Reproductive Endocrinology and Infertility
Reproductive endocrinology and infertility tests the workup of infertility, ovulation disorders, polycystic ovary syndrome, endometriosis, and assisted reproduction. The OEOG favors first-line treatment choices and correct interpretation of hormone tests.
Core rules
- Infertility is failure to conceive after 12 months of unprotected intercourse, or 6 months if the woman is 35 or older. Initial workup includes semen analysis, ovulation assessment, tubal patency testing, and ovarian reserve testing.
- PCOS uses the Rotterdam criteria: two of three of oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology. Exclude thyroid disease, hyperprolactinemia, and nonclassic congenital adrenal hyperplasia.
- Letrozole is first-line ovulation induction for anovulatory PCOS and produces higher live birth rates than clomiphene. Metformin is used for insulin resistance and metabolic risk.
- Endometriosis is diagnosed by laparoscopy; hormonal suppression treats pain, while surgery is used for infertility or endometrioma.
- Recurrent pregnancy loss is three or more losses; check antiphospholipid antibodies, parental karyotype, uterine anatomy, and thyroid function.
Worked example
A 29-year-old with PCOS, BMI 32, and no menses for 4 months wants to conceive. Reasoning: start with lifestyle change and weight loss, then give letrozole 2.5-5 mg daily for 5 days. Check hCG if withdrawal bleeding does not occur. Do not start clomiphene first, because letrozole is the evidence-based first-line agent in PCOS.
Traps
- Using a day-21 progesterone level to confirm ovulation in a woman with irregular cycles.
- Missing hyperprolactinemia or thyroid disease before fertility treatment.
- Treating male factor infertility with intrauterine insemination without a semen analysis.