question and answer
First steps when the baby doesn’t come
July 2010
How should a family doctor work up a couple who suspect infertility before deciding to refer to a specialist? I. D’Souza, Toronto, ON

Almost 1 in 6 couples will have trouble getting pregnant and that number increases to more than 50% after age 39. Female and male factor infertility each account for 40% of cases. In up to 20% of cases, the cause is unexplained.

In cases of primary or secondary infertility, the more information that can be passed on to the specialist at the time of consultation, the better.

Couples who haven’t conceived after one year of unprotected sexual intercourse should be offered investigations and referral to a specialist. In some situations, it may be appropriate to offer investigations or referral sooner. Women who are over age 35 or who have a history of amenorrhea/oligomenorrhea, previous abdominal/pelvic surgery, previous PID/STI, endometriosis, or an abnormal pelvic examination should be referred sooner. Early referral should also be considered for couples when the male partner has a history of urogenital surgery, previous STI, varicocele, or significant systemic illness.

Useful tests to consider for assessing fertility (and preparing for pregnancy) include: Day 3 levels of FSH and estradiol, TSH, prolactin, VZV IgG, rubella titre, blood type, HIV, hepatitis B and C. A mid-luteal phase progesterone done 7 days before the woman’s next expected menses (usually day 21) will help to determine if ovulation is occurring. A pelvic examination to check for any pelvic abnormalities and including a Pap test and cervical swabs for GC, CT, mycoplasma, and ureaplasma is also helpful. Some physicians may have access to ultrasound tests for tubal patency. If you don’t, the specialist will likely arrange a hysterosalpingogram at the time of consultation to determine if both fallopian tubes are patent. Don’t forget the male partner! A semen analysis should also be performed. It’s helpful if the female partner can bring a menstrual calendar to her appointment with the specialist.

Also, remember the importance of counselling on folic acid supplementation and smoking cessation while they’re trying to conceive. In addition, you might advise an overweight woman to aim for a BMI < 30 as this will often be relevant to their baseline fertility and ongoing management.

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