Before Your First: Infertility Clinic

Walking into your first infertility clinic visit and not sure what to expect? In this episode, Dr. Valdez-Sinon walks through the definition of infertility, how to take a thorough history for both partners, the key workup for ovulatory, tubal, uterine, and male factors, and when to refer to REI. Definition What is infertility? Failure to achieve pregnancy after 12 months of regular unprotected intercourse — for patients under 35 Shorten to 6 months for patients 35 and older Anyone 40+ should be seen as soon as they start trying — don't wait Immediate evaluation warranted for: Oligomenorrhea or amenorrhea Known uterine or tubal disease Stage III/IV endometriosis Resource: ACOG Committee Opinion No. 781 and ASRM guidelines History & Exam HISTORY — PATIENT Comprehensive medical and surgical history Menstrual history — are cycles regular? (regular cycles suggest ovulation, but ~1/3 of regular cyclers can still be anovulatory) Full GYN history — pelvic infections, STIs, known fibroids, endometriosis Prior pregnancies with previous partners? (establishes primary vs. secondary infertility) Ask about: thyroid disease, galactorrhea, hirsutism, pelvic/abdominal pain, dyspareunia Family history: developmental delay, early menopause, reproductive problems Social history: tobacco, alcohol, recreational drugs HISTORY — PARTNER Obtain medical and reproductive history — pregnancy takes two Prior pregnancies with previous partners? Intercourse frequency — ideally unprotected sex ~2x/week PHYSICAL EXAM Vitals, weight and BMI — extremes affect fertility Thyroid exam; breast exam (look for galactorrhea if indicated) Signs of androgen excess — acne, hirsutism, male-pattern hair Pelvic exam — uterine size, shape, mobility; adnexal masses or tenderness Ovarian & Ovulatory Evaluation COMMON CAUSES PCOS — most common cause of ovulatory-related infertility Primary ovarian insufficiency (POI) Thyroid disease, hyperprolactinemia WORK-UP Mid-luteal progesterone — obtain ~day 21 of a 28-day cycle; value >3 ng/mL suggests ovulation For PCOS evaluation: LH, FSH, testosterone Thyroid function studies and prolactin as indicated Ovarian reserve: Antral follicle count on early-cycle ultrasound AMH — value <1 ng/mL suggests diminished ovarian reserve A low AMH does not mean infertility — it only takes one egg. AMH estimates ovarian reserve and responsiveness to gonadotropins for IVF/oocyte preservation. TREATMENT FOR ANOVULATION Ovulation induction with clomiphene (estrogen receptor antagonist) or letrozole (aromatase inhibitor) Tubal Evaluation HSG (hysterosalpingogram) — gold standard for tubal patency Radio-opaque dye injected through cervix; X-ray visualizes "fill and spill" through tubes Low positive predictive value — non-patency needs follow-up Hydrosalpinx: salpingectomy often recommended before IVF — fluid impairs implantation Known tubal factor → IVF required for conception Uterine Evaluation Look for: polyps, fibroids, septum, adhesions (synechiae) — >16% of patients with infertility have a uterine abnormality on sono Saline infusion sonogram (SIS) — preferred over standa...