Reproductive Endocrinology, Infertility, and Family Planning
Core concepts
Reproductive endocrinology links the hypothalamic–pituitary–ovarian axis to clinical problems. Gonadotropin-releasing hormone pulses stimulate FSH and LH; the mid-cycle LH surge triggers ovulation. Infertility is the failure to conceive after 12 months of unprotected intercourse, or 6 months if the woman is over 35. Evaluation includes ovulation assessment, semen analysis, tubal patency, and uterine cavity assessment. PCOS is diagnosed by the Rotterdam criteria: two of three-oligo-ovulation, hyperandrogenism, and polycystic ovaries-after excluding alternatives. Ovulation induction uses letrozole or clomiphene; letrozole is often first-line in PCOS. Family planning requires matching method to medical eligibility. Combined hormonal contraception is contraindicated in migraine with aura, uncontrolled hypertension, and a history of venous thromboembolism. Emergency contraception includes copper IUD, ulipristal, and levonorgestrel.
Traps
Do not investigate infertility before the appropriate duration unless there is a known cause. Do not prescribe combined hormonal contraception in women with migraine with aura. Do not assume a normal semen analysis excludes male factor; repeat abnormal results.
Worked example
A 32-year-old woman with PCOS, BMI 34, and no comorbidities requests conception. First-line management is weight loss and letrozole ovulation induction. If she does not ovulate, consider metformin as an adjunct or gonadotropins, with monitoring for multiple pregnancy.
Rule of thumb: in infertility, treat the couple, not just the woman; and in contraception, use the WHO eligibility categories.