Continuing Education Activity

Infertility is a medical condition that can cause psychological, physical, mental, spiritual, and medical detriments to the patient. The unique quality of this medical condition involves affecting both the patient and the patient's partner as a couple. Although male infertility is an important part of any infertility discussion, this topic reviews the evaluation, management, and treatment of female infertility. To understand infertility, one must understand normal fecundability, the probability of achieving pregnancy in one menstrual cycle. This activity reviews the evaluation, management, and treatment of female infertility and highlights the interprofessional healthcare team's role in improving care for this patient population.

Objectives:

• Identify the epidemiology of female infertility.
• Evaluate the most common findings of female infertility.
• Determine how best to manage female infertility.
• Communicate the importance of improving healthcare coordination among the interprofessional team to enhance and improve outcomes for female patients with infertility.

Introduction

Infertility is a medical condition that can cause psychological, physical, mental, spiritual, and medical detriments to the patient. The unique quality of this medical condition involves affecting both the patient and the patient's partner as a couple. Although male infertility is an important part of any infertility discussion, this topic reviews the evaluation, management, and treatment of female infertility. To understand infertility, one must understand normal fecundability, the probability of achieving pregnancy in 1 menstrual cycle. This basic understanding helps the healthcare team properly counsel the patient on referrals and provide basic education and understanding of this medical condition. 

The research community has established a fecundability rate multiple times, which has helped establish normal pregnancy rates to assist in diagnosing infertility. The largest study identified that 85% of women would conceive within 12 months. Based on this study's findings, fecundability is 25% in the first 3 months of unprotected intercourse and then decreased to 15% for the remaining 9 months.[1] This research has helped the American Society of Reproductive Medicine (ASRM) establish when a couple should undergo an infertility evaluation. The ASRM recommends initiating an evaluation for infertility after failing to achieve pregnancy within 12 months of unprotected intercourse or therapeutic donor insemination in women younger than 35 years or within 6 months in women older than 35.[2]

Etiology

The World Health Organization (WHO) performed a large multinational study to determine gender distribution and infertility etiologies. In 37% of infertile couples, female infertility was the cause; in 35% of couples, both male and female causes were identified; in 8%, there was male factor infertility.[3] In the same study, the most common identifiable factors of female infertility are as follows:

• Ovulatory disorders: 25%
• Endometriosis: 15%
• Pelvic adhesions: 12%
• Tubal blockage: 11%
• Other tubal/uterine abnormalities: 11%
• Hyperprolactinemia: 7%

These causes are further investigated in later portions of this topic; male and unknown factors are outside the scope of this topic. Even though these factors are not discussed here, it is important to realize that male factor infertility represents a substantial portion of the identifiable factors causing infertility.

Epidemiology

In a study conducted by the National Survey of Family Growth that interviewed 12,000 women in the United States, the prevalence of infertility decreased with the increase in the woman’s age.[4] As a woman gets older, her chances of infertility increase. In women aged 15 to 34 years, infertility rates ranged from 7.3% to 9.1%. In women ages 35 to 39 years old, the infertility rates increased to 25%. Lastly, women from ages 40 to 44 years had a 30% chance of infertility.[4] Worldwide, infertility rates are higher in Eastern Europe, North Africa, and the Middle East. Worldwide, 2% of women aged 20 to 44 were never able to have a live birth, and 11% with a previous live birth were unable to have an additional birth.[5]

Pathophysiology

Anovulation

Ovulatory disorders make up 25% of the known causes of female infertility. Oligo-ovulation or anovulation results in infertility because no oocyte are released monthly. Without an oocyte, there is no opportunity for fertilization and pregnancy. To help with treatment and further classification, the World Health Organization subdivided ovulatory disorders into 4 classes:

1. Hypogonadotropic hypogonadal anovulation: Hypothalamic amenorrhea
2. Normogonadotropic normoestrogenic anovulation: Polycystic ovarian syndrome (PCOS)
3. Hypergonadotropic hypoestrogenic anovulation: Premature ovarian failure
4. Hyperprolactinemic anovulation: Pituitary adenoma

Hypothalamic amenorrhea or functional hypothalamic amenorrhea (FHA) is associated with eating disorders and excessive exercise, which results in a decrease in hypothalamic GnRH secretion.[6] The decreased caloric intake, associated weight loss, or excessive exercise leads to elevated cortisol, which causes a suppression of GnRH.[7] The decreased or absent pulsatility of GnRH results in a decrease in the release of gonadotropins, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) from the anterior pituitary gland. These 2 deficiencies result in abnormal follicle growth, anovulation, and low estrogen levels.[8] The FSH and LH have variations ranging from normal to low, but the hormone ratio resembles a prepubertal female, with FSH higher than LH.[8] 

The most common type of Normogonadotropic normoestrogenic anovulation is PCOS. PCOS accounts for 80% to 85% of all anovulatory patients and affects 8% of all reproductive-aged females.[9] PCOS can be diagnosed using the Rotterdam criteria, which requires at least 2 of the 3 below-listed criteria in the absence of other pathological causes:

• Oligoovulation/anovulation
• Clinical signs of hyperandrogenism or serological elevations of androgens
• Polycystic ovaries demonstrated with ultrasound [10]

Infertility caused by PCOS is thought to be associated with a dysfunction in developing a mature follicle, leading to anovulation. The FSH and estrogen are be within normal laboratory limits. The LH can either be normal or elevated. The pathophysiology behind PCOS and infertility is not well understood; classically, abnormal pulsatility of GnRH is described as a possible underlying cause. Correlating the high number of arrested follicles and polycystic-appearing ovaries is the elevation of the anti-Mullerian hormone (AMH).[11] 

Hypergonadotropic hypoestrogenic anovulation is the category of premature ovarian insufficiency and ovarian resistance associated with females' age. As mentioned before, a woman’s age affects fertility due to a well-studied phenomenon of a steady decline in the quality and quantity of the patient’s oocytes. In quantity, the female fetus at 20 weeks gestation has roughly 6 million follicles. The newborn has approximately 1 million follicles. At the onset of puberty, the number of follicles decreases to 300,000.[12] The rate of follicle loss continues throughout a woman’s life and increases in rate around her mid-thirties.[13] External factors are also associated with decreased follicular quantity. The most notable and highly researched is cigarette smoking. Fecundability and follicular quantity are both inversely proportional to the amount of cigarette smoking. Early menopause (under 40 years old) is also associated with cigarette smoking; there is a more than 30% increase in early menopause among ever-smokers.[14]

Ovarian quality is also essential to overall fertility. The loss of the oocyte quality throughout a woman’s life is associated with meiotic nondisjunction, resulting in aneuploidy. This is thought to be related to accumulated damage throughout life and age-related changes in the granulosa cells.[15] As women age, there is a significant increase in the number of meiotic nondisjunction events and corresponding aneuploid or chromosomally abnormal oocytes and embryos.[15]

Primary ovarian insufficiency (POI) is defined as hypergonadotropic hypogonadism before the age of 40. This disease is characterized by a lack of folliculogenesis, a decrease in estrogen, loss of oocytes, and infertility.[16] The most common cause of POI is Turner syndrome, monosomy of the sex chromosomes leading to a 45X karyotype.[17] Further discussion of Turner syndrome is outside the scope of this manuscript. 

