Clinical Case 47 - Infertility

TEACHING CASE 47
Infertility
Student Handout
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.
r 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-
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.
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:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 39 Infertility. Pages 384-395.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 35 Infertility
and Assisted Reproductive Technologies. Pages 413-421.
Infertility
Preceptor Handout
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:
A. Define infertility *
B. Describe the causes of male and female infertility *
C. Describe the evaluation and management of infertility
D. List the psychosocial issues associated with infertility
*Designated as Priority One in the APGO Medical Student Educational Objectives, 8 th

Edition
Infertility
Preceptor Handout
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.
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-
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.
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 orderd.
Discussion Questions:
1. What is the definition of infertility?
Inability to become pregnant despite 12 months of trying to conceive

without using contraception. About 15% of couples experience this
problem.
2. What are the etiologies of infertility?
Ovulatory dysfunction (around 20%) - anovulation

Male factor (around 30%) decreased sperm count, decreased motility or
normal forms
Tubal and pelvic (30%) tubal damage due to pelvic infection, pelvic
factor - endometriosis, pelvic adhesions
Unexplained (10%)
Unusual problems (10%)
3. What is the initial work-up for infertile couples and what tests would you add for
this particular couple?
Physical examination
Medical history
Semen analysis
Check for ovulation basal body temperature, ovulation prediction kits,
luteal phase serum progesterone
Hysterosalpingogram: check for normal uterus and open fallopian tubes
Discussion about frequency and timing of intercourse
For this couple specifically, TSH and prolactin
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? Imipramine, a monoamine oxidase inhibitor stimulates prolactin
production because it decreases dopamine which inhibits secretion
of prolactin.
Anovulation secondary to hyperprolactinemia from imipramine
Oligospermia repeat semen analysis once or twice to confirm the
diagnosis
5. What is the appropriate management for both these diagnoses?
For anovulation secondary to imipramine, the patient should taper her

imipramine. If she was still anovulatory, the patient could empirically use
clomiphene citrate for ovulation induction
For oligospermia, options include in vitro fertilization, artificial
sperm, adoption.
References:
Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 39 Infertility. Pages 384-395.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 35 Infertility
and Assisted Reproductive Technologies. Pages 413-421.

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TEACHING CASE 47

1. What is the definition of infertility?

2. What are the etiologies of infertility?

5. What is the appropriate management for both these diagnoses?

The evaluation and management of an infertile couple requires an understanding of the

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

ejaculation or pain with intercourse. He has had no prior urogenital infections or

1. What is the definition of infertility?

Inability to become pregnant despite 12 months of trying to conceive

2. What are the etiologies of infertility?

Ovulatory dysfunction (around 20%) - anovulation

4. Studies were reviewed and showed a normal TSH, a prolactin of 60 ng/ml

5. What is the appropriate management for both these diagnoses?

For anovulation secondary to imipramine, the patient should taper her

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