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LEARNING OBJECTIVES

  1. Differentiate between primary and secondary infertility, and fecundity.

  2. Identify potential causes of female infertility.

  3. Formulate a strategy to evaluate women with infertility.

  4. Distinguish between different assisted reproductive technologies, their indication and potential complications.

  5. Develop a treatment plan for female infertility using pharmacological agents and monitoring for safety and efficacy.

INTRODUCTION

Infertility is defined by the World Health Organization (WHO) as a “disease of the reproductive system defined by the failure to achieve clinical pregnancy after 12 months of regular, unprotected sexual intercourse.1 Women who have not become pregnant after 1 year of regular intercourse without the use of birth control should consider getting an infertility evaluation.2 Women older than 35 years of age who have not become pregnant after 6 months of unprotected intercourse should consider obtaining an infertility evaluation.2 Fecundity is the likelihood of attaining a pregnancy within a given period. Fecundity rates vary by age. The probability of pregnancy following intercourse on any given day relative to ovulation for women 19 to 26 years of age is up to 50% compared to 25% for women 35 to 39 years of age.3 The cumulative probability of conception for couples using natural family planning at one, three, six, and twelve cycles was 38%, 68%, 81%, and 92%, respectively.4 The cause of infertility may be due to the male and/or female partner.

Infertility can be categorized as primary or secondary according to the World Health Organization.1 Primary infertility is when a woman is unable to ever bear a child either due to the inability to become pregnant or the inability to carry pregnancy to a live birth such as miscarriage.1 Secondary infertility is the inability to bear a child or carry a pregnancy to live birth following either a previous pregnancy or previous ability to carry a pregnancy to live birth.4 To some extent, this designation helps healthcare providers manage patients and identify causes of infertility.

EPIDEMIOLOGY

According to the National Survey of Family Growth from 2011 to 2015, 6.7% of US married women aged 15 to 44 are infertile.5 In the same survey, 12% or 7.3 million women aged 15 to 44 have ever used fertility services.5 The type of infertility services received were medical advice for infertility (6.3%), medical help to prevent miscarriage (5.4%), and infertility testing (5.2%).5 Infertility service use was highest among older and nulliparous women, women with current fertility problems, and women with higher levels of education and household income.6

Age and Fertility

After its peak in the early 20s, a woman’s fertility begins to decline; the decline becomes considerable when she reaches the late 30s.3 The causes of decreased fertility with aging are multiple: ovarian aging (the “biological clock”), gynecological diseases such as endometriosis (which interferes with conception), hormonal ...

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