As mentioned above, the WHO recognizes prolactinemia as a leading cause of female infertility; however, the ASRM recently published guidelines that the initial workup does not need to include prolactin.[2] Prolactin causes suppression of hypothalamic GnRH secretion, leading to a low LH, resulting in anovulation, corresponding oligomenorrhea, or amenorrhea. Prolactin serum values of 20 to 50 ng/mL cause insufficient progesterone release from the corpus luteum, which shortens the luteal phase. Although controversial, prolactinemia is described as an etiology of luteal phase defects leading to infertility. Prolactin values of 50 to 100 ng/mL cause amenorrhea or oligomenorrhea due to abnormal feedback on the hypothalamic-pituitary-ovarian axis. A concentration greater than 100 ng/mL is associated with overt hypogonadism and amenorrhea and is most commonly associated with pituitary adenomas.[18] 

Endometriosis

Endometriosis is defined as endometrial tissue outside the uterine cavity. The diagnosis is based on the histological identification of endometrial glands or stroma outside the uterus. Endometriosis is most commonly found in the pelvis but can spread throughout the entire abdomen and affects 10% to 15% of reproductive-age women.[19] Of women with endometriosis, 40% to 50% experience infertility.[20] Endometriosis is categorized into 4 stages, according to the American Society of Reproductive Medicine, with stage I being minimal and stage IV severe. Endometriosis is known to cause infertility, but the pathophysiology is thought to change according to the stage.[21] For stages I and II, infertility is believed to be associated with inflammation and increased production of prostaglandins and cytokines, macrophages, and natural killer cells. [22] The inflammation impairs ovarian and tubal function, resulting in defective follicular formation, fertilization, and implantation.[23] Stages III and IV are associated with pelvic adhesions or masses that distort pelvic anatomy; this inherently impairs tubal motility, oocyte release, and sperm motility.[24] Also, advanced endometriosis is hypothesized to impair folliculogenesis, reducing fertilization potential.[25] 

Pelvic/Tubal Adhesions

Pelvic and tubal adhesions, along with uterine and tubal abnormalities, account for a large portion of female infertility. Infectious processes within the abdomen are the leading cause of pelvic/tubal adhesions; the most common infectious process to affect infertility is pelvic inflammatory disease (PID). The microorganism that carries the greatest risk of infertility in association with PID is Chlamydia trachomatis. One in 4 women with tubal factor infertility has positive antibodies to chlamydia, which are inversely proportional to pregnancy rates.[26] The number of PID episodes and the severity play a role in the likelihood of infertility. One study demonstrated that the pregnancy rates following PID were 89% after 1 episode, 77% after two episodes, and 46% after 3 episodes.[27] Regarding PID severity of mild, moderate, and severe, the live-birth rates were 90%, 82%, and 57%, respectively.[28]

Hydrosalpinges, are a tubal abnormality caused by acute and chronic inflammation that damages the structural integrity of the fallopian. This damage leads to tubal obstruction, which blocks the distribution of physiologic fluid in the fallopian tube and results in fluid accumulation. The belief is that hydrosalpinges impair fertility through the retrograde flow of toxins and prostaglandins into the endometrium, creating a hostile environment for implantation by impairing endometrial receptivity.[29] The literature has demonstrated that patients undergoing in-vitro fertilization have a 50% decrease in pregnancy if a hydrosalpinx is present.[30]

Uterine Causes

Uterine causes of infertility are associated with either space-occupying lesions or reduced endometrial receptivity. In regards to uterine leiomyomas (fibroids), 1 meta-analysis demonstrated that only submucosal or intracavitary fibroids impaired implantation and pregnancy rates compared to other infertile controls.[31] Congenital uterine abnormalities (CUA), although rare, are also associated with infertility. Most commonly found are uterine septums, which are also associated with recurrent pregnancy loss. Interestingly, one study demonstrated that the prevalence of CUA in the fertile and infertile population is the same.[32] Infertility due to CUA is thought to account for roughly 8% of the female causes of infertility; however, 25% of women with late first-trimester or second-trimester miscarriages are found to have CUAs.[33] A detailed discussion of the classifications and pathophysiology of CUAs is outside the scope of this manuscript.

History and Physical

Infertility evaluation is indicated in women with unsuccessful pregnancies after 12 months of unprotected regular intercourse or 6 months if they are over 35 years old.[34] This topic focuses on female infertility, but it is essential to remember that a male infertility evaluation is needed and should be initiated simultaneously. For women planning to use donor sperm, they should receive the same female infertility workup before inseminations.[2] The key aspects of the history of the infertile woman are listed below:

• Duration of infertility
• Obstetrical history
• Menstrual history, including molimina
• Medical, surgical, and gynecological history to include a history of sexually transmitted infections
• Sexual history to include coital frequency and timing

  • Focusing on the male partner, which includes issues with erection and ejaculation
• Social and lifestyle history to include cigarettes, alcohol, and illicit drug use, exercise, and diet, occupation
• Family history, screening for genetic issues, history of venous thrombotic events, recurrent pregnancy loss, and infertility

 The physical exam should include the following:

• Vital signs and body mass index
• Thyroid evaluation
• Breast exam for galactorrhea
• Signs of androgen excess: dermatological and external genitalia exam
• The appearance of abnormal vaginal or cervical anatomy
• Pelvic masses or tenderness
• Uterine enlargement or irregularity
• Transvaginal ultrasonography is often done at the bedside as part of the initial physical exam

Evaluation

The 5 diagnostic evaluation categories are:

1. Semen analysis
2. Assessment of ovarian function and reserve
3. Assessment of the uterine cavity
4. Assessment of the fallopian tubes
5. Endocrinological serum studies

The evaluation and interpretation of a semen analysis are outside the scope of this review; however, the importance of this test as part of the initial evaluation before initiating treatments cannot be reiterated enough.

Assessment of ovarian function can be as simple as the menstrual cycle history. Women with predictable, regular cycles and predictable menstrual flow and molimina (bloating, fatigue, breast tenderness) are more than likely ovulating. At-home urinary LH predictor kits detect a mid-cycle LH surge, which is indirect evidence of ovulation and helps identify the fertile window.[35] Ovulation can also be detected by a cycle day 21 progesterone serum level or, more accurately, a mid-luteal phase progesterone level. The lab should be taken approximately 1 week before menses, and a progesterone lab value greater than 3 ng/mL is evidence of ovulation.[36] A more invasive, more accurate, but likely unnecessary means of determining ovulation is daily ultrasounds for following the growth and disappearance of a follicle.[37]

There are multiple available tests to assess ovarian reserve, and this topic only discusses the 2 most common: Cycle day 3 FSH and estradiol and Anti-Mullerian hormone (AMH). The theory of day 3 FSH and estradiol is that women with good ovarian reserve have early sufficient ovarian hormones from small follicles to allow FSH to remain lower. According to multiple examples in the literature, it is most important to identify women with a reduced follicle count that produces insufficient hormones, causing a lack of inhibition, resulting in an elevated FSH. FSH levels less than 10 IU/mL demonstrate likely normal ovarian reserve, 10 to 20 IU/mL is intermediate, and an FSH greater than 20 IU/mL is a poor prognosis for spontaneous ovulation due to low ovarian reserve. According to one study, the pregnancy rates per natural menstrual cycle, corresponding to the FSH levels above, are 32%, 17% to 19%, and 3%.[38] Day 3 estradiol less than 80 pg/mL is normal with adequate ovarian reserve. Values greater than 80 pg/mL resulted in lower pregnancy rates, and values >100 pg/mL had a 0% pregnancy rate.[39]

AMH is a hormone expressed by preantral and antral follicles, representing a marker of ovarian function that can be measured at any time during a woman’s cycle.[40] The AMH levels gradually decline throughout a woman’s natural reproductive life to undetectable levels at menopause.[41] AMH levels seem to be a good predictor of exogenous gonadotropin response[42]:

• Less than 0.5 ng/mL: Predicts difficulty getting more than 3 follicles to grow
• Less than 1.0 ng/mL: Shows limited egg supply that may require more aggressive ovulation induction protocols
• 1.0 to 3.5 ng/mL: Shows normal values
• Greater than 3.5: Shows ample supply and may require mild induction to prevent ovarian hyperstimulation syndrome

It is important to remember that the available ovarian reserve tests are reliable in predicting ovulation induction difficulties but are not diagnostic in predicting live births. They should not be used to exclude patients from in vitro fertilization (IVF) treatment.[43] 

Antral follicle counts, measuring the number of follicles less than 9mm in the ovaries with transvaginal ultrasound in the early follicular phase, is also an accurate measure of ovarian reserve and predictive of ovarian response to stimulation.[44]

Tubal Evaluation

The gold standard for the evaluation of tubal patency is laparoscopy with chromopertubation. Laparoscopy is indicated as a first-line diagnostic test for suspected pelvic adhesions, endometriosis, or other pelvic pathologies; however, due to high specificity and being less invasive, the hysterosalpingogram (HSG) is more commonly used for the first-line evaluation for tubal patency and abnormalities.[45] The ability to detect abnormalities is best for proximal occlusion, followed by distal occlusions; however, the HSG has poor predictability for intrauterine and tubal adhesions.[46] Another added benefit of the HSG is increased pregnancy and live birth rates with oil-soluble media. A meta-analysis showed that after HSG, pregnancy, and live birth rates increased compared to controls (overall response, 2.98; 95% CI 1.05-6.37).[47] 

Uterine Cavity

The gold standard for assessing the uterine cavity is hysteroscopy, which allows direct visualization of the intrauterine pathology and provides an opportunity for immediate surgical correction. Although hysteroscopy is considered the gold standard, a less invasive approach is more commonly utilized with a saline infusion sonogram (SIS). The SIS is highly sensitive and specific for all intrauterine abnormalities and is adequate as a screening tool before infertility treatment, with or without 3-D model rendering.[48]

Treatment / Management

Lifestyle Changes

Women with extremes in body mass index (BMI) frequently present with infertility and ovulatory dysfunction.[49] Women with a BMI of less than 17 kg/m^2 with a history of intense exercise regimens or women with eating disorders are likely to develop hypogonadotropic hypogonadism, which causes decreased pituitary gonadotropin secretions.[50] In The United States, controlled ovarian stimulation using exogenous gonadotropins is used to induce ovulation; however, in Europe, women who fail to respond to therapy can receive pulsatile GnRH therapy.[51] One study demonstrated the importance of behavioral change in inducing ovulation. Of the women who received individual-directed therapy to correct energy deficiencies or behavior problems, 87% resumed regular ovarian function to correct the abnormal BMI.[52]

Women with a BMI greater than 27 kg/m^2 with anovulation can improve ovulation with weight loss alone. Multiple studies have shown that losing 10% of body weight restores normal ovulation in 50% to 100% of women in less than 1 year.[53] Even though weight loss is important for many aspects of a patient's life, one study showed that obese women who received counseling and interventions for weight loss before infertility treatment did not have higher pregnancy or live birth rates compared to obese women who had infertility treatment without weight-loss interventions. Therefore, a specific BMI is not required to initiate fertility treatment.[54]

Controlled Ovarian Hyperstimulation

The first-line medication for infertility of unknown origin and the medication most providers use is clomiphene citrate (CC). Clomiphene is a selective estrogen receptor modulator (SERM) with estrogen antagonists and agonist effects that ultimately increase gonadotropin release from the anterior pituitary. Clomiphene treats WHO class 2 anovulation effectively but is ineffective in WHO class 1 and class 3 anovulation. Clomiphene is dosed starting at 50mg starting on cycle days 2, 3, 4, or 5 for 5 sequential days. The couple is encouraged to have intercourse every other day for 1 week, beginning 5 days after the last pill. However, the odds of pregnancy may be increased when clomiphene is combined with intrauterine insemination (IUI). There is little difference in the results of ovulation, pregnancy, or live birth regarding which day the medication is started, between cycle days 2 to 5.[55]

Another commonly used oral medication for ovulation induction is letrozole. Letrozole is an aromatase inhibitor that prevents estrogen production by preventing the conversion of androstenedione and testosterone to estrone and estradiol.[56] Letrozole is FDA-indicated for the extended adjuvant treatment of breast cancer, and its use for ovulation induction is considered off-label. However, an abundance of scientific literature and multiple committee opinions support both the efficacy and safety of its use in ovulation induction. Letrozole is dosed starting at 2.5, 5, or 7.5 mg/day on cycle days 3, 4, 5, 6, and 7, with intercourse every other day 5 days after completing the medication, which is similar to clomiphene. According to ACOG, letrozole should be considered the first-line treatment for women with PCOS over clomiphene.[57] The benefits of letrozole over clomiphene are:

• Higher rate of monofollicular development and a corresponding decrease in twin gestations
• Shorter half-life
• No antiestrogenic effects on the endometrium and central nervous system
• Lower estradiol levels, which is a benefit for women with breast cancer undergoing IVF 

Letrozole's beneficial profile compared to clomiphene may replace clomiphene as a first-line treatment.[58]

Gonadotropin therapy is a more intensive medical regimen used for WHO Class 1, 2, or 3 anovulatory disorders. Gonadotropins are beneficial as a second-line treatment option for women who fail to conceive after multiple cycles of clomiphene. There is one study that showed an increased live birth rate with gonadotropins compared to continued clomiphene usage.[59] Multiple dosing protocols are used depending on the provider's preferences and on the infertility treatment decided. Those protocols are outside the scope of this review. However, it is important to discuss that close monitoring is required while using more invasive and intensive gonadotropins. To evaluate mature follicles, transvaginal ultrasounds are used to monitor follicular growth every 2 to 3 days during the late follicular phase. A mature follicle is over 18 mm in diameter, and estradiol levels are greater than 200 pg/mL. Once a mature follicle is identified, a 250 mg recombinant HCG subcutaneous injection or intramuscular injection of 10,000U of urinary-derived HCG is given to trigger ovulation.[60] Once the trigger shot is given, an IUI occurs 24-36 hours later. IUIs can be used in combination with all ovarian induction agents, and IUI with medication is encouraged to increase pregnancy rates, which is discussed below. There is unclear evidence as to the superiority of allowing a natural LH surge versus an HCG trigger before IUI. A meta-analysis completed in 2010 showed no clear evidence of 1 treatment option over the other, and the treatment choice should be based on cost, hospital staffing restrictions, and patient convenience.[61] 

Tubal and Pelvic Adhesions 

In vitro fertilization (IVF) is the first-line treatment for bilateral tubal factor infertility. Tubal corrective surgeries have worse pregnancy outcomes and have an increased risk of ectopic pregnancy. Women with severe tubal disease, including hydrosalpinx, are encouraged to have a bilateral salpingectomy to increase the pregnancy rate of IVF.[62] For women with mild distal tubal disease, fimbrioplasty is an option to allow for multiple pregnancies without IVF. One small study showed that the pregnancy rate was equal to IVF for mild tubal disease, but the risk of ectopic pregnancy was 15% compared to 0.7% for IVF treatment.[63]

The patients with a prior bilateral salpingectomy or tubal ligation for contraception are an important tubal factor population. It is always important for healthcare providers to discuss the risk of regret with all women who desire tubal ligation. The chance of pregnancy after tubal reanastomosis depends on the patient's age, the type of ligation, and the tubal length available. Younger women who had a ring or a clip with more than 4 cm of tubal length are the best candidates and have comparable pregnancy rates to IVF.[64] However, the time to pregnancy is significantly longer following tubal surgery as compared to IVF.

Uterine Abnormalities

There is unclear evidence on the effect of leiomyomas on infertility and live birth rates. It is recommended that the patient receive a complete infertility workup before further investigation into fibroids. The most important aspect of fibroids is the location. Fibroids that impinge on the endometrium and distort the uterine cavity result in impaired implantation and increased miscarriage rates.[65] Women with submucosal or submucosal-intramural fibroids that distort the uterine cavity have been proven to have decreased pregnancy rates. With the removal of these fibroids, pregnancy, and live birth rates increase.[66] The first-line treatment for the removal of the most detrimental fibroids is operative hysteroscopy. Other uterine pathologies like uterine synechiae and septa are more related to recurrent pregnancy loss but are capable of causing infertility. Operative hysteroscopy has shown a marked reduction in pregnancy loss for women with both synechiae and septa.[67]  Asymptomatic polyps have also been shown to cause infertility. One study showed a polypectomy on asymptomatic infertile women before IUI increased pregnancy rates from 28% to 63%.[68] 

IVF Procedures

This section discusses an overview of IVF procedures without discussing medication protocols as the most effective treatment option for infertility. Step 1 is controlled ovarian hyperstimulation with injectable gonadotropins, most commonly. Thirty-six hours after a trigger shot or HCG injection, a specialist performs a transvaginal ultrasonography-guided needle aspiration and oocyte retrieval. After retrieval, the oocytes are transferred to a special media, and normal sperm is transferred to the dish for insemination. If there is abnormal sperm, intracytoplasmic sperm injection (ICSI) is performed. ICSI is a procedure that places a single spermatozoon directly into the egg cytoplasm. After fertilization, the embryo is assessed and graded. The embryos are then transferred on Day 3 or Day 5. Preimplantation genetic testing (PGT) is an additional IVF procedure that helps detect known parental genetic mutations or balanced translocation. PGT can also be used to detect aneuploidy, both monosomies and trisomies, from all 23 chromosome pairs. Apart from a known parental carrier for a genetic mutation or balanced translocation, PGT is likely beneficial for advanced maternal age, repeated IVF failures with high-grade embryos, recurrent pregnancy loss, and unexplained infertility.

Differential Diagnosis

Infertility is a highly complex disorder with significant effects on the couple as a whole. It is important to remember that there can be, and regularly are, multiple causes of infertility. The differential diagnosis for infertility can be extensive, and a thorough workup is required to ensure no harmful disease process is missed. Due to the expansive nature of this discussion, this topic focuses on the differential diagnosis of PCOS due to its high prevalence in the infertile population. 

The differential diagnosis for patients with suspected PCOS includes:

• Androgen-producing ovarian tumors
• Adrenal tumors
• Nonclassic congenital adrenal hyperplasia
• Cushing syndrome
• Prolactinemia disorders
• Thyroid disorders

The investigation of PCOS should include total testosterone, DHEA-S, and 17-Hydroxyprogesterone for evaluation of a virilizing ovarian or adrenal tumor or nonclassical congenital adrenal hyperplasia (CAH). There is a suggestion that DHEA-S should only be reserved for women with severe virilization because an asymptomatic, slightly elevated DHEA-S level does not affect management. Additionally, prolactin and thyroid-stimulating hormones should be measured.

• The upper limit of normal for female testosterone is 45 to 60 ng/dL.[69]
• A testosterone value greater than 150 ng/dL warrants investigation for ovarian and adrenal androgen-secreting tumors.[69]
• DHEA-S of greater than 500 to 700 mcg/dL warrants further investigation of an adrenal tumor.[70]
• A fasting 17-hydroxyprogesterone greater than 200 ng/dL collected during the follicular phase warrants an ACTH stimulation test, and a value greater than 500 ng/dL is diagnostic for nonclassical congenital adrenal hyperplasia.[71]

The clinical signs and further evaluation of these disorders are outside the scope of this paper.

Prognosis

This section covers the pregnancy rates per cycle for each treatment modality. The data are mostly from evaluating unexplained infertility but are also consistent with known causes. The rates of IVF vary drastically according to multiple individual factors. The following pregnancy rates were collected from a retrospective analysis of 45 separate studies:

• No treatment: 1.3% to 3.8%
• IUI alone: 4%
• Clomiphene citrate (CC) alone: 5.6%
• CC with IUI: 8.3%
• Gonadotropins alone: 7.7%
• Gonadotropins with IUI: 17.1%
• IVF: 20.7% [72]

Letrozole alone and letrozole with IUI result in similar pregnancy rates as CC plus IUI and can be used for women for who IVF is not an option and who have failed CC plus IUI.[73]

In 2009, a study showed that women who failed CC plus IUI should go straight to IVF instead of gonadotropins plus IUI before IVF. This study resulted in less time to achieve pregnancy, fewer treatment cycles, and lower total financial cost per delivery.[74] The IVF pregnancy rates have increased since the paper reported above; however, the data still proves that IVF results in the highest pregnancy rates of all treatment options.

The research above suggests that providers can use clomiphene alone as a first-line treatment for infertility. This is no longer true. In 2008, a randomized control trial showed that clomiphene alone had lower live birth rates than expectant management, respectively 14% and 17%.[75] This paper did show a benefit regarding patient satisfaction versus expectant management; however, most women in both categories were satisfied with their care. In light of this study, ASRM published a committee opinion stating that clomiphene with timed intercourse should be discouraged as a first-line treatment for unexplained infertility.[75]

Complications

The 3 primary complications associated with infertility treatments are multiples, ectopic pregnancy, and ovarian hyperstimulation syndrome.

Multiple Gestations

The risk of multiples has been a problem for artificial reproductive technologies since the practice's inception. In the US, 32% of assisted reproductive technology pregnancies were multiples compared to 3.4% of naturally conceived births.[76] In 2009, according to the Centers for Disease Control (CDC), the chances of singleton, twin, or higher-order pregnancies with IVF fresh embryo transfer were 62%, 29%, and 3%, respectively.[77] The oral ovarian induction agents, clomiphene and letrozole, have a lower risk of multiple gestations than gonadotropins, with the percentages of twins, triplets, and quadruplets of 7%, 0.5%, and 0.3%, respectively. Gonadotropins have a 13% chance of multiple gestations, including triplets.[78] 

Currently, the ASRM and CDC have strongly promoted the use of elective single embryo transfer (eSET) for good prognosis patients. With the use of eSET, the rates of twins and triplets dropped to less than 1%. Additionally, there is active debate about whether gonadotropins should be used for ovulation induction outside of an IVF protocol due to the high risk of multiples.[79] As the use of IVF increases, the use of gonadotropins in conjunction with IUI is likely to continue to decrease.

Ectopic Pregnancy

Ectopic pregnancy following treatment of infertile patients is another risk that requires extensive counseling. There is a two-to-threefold increase in ectopic pregnancies among infertility patients. This is thought to be associated with a high percentage of tubal factor infertility.[80] The highest associated risk of ectopic pregnancy is after tubal surgery to correct tubal factor infertility. Rates of ectopic pregnancy following tubal reconstructive surgery are approximately 9%, with other reports as high as 30%.[63] The risk of ectopic pregnancy with IVF fresh embryo transfer is higher than frozen embryo transfer, but the overall rate of ectopic pregnancies with IVF is roughly 1.3%.[81] There does not seem to be an increase in ectopic pregnancies with the use of ovulation induction agents combined with IUI versus natural conception; however, in a large study comparing the ovulation induction agents, clomiphene, letrozole, and gonadotropins had ectopic pregnancy rates of 4%, 6%, and 8%, respectively.[82] 

Ovarian Hyperstimulation Syndrome 

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of controlled ovarian hyperstimulation that results in a broad range of signs and symptoms, ranging from abdominal distention, nausea, vomiting, enlarged ovaries, third-spacing of fluids, renal failure, and venous thrombosis, acute respiratory distress syndrome, electrolyte derangements, cardiac arrhythmias, and sepsis. If severe OHSS is not treated and monitored, mortality can result from the listed complications. The different stages of OHSS were classified by Golan et al. in 1989.[83] The underlying pathophysiological feature is increased capillary permeability, resulting in a fluid shift into the third space. Women at the highest risk of developing OHSS are those patients with greater than 20 mature follicles who also receive an HCG trigger shot. The incidence of moderate and severe OHSS with IVF ranges from 6% to 1%, respectively.[84] The diagnosis, prevention, and management of OHSS are outside the scope of this manuscript.

Deterrence and Patient Education

Women should see their providers for a referral to an infertility subspecialist if they are unable to achieve pregnancy after 1 year of unprotected timed intercourse or if she is older than 35 years of age, 6 months of unprotected timed intercourse.[2] It is important to explain that infertility can result from both female and male factors or a combination of the two. This is important to remember, as most couples with infertility seek care through the female partner's health provider, potentially overlooking the male contribution. The medications and procedures available for female infertility are well-studied and have a well-known risk profile. The patient needs to be aware of the risk of multiple gestations, ectopic pregnancy, and OHSS. Finally, the patient needs to understand the odds of pregnancy per treatment cycle for each modality. The inability to conceive, even with IVF, is a possibility that needs to be fully understood before dedicating a large number of resources required for infertility treatment.

Enhancing Healthcare Team Outcomes

As mentioned at the beginning of this topic, infertility is a devastating diagnosis and should be considered a disease process by all healthcare team members. The author believes the best way to improve the physical, emotional, social, and interpersonal stressors of infertility for the patient is to complete an immediate and thorough investigation into both partners. The evaluation is straightforward and can be completed before referral to a fertility subspecialist. This expedites and enhances the specialist's ability to initiate follow-up studies and treatments. The use of either clomiphene or letrozole with timed intercourse alone can be used to correct a known cause of anovulation but should not prolong the referral to a subspecialist. All primary care providers need to set realistic expectations of the chances of pregnancy and the possibility of complications when counseling couples suffering from infertility. Lastly, this manuscript is not all-encompassing but provides a basic foundation of knowledge to feel comfortable discussing a patient's family planning goals, initiating an evaluation, and reviewing available treatments.  

Review Questions

• Access free multiple choice questions on this topic.
• Click here for a simplified version.
• Comment on this article.

References

1.

GUTTMACHER AF. Factors affecting normal expectancy of conception. J Am Med Assoc. 1956 Jun 30;161(9):855-60. [PubMed: 13319020]

2.

Infertility Workup for the Women's Health Specialist: ACOG Committee Opinion, Number 781. Obstet Gynecol. 2019 Jun;133(6):e377-e384. [PubMed: 31135764]

3.

Recent advances in medically assisted conception. Report of a WHO Scientific Group. World Health Organ Tech Rep Ser. 1992;820:1-111. [PubMed: 1642014]

4.

Chandra A, Copen CE, Stephen EH. Infertility and impaired fecundity in the United States, 1982-2010: data from the National Survey of Family Growth. Natl Health Stat Report. 2013 Aug 14;(67):1-18, 1 p following 19. [PubMed: 24988820]

5.

Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS Med. 2012;9(12):e1001356. [PMC free article: PMC3525527] [PubMed: 23271957]

6.

Santoro N, Filicori M, Crowley WF. Hypogonadotropic disorders in men and women: diagnosis and therapy with pulsatile gonadotropin-releasing hormone. Endocr Rev. 1986 Feb;7(1):11-23. [PubMed: 3082615]

7.

Ackerman KE, Patel KT, Guereca G, Pierce L, Herzog DB, Misra M. Cortisol secretory parameters in young exercisers in relation to LH secretion and bone parameters. Clin Endocrinol (Oxf). 2013 Jan;78(1):114-9. [PMC free article: PMC3443505] [PubMed: 22671919]

8.

Perkins RB, Hall JE, Martin KA. Neuroendocrine abnormalities in hypothalamic amenorrhea: spectrum, stability, and response to neurotransmitter modulation. J Clin Endocrinol Metab. 1999 Jun;84(6):1905-11. [PubMed: 10372685]

9.

Hull MG. Epidemiology of infertility and polycystic ovarian disease: endocrinological and demographic studies. Gynecol Endocrinol. 1987 Sep;1(3):235-45. [PubMed: 3140583]

10.

Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004 Jan;19(1):41-7. [PubMed: 14688154]

11.

Fauser BC, Van Heusden AM. Manipulation of human ovarian function: physiological concepts and clinical consequences. Endocr Rev. 1997 Feb;18(1):71-106. [PubMed: 9034787]

12.

Baker TG. Radiosensitivity of mammalian oocytes with particular reference to the human female. Am J Obstet Gynecol. 1971 Jul 01;110(5):746-61. [PubMed: 4935165]

13.

Richardson SJ, Senikas V, Nelson JF. Follicular depletion during the menopausal transition: evidence for accelerated loss and ultimate exhaustion. J Clin Endocrinol Metab. 1987 Dec;65(6):1231-7. [PubMed: 3119654]

14.

Westhoff C, Murphy P, Heller D. Predictors of ovarian follicle number. Fertil Steril. 2000 Oct;74(4):624-8. [PubMed: 11020495]

15.

Broekmans FJ, Soules MR, Fauser BC. Ovarian aging: mechanisms and clinical consequences. Endocr Rev. 2009 Aug;30(5):465-93. [PubMed: 19589949]

16.

Nelson LM, Anasti JN, Kimzey LM, Defensor RA, Lipetz KJ, White BJ, Shawker TH, Merino MJ. Development of luteinized graafian follicles in patients with karyotypically normal spontaneous premature ovarian failure. J Clin Endocrinol Metab. 1994 Nov;79(5):1470-5. [PubMed: 7962345]

17.

Nelson LM. Clinical practice. Primary ovarian insufficiency. N Engl J Med. 2009 Feb 05;360(6):606-14. [PMC free article: PMC2762081] [PubMed: 19196677]

18.

Seppälä M, Ranta T, Hirvonen E. Hyperprolactinaemia and luteal insufficiency. Lancet. 1976 Jan 31;1(7953):229-30. [PubMed: 55535]

19.

Olive DL, Pritts EA. Treatment of endometriosis. N Engl J Med. 2001 Jul 26;345(4):266-75. [PubMed: 11474666]

20.

Prescott J, Farland LV, Tobias DK, Gaskins AJ, Spiegelman D, Chavarro JE, Rich-Edwards JW, Barbieri RL, Missmer SA. A prospective cohort study of endometriosis and subsequent risk of infertility. Hum Reprod. 2016 Jul;31(7):1475-82. [PMC free article: PMC4901880] [PubMed: 27141041]

21.

Macer ML, Taylor HS. Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility. Obstet Gynecol Clin North Am. 2012 Dec;39(4):535-49. [PMC free article: PMC3538128] [PubMed: 23182559]

22.

Bulun SE. Endometriosis. N Engl J Med. 2009 Jan 15;360(3):268-79. [PubMed: 19144942]

23.

Gupta S, Goldberg JM, Aziz N, Goldberg E, Krajcir N, Agarwal A. Pathogenic mechanisms in endometriosis-associated infertility. Fertil Steril. 2008 Aug;90(2):247-57. [PubMed: 18672121]

24.

Holoch KJ, Lessey BA. Endometriosis and infertility. Clin Obstet Gynecol. 2010 Jun;53(2):429-38. [PubMed: 20436320]

25.

Toya M, Saito H, Ohta N, Saito T, Kaneko T, Hiroi M. Moderate and severe endometriosis is associated with alterations in the cell cycle of granulosa cells in patients undergoing in vitro fertilization and embryo transfer. Fertil Steril. 2000 Feb;73(2):344-50. [PubMed: 10685541]

26.

Weström L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis. 1992 Jul-Aug;19(4):185-92. [PubMed: 1411832]

27.

Weström L. Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol. 1980 Dec 01;138(7 Pt 2):880-92. [PubMed: 7008604]

28.

Lepine LA, Hillis SD, Marchbanks PA, Joesoef MR, Peterson HB, Westrom L. Severity of pelvic inflammatory disease as a predictor of the probability of live birth. Am J Obstet Gynecol. 1998 May;178(5):977-81. [PubMed: 9609570]

29.

Meyer WR, Castelbaum AJ, Somkuti S, Sagoskin AW, Doyle M, Harris JE, Lessey BA. Hydrosalpinges adversely affect markers of endometrial receptivity. Hum Reprod. 1997 Jul;12(7):1393-8. [PubMed: 9262264]

30.

Van Voorhis BJ, Mejia RB, Schlaff WD, Hurst BS. Is removal of hydrosalpinges prior to in vitro fertilization the standard of care? Fertil Steril. 2019 Apr;111(4):652-656. [PubMed: 30929723]

31.

Pritts EA. Fibroids and infertility: a systematic review of the evidence. Obstet Gynecol Surv. 2001 Aug;56(8):483-91. [PubMed: 11496160]

32.

Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN, Devroey P. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod Update. 2001 Mar-Apr;7(2):161-74. [PubMed: 11284660]

33.

Chan YY, Jayaprakasan K, Zamora J, Thornton JG, Raine-Fenning N, Coomarasamy A. The prevalence of congenital uterine anomalies in unselected and high-risk populations: a systematic review. Hum Reprod Update. 2011 Nov-Dec;17(6):761-71. [PMC free article: PMC3191936] [PubMed: 21705770]

34.

Practice Committee of the American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss: a committee opinion. Fertil Steril. 2013 Jan;99(1):63. [PubMed: 23095139]

35.

Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility. Optimizing natural fertility. Fertil Steril. 2008 Nov;90(5 Suppl):S1-6. [PubMed: 19007604]

36.

Wathen NC, Perry L, Lilford RJ, Chard T. Interpretation of single progesterone measurement in diagnosis of anovulation and defective luteal phase: observations on analysis of the normal range. Br Med J (Clin Res Ed). 1984 Jan 07;288(6410):7-9. [PMC free article: PMC1444184] [PubMed: 6418326]

37.

Ecochard R, Boehringer H, Rabilloud M, Marret H. Chronological aspects of ultrasonic, hormonal, and other indirect indices of ovulation. BJOG. 2001 Aug;108(8):822-9. [PubMed: 11510707]

38.

Abdalla H, Thum MY. An elevated basal FSH reflects a quantitative rather than qualitative decline of the ovarian reserve. Hum Reprod. 2004 Apr;19(4):893-8. [PubMed: 15016786]

39.

Smotrich DB, Widra EA, Gindoff PR, Levy MJ, Hall JL, Stillman RJ. Prognostic value of day 3 estradiol on in vitro fertilization outcome. Fertil Steril. 1995 Dec;64(6):1136-40. [PubMed: 7589666]

40.

Dewailly D, Andersen CY, Balen A, Broekmans F, Dilaver N, Fanchin R, Griesinger G, Kelsey TW, La Marca A, Lambalk C, Mason H, Nelson SM, Visser JA, Wallace WH, Anderson RA. The physiology and clinical utility of anti-Mullerian hormone in women. Hum Reprod Update. 2014 May-Jun;20(3):370-85. [PubMed: 24430863]

41.

de Vet A, Laven JS, de Jong FH, Themmen AP, Fauser BC. Antimüllerian hormone serum levels: a putative marker for ovarian aging. Fertil Steril. 2002 Feb;77(2):357-62. [PubMed: 11821097]

42.

Toner JP, Seifer DB. Why we may abandon basal follicle-stimulating hormone testing: a sea change in determining ovarian reserve using antimüllerian hormone. Fertil Steril. 2013 Jun;99(7):1825-30. [PubMed: 23548941]

43.

Steiner AZ, Pritchard D, Stanczyk FZ, Kesner JS, Meadows JW, Herring AH, Baird DD. Association Between Biomarkers of Ovarian Reserve and Infertility Among Older Women of Reproductive Age. JAMA. 2017 Oct 10;318(14):1367-1376. [PMC free article: PMC5744252] [PubMed: 29049585]

44.

Vrontikis A, Chang PL, Kovacs P, Lindheim SR. Antral follice counts (AFC) predict ovarian response and pregnancy outcomes in oocyte donation cycles. J Assist Reprod Genet. 2010 Jul;27(7):383-9. [PMC free article: PMC2922700] [PubMed: 20467804]

45.

Mol BW, Swart P, Bossuyt PM, van der Veen F. Is hysterosalpingography an important tool in predicting fertility outcome? Fertil Steril. 1997 Apr;67(4):663-9. [PubMed: 9093191]

46.

Papaioannou S, Bourdrez P, Varma R, Afnan M, Mol BW, Coomarasamy A. Tubal evaluation in the investigation of subfertility: a structured comparison of tests. BJOG. 2004 Dec;111(12):1313-21. [PubMed: 15663113]

47.

Luttjeboer F, Harada T, Hughes E, Johnson N, Lilford R, Mol BW. Tubal flushing for subfertility. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003718. [PubMed: 17636730]

48.

Seshadri S, El-Toukhy T, Douiri A, Jayaprakasan K, Khalaf Y. Diagnostic accuracy of saline infusion sonography in the evaluation of uterine cavity abnormalities prior to assisted reproductive techniques: a systematic review and meta-analyses. Hum Reprod Update. 2015 Mar-Apr;21(2):262-74. [PubMed: 25505226]

49.

Frisch RE. The right weight: body fat, menarche and ovulation. Baillieres Clin Obstet Gynaecol. 1990 Sep;4(3):419-39. [PubMed: 2282736]

50.

Yen SS, Rebar R, Vandenberg G, Ehara Y, Siler T. Pituitary gonadotrophin responsiveness to synthetic LRF in subjects with normal and abnormal hypothalamic-pituitary-gonadal axis. J Reprod Fertil Suppl. 1973 Dec;20(0):137-61. [PubMed: 4599401]

51.

Abraham S, Mira M, Llewellyn-Jones D. Should ovulation be induced in women recovering from an eating disorder or who are compulsive exercisers? Fertil Steril. 1990 Mar;53(3):566-8. [PubMed: 2407567]

52.

Berga SL, Marcus MD, Loucks TL, Hlastala S, Ringham R, Krohn MA. Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavior therapy. Fertil Steril. 2003 Oct;80(4):976-81. [PubMed: 14556820]

53.

Crosignani PG, Colombo M, Vegetti W, Somigliana E, Gessati A, Ragni G. Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements in anthropometric indices, ovarian physiology and fertility rate induced by diet. Hum Reprod. 2003 Sep;18(9):1928-32. [PubMed: 12923151]

54.

Mutsaerts MA, van Oers AM, Groen H, Burggraaff JM, Kuchenbecker WK, Perquin DA, Koks CA, van Golde R, Kaaijk EM, Schierbeek JM, Oosterhuis GJ, Broekmans FJ, Bemelmans WJ, Lambalk CB, Verberg MF, van der Veen F, Klijn NF, Mercelina PE, van Kasteren YM, Nap AW, Brinkhuis EA, Vogel NE, Mulder RJ, Gondrie ET, de Bruin JP, Sikkema JM, de Greef MH, ter Bogt NC, Land JA, Mol BW, Hoek A. Randomized Trial of a Lifestyle Program in Obese Infertile Women. N Engl J Med. 2016 May 19;374(20):1942-53. [PubMed: 27192672]

55.

Wu CH, Winkel CA. The effect of therapy initiation day on clomiphene citrate therapy. Fertil Steril. 1989 Oct;52(4):564-8. [PubMed: 2806595]

56.

Cole PA, Robinson CH. Mechanism and inhibition of cytochrome P-450 aromatase. J Med Chem. 1990 Nov;33(11):2933-42. [PubMed: 2231592]

57.

ACOG Committee Opinion No. 738: Aromatase Inhibitors in Gynecologic Practice. Obstet Gynecol. 2018 Jun;131(6):1. [PubMed: 29794680]

58.

Casper RF, Mitwally MF. Review: aromatase inhibitors for ovulation induction. J Clin Endocrinol Metab. 2006 Mar;91(3):760-71. [PubMed: 16384846]

59.

Weiss NS, Nahuis MJ, Bordewijk E, Oosterhuis JE, Smeenk JM, Hoek A, Broekmans FJ, Fleischer K, de Bruin JP, Kaaijk EM, Laven JS, Hendriks DJ, Gerards MH, van Rooij IA, Bourdrez P, Gianotten J, Koks C, Lambalk CB, Hompes PG, van der Veen F, Mol BWJ, van Wely M. Gonadotrophins versus clomifene citrate with or without intrauterine insemination in women with normogonadotropic anovulation and clomifene failure (M-OVIN): a randomised, two-by-two factorial trial. Lancet. 2018 Feb 24;391(10122):758-765. [PubMed: 29273245]

60.

Ludwig M, Doody KJ, Doody KM. Use of recombinant human chorionic gonadotropin in ovulation induction. Fertil Steril. 2003 May;79(5):1051-9. [PubMed: 12738494]

61.

Cantineau AE, Janssen MJ, Cohlen BJ. Synchronised approach for intrauterine insemination in subfertile couples. Cochrane Database Syst Rev. 2010 Apr 14;(4):CD006942. [PubMed: 20393953]

62.

Johnson NP, Mak W, Sowter MC. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database Syst Rev. 2004;(3):CD002125. [PubMed: 15266464]

63.

Audebert A, Pouly JL, Bonifacie B, Yazbeck C. Laparoscopic surgery for distal tubal occlusions: lessons learned from a historical series of 434 cases. Fertil Steril. 2014 Oct;102(4):1203-8. [PubMed: 25150389]

64.

Boeckxstaens A, Devroey P, Collins J, Tournaye H. Getting pregnant after tubal sterilization: surgical reversal or IVF? Hum Reprod. 2007 Oct;22(10):2660-4. [PubMed: 17670765]

65.

Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril. 2009 Apr;91(4):1215-23. [PubMed: 18339376]

66.

Casini ML, Rossi F, Agostini R, Unfer V. Effects of the position of fibroids on fertility. Gynecol Endocrinol. 2006 Feb;22(2):106-9. [PubMed: 16603437]

67.

March CM, Israel R. Gestational outcome following hysteroscopic lysis of adhesions. Fertil Steril. 1981 Oct;36(4):455-9. [PubMed: 6269905]

68.

Pérez-Medina T, Bajo-Arenas J, Salazar F, Redondo T, Sanfrutos L, Alvarez P, Engels V. Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination: a prospective, randomized study. Hum Reprod. 2005 Jun;20(6):1632-5. [PubMed: 15760959]

69.

Milczarek M, Kucharska A, Borowiec A. Difficulties in diagnostics of polycystic ovary syndrome in adolescents - a preliminary study. Pediatr Endocrinol Diabetes Metab. 2019;25(3):122-126. [PubMed: 31769270]

70.

Derksen J, Nagesser SK, Meinders AE, Haak HR, van de Velde CJ. Identification of virilizing adrenal tumors in hirsute women. N Engl J Med. 1994 Oct 13;331(15):968-73. [PubMed: 8084355]

71.

Azziz R, Dewailly D, Owerbach D. Clinical review 56: Nonclassic adrenal hyperplasia: current concepts. J Clin Endocrinol Metab. 1994 Apr;78(4):810-5. [PubMed: 8157702]

72.

Zolton JR, Lindner PG, Terry N, DeCherney AH, Hill MJ. Gonadotropins versus oral ovarian stimulation agents for unexplained infertility: a systematic review and meta-analysis. Fertil Steril. 2020 Feb;113(2):417-425.e1. [PubMed: 31973903]

73.

Liu A, Zheng C, Lang J, Chen W. Letrozole versus clomiphene citrate for unexplained infertility: a systematic review and meta-analysis. J Obstet Gynaecol Res. 2014 May;40(5):1205-16. [PubMed: 24754848]

74.

Reindollar RH, Regan MM, Neumann PJ, Levine BS, Thornton KL, Alper MM, Goldman MB. A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial. Fertil Steril. 2010 Aug;94(3):888-99. [PubMed: 19531445]

75.

Practice Committee of the American Society for Reproductive Medicine. Use of clomiphene citrate in infertile women: a committee opinion. Fertil Steril. 2013 Aug;100(2):341-8. [PubMed: 23809505]

76.

Sunderam S, Kissin DM, Zhang Y, Folger SG, Boulet SL, Warner L, Callaghan WM, Barfield WD. Assisted Reproductive Technology Surveillance - United States, 2016. MMWR Surveill Summ. 2019 Apr 26;68(4):1-23. [PMC free article: PMC6493873] [PubMed: 31022165]

77.

Yu B, Vega M, Zaghi S, Fritz R, Jindal S, Buyuk E. Comparison of perinatal outcomes following frozen embryo transfer cycles using autologous versus donor oocytes in women 40 to 43 years old: analysis of SART CORS data. J Assist Reprod Genet. 2018 Nov;35(11):2025-2029. [PMC free article: PMC6240548] [PubMed: 30128819]

78.

Hansen KR, He AL, Styer AK, Wild RA, Butts S, Engmann L, Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson P, Christman GM, Huang H, Santoro N, Eisenberg E, Zhang H., Eunice Kennedy Shriver National Institute of Child Health and Human Development Reproductive Medicine Network. Predictors of pregnancy and live-birth in couples with unexplained infertility after ovarian stimulation-intrauterine insemination. Fertil Steril. 2016 Jun;105(6):1575-1583.e2. [PMC free article: PMC4893990] [PubMed: 26949110]

79.

Practice Committee of the American Society for Reproductive Medicine. Electronic address: ASRM@asrm.org; Practice Committee of the Society for Assisted Reproductive Technology. Guidance on the limits to the number of embryos to transfer: a committee opinion. Fertil Steril. 2017 Apr;107(4):901-903. [PubMed: 28292618]

80.

Li C, Zhao WH, Zhu Q, Cao SJ, Ping H, Xi X, Qin GJ, Yan MX, Zhang D, Qiu J, Zhang J. Risk factors for ectopic pregnancy: a multi-center case-control study. BMC Pregnancy Childbirth. 2015 Aug 22;15:187. [PMC free article: PMC4546260] [PubMed: 26296545]

81.

Londra L, Moreau C, Strobino D, Garcia J, Zacur H, Zhao Y. Ectopic pregnancy after in vitro fertilization: differences between fresh and frozen-thawed cycles. Fertil Steril. 2015 Jul;104(1):110-8. [PubMed: 25956363]

82.

Diamond MP, Legro RS, Coutifaris C, Alvero R, Robinson RD, Casson P, Christman GM, Ager J, Huang H, Hansen KR, Baker V, Usadi R, Seungdamrong A, Bates GW, Rosen RM, Haisenleder D, Krawetz SA, Barnhart K, Trussell JC, Ohl D, Jin Y, Santoro N, Eisenberg E, Zhang H., NICHD Reproductive Medicine Network. Letrozole, Gonadotropin, or Clomiphene for Unexplained Infertility. N Engl J Med. 2015 Sep 24;373(13):1230-40. [PMC free article: PMC4739644] [PubMed: 26398071]

83.

Golan A, Ron-el R, Herman A, Soffer Y, Weinraub Z, Caspi E. Ovarian hyperstimulation syndrome: an update review. Obstet Gynecol Surv. 1989 Jun;44(6):430-40. [PubMed: 2660037]

84.

Delvigne A, Rozenberg S. Epidemiology and prevention of ovarian hyperstimulation syndrome (OHSS): a review. Hum Reprod Update. 2002 Nov-Dec;8(6):559-77. [PubMed: 12498425]

Disclosure: Matthew Walker declares no relevant financial relationships with ineligible companies.

Disclosure: Kyle Tobler declares no relevant financial relationships with ineligible companies.