Before Your First: Infertility Clinic

Walking into your first infertility clinic visit and not sure what to expect? In this episode, Dr. Valdez-Sinon walks through the definition of infertility, how to take a thorough history for both partners, the key workup for ovulatory, tubal, uterine, and male factors, and when to refer to REI. Definition What is infertility? • Failure to achieve pregnancy after 12 months of regular unprotected intercourse — for patients under 35 • Shorten to 6 months for patients 35 and older • Anyone 40+ should be seen as soon as they start trying — don't wait • Immediate evaluation warranted for: • Oligomenorrhea or amenorrhea • Known uterine or tubal disease • Stage III/IV endometriosis • Resource: ACOG Committee Opinion No. 781 (https://www.acog.org/clinical/clinica...)  and ASRM guidelines (https://www.asrm.org/practice-guidanc...) History & Exam HISTORY — PATIENT • Comprehensive medical and surgical history • Menstrual history — are cycles regular? (regular cycles suggest ovulation, but ~1/3 of regular cyclers can still be anovulatory) • Full GYN history — pelvic infections, STIs, known fibroids, endometriosis • Prior pregnancies with previous partners? (establishes primary vs. secondary infertility) • Ask about: thyroid disease, galactorrhea, hirsutism, pelvic/abdominal pain, dyspareunia • Family history: developmental delay, early menopause, reproductive problems • Social history: tobacco, alcohol, recreational drugs HISTORY — PARTNER • Obtain medical and reproductive history — pregnancy takes two • Prior pregnancies with previous partners? • Intercourse frequency — ideally unprotected sex ~2x/week PHYSICAL EXAM • Vitals, weight and BMI — extremes affect fertility • Thyroid exam; breast exam (look for galactorrhea if indicated) • Signs of androgen excess — acne, hirsutism, male-pattern hair • Pelvic exam — uterine size, shape, mobility; adnexal masses or tenderness Ovarian & Ovulatory Evaluation COMMON CAUSES • PCOS — most common cause of ovulatory-related infertility • Primary ovarian insufficiency (POI) • Thyroid disease, hyperprolactinemia WORK-UP • Mid-luteal progesterone — obtain ~day 21 of a 28-day cycle; value ＞3 ng/mL suggests ovulation • For PCOS evaluation: LH, FSH, testosterone • Thyroid function studies and prolactin as indicated • Ovarian reserve: • Antral follicle count on early-cycle ultrasound • AMH — value ＜1 ng/mL suggests diminished ovarian reserve • A low AMH does not mean infertility — it only takes one egg. AMH estimates ovarian reserve and responsiveness to gonadotropins for IVF/oocyte preservation. TREATMENT FOR ANOVULATION • Ovulation induction with clomiphene (estrogen receptor antagonist) or letrozole (aromatase inhibitor) Tubal Evaluation • HSG (hysterosalpingogram) — gold standard for tubal patency • Radio-opaque dye injected through cervix; X-ray visualizes "fill and spill" through tubes • Low positive predictive value — non-patency needs follow-up • Hydrosalpinx: salpingectomy often recommended before IVF — fluid impairs implantation • Known tubal factor → IVF required for conception Uterine Evaluation • Look for: polyps, fibroids, septum, adhesions (synechiae) — ＞16% of patients with infertility have a uterine abnormality on sono • Saline infusion sonogram (SIS) — preferred over standard TVUS; saline distends the cavity to reveal lesions • 3D ultrasound can also be helpful • Follow-up hysteroscopy — both diagnostic and therapeutic Sperm / Male-Factor Evaluation • Male factor contributes to infertility in 40–50% of couples — do not overlook • Semen analysis — gold standard; order early in the evaluation • At-home semen tests available as a screening step if insurance or access is a barrier Quick Recap & Intern Pearls BUCKETS OF INFERTILITY • Female factor (~ovarian, tubal, or uterine) • Male factor (40–50% of couples) • Unexp...