Reproductive Endocrinology and Infertility
Domain overview
The Reproductive Endocrinology and Infertility domain tests infertility evaluation, ovulatory disorders, polycystic ovary syndrome (PCOS), menopause, and assisted reproduction. It emphasizes cost-effective workup and first-line treatment.
Core rules
- Infertility is failure to conceive after 12 months of regular unprotected intercourse. Evaluate after 6 months if the female partner is older than 35, and earlier if risk factors exist (irregular menses, pelvic surgery, known tubal disease).
- Initial workup includes semen analysis, ovulation assessment (cycle history, mid-luteal progesterone, or urinary LH), tubal patency testing (hysterosalpingography or saline infusion sonohysterography), and uterine cavity evaluation.
- PCOS is diagnosed by the Rotterdam criteria: two of three-oligo-ovulation or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound-after excluding other causes.
- Letrozole is first-line ovulation induction for anovulatory infertility, especially in PCOS; clomiphene is an alternative. Metformin may be added for insulin resistance.
- Menopause hormone therapy is indicated for vasomotor symptoms; use the lowest effective dose and add a progestogen if the uterus is present.
Worked example
A 32-year-old woman has 14 months of infertility and irregular cycles. Reasoning: irregular cycles suggest anovulation, commonly from PCOS. Check TSH and prolactin, obtain a semen analysis, and confirm tubal patency before treatment. Start letrozole for ovulation induction; if no response, escalate therapy.
Traps
Do not begin ovulation induction before confirming tubal patency and evaluating the partner. Do not assume regular cycles guarantee ovulation. Also, avoid clomiphene as first-line in PCOS when letrozole is available.