection disease